Every finding on record at Peak Resources - Gastonia

Based on observations, record review, resident and staff interviews, the facility failed to assist a resident, who required staff assistance with transfers, out of bed when requested for 1 of 5 sampled residents reviewed for activities of daily living (Resident #8).Findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses that included disease of spinal cord, chronic pain, chronic obstructive pulmonary disease (difficulty breathing), left hand contracture, and history of falling.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 had intact cognition and impairment on one side of the upper extremity. She required partial/moderate staff assistance with moving from lying to sitting on the side of the bed and chair/bed-to chair transfers and required substantial/maximal staff assistance with sit-to-stand. Resident #8 displayed no behaviors and did not reject care during the MDS assessment look-back period.Review of Resident #8's comprehensive care plans, last reviewed/revised on 06/11/26 revealed the following active care plans:Resident Profile - Standards of Care Required for Resident indicated Resident #8 had impaired vision due to blindness in the right eye and required one-person assist with transfers. Activities of Daily Living (ADL) Functional Status/Rehabilitation Potential indicated Resident #8 needed assistance with ADL. Interventions included for staff to assist Resident #8 with all ADL that she was unable to complete independently.During an observation and interview on 06/14/26 at 3:36 PM, Resident #8 was in her room sitting in her wheelchair watching TV. Resident #8 reported she liked to get up early each day, at the very least by 10:00 AM, and was unable to transfer independently. Resident #8 stated on Saturday 06/13/26, she wasn't assisted out of bed until 2:45 PM and she missed attending BINGO. Resident #8 stated she used her call bell repeatedly and yelled out for staff for assistance and when staff finally arrived to her room, she was told they were running behind. Resident #8 stated it hurt her feelings when she had to repeatedly request for staff to help her get out of bed.During a follow-up interview on 06/17/26 at 1:42 PM, Resident #8 confirmed she started using her call bell after breakfast for assistance with getting up out of bed and told both NA #1 and Nurse #2 that she wanted up to get a shower and attend BINGO that afternoon. Resident #8 stated as it got closer to lunch time, she even screamed at the top of her lungs for someone to come assist. Resident #8 verified she wasn't assisted up out of bed until 2:45 PM.During a phone interview on 06/17/26 at 9:12 AM, Nurse Aide (NA) #2 confirmed she was assigned to provide care to the residents at the bottom of 300 Hall on 06/13/26 during the hours of 7:00 AM to 3:00 PM. NA #2 stated NA #1 was assigned to the top of 300 Hall where Resident #8 resided. She stated NA #1 was new to the hall and was not that familiar with the residents and she (NA #2) did help NA #1 by telling her what the residents needed at the start of the shift. NA #2 stated Resident #8 was a one person assist with a stand/pivot transfer and usually stayed in bed except to attend BINGO and get a shower. NA #2 recalled Resident #8 mentioning she wanted to attend BINGO on 06/13/26. She stated it was around 2:30 PM before Resident #8 was assisted out of bed and she felt NA #1 just got behind. NA #1 stated NA #2 did not ask her for assistance with any of the residents on 06/13/26.During a phone interview on 06/17/26 at 9:29 AM, NA #1 confirmed she was assigned to provide Resident #8's care on 06/13/26 during the hours of 7:00 AM to 3:30 PM. NA #1 stated she was assigned to the resident rooms at the top of the hall where Resident #8 resided and it was her first time working with the residents on 300 Hall. NA #1 reported she was usually assigned to 100 Hall where they had three NAs to provide resident care and 300 Hall only had two NAs. NA #1 stated she got behind because she really didn't know the care needs of the residents she was assigned, had two resident showers to provide and was assigned to assist residents in the dining room during lunch. NA #1 recalled she assisted Resident #8 out of bed around 2:30 PM and provided her a shower. NA #1 did not recall Resident #8 mentioning anything about wanting to attend BINGO that afternoon and the only thing Resident #8 had requested was for NA #1 to put Vaseline on her skin after her shower. NA #1 did not recall hearing Resident #8 yelling out for assistance and stated that anytime Resident #8 had used her call bell, she went into the room to let her know that she hadn't forgotten about her and would assist her just as soon as she finished with another resident. NA #1 stated she had asked NA #2 questions about resident care but did not specifically ask her to assist with getting Resident #8 up out of bed. NA #1 stated she did the best she could and made sure all resident care was provided before she left for the day.During a phone interview on 06/17/26 at 9:53 AM, Nurse #2 confirmed she was assigned to provide Resident #8's care on 06/13/26. Nurse #2 could not recall the exact time(s) but stated some time before lunch, Resident #8 did state that she wanted to go to BINGO and voiced concerns that no one had assisted her up out of bed. Nurse #2 stated she explained to Resident #8 that NA #1 got behind due to having several showers to give but NA #1 would assist her out of bed as soon as she could. Nurse #2 could not recall the exact time when Resident #8 was assisted out of bed but thought it was around 2:00 PM when she was given a shower. Nurse #2 confirmed Resident #8 was a one-person assist with a stand/pivot transfer and stated she did not offer to assist Resident #8 because she was finishing up her medication pass.During an interview on 06/17/26 at 10:38 AM, the Nurse Supervisor stated she facilitated the BINGO activity for residents every other Saturday and the NAs helped get residents to the dining room for the activity. The Nurse Supervisor verified BINGO was scheduled for 2:30 PM on Saturday 06/13/26. She stated Resident #8 usually attended BINGO and it had crossed her mind to go check on Resident #8 but didn't because she got sidetracked getting everything together for the activity. The Nurse Supervisor stated no one had mentioned anything to her on 06/13/26 that Resident #8 had not been assisted out of bed and had she known, she would have gone to assist Resident #8 so that she could have attended BINGO.During an interview on 06/17/26 at 2:27 PM, the Director of Nursing (DON) stated Resident #8 never mentioned any concerns to her about staff not assisting her out of bed on 06/13/26 when requested and she missed attending BINGO. The DON stated NA #1 reported that the only concern Resident #8 had mentioned on 06/13/26 was that she wanted NA #1 to put Vaseline on her skin after the shower. The DON was unaware that Nurse #2 knew that Resident #8 requested to get out of bed and stated Nurse #2 should have assisted Resident #8 as requested if NA #1 was unavailable.During an interview on 06/17/26 at 2:58 PM, the Administrator stated normally with any care concern, it was addressed through the facility's grievance process but Resident #8 never mentioned anything to her or other staff regarding not being assisted out of bed when requested on 06/13/26. The Administrator stated she felt it was an isolated incident. She stated if Resident #8 asked for assistance with getting up out of bed, staff should have provided her with assistance when requested.

Based on record review, observation and staff interviews, the facility failed to follow their infection control policy and procedure for Enhanced Barrier Precautions (EBP) when Nurse #1, did not put on a personal protective equipment (PPE) gown prior to urinary catheter care provided to a resident (Resident #7). The deficient practice occurred for 1 of 4 staff members reviewed for infection control (Nurse #1). Findings included: A review of the facility's Infection Prevention and Control Program for EBP last revised on 10/2025 read in part, EBPs were designed to reduce transmission of multidrug resistant organisms (MDRO) by employing targeted gown use during high-contact resident care activities. EBPs in conjunction with standard precautions to expand the use of PPE to donning (put on) a gown during high-contact resident care activities that provide opportunities for transfer of MDRO's to clothing. PPE - wear a gown for the high-contact care activity of a urinary catheter. An observation of Resident #7's urinary catheter care provided by Nurse #1 was conducted on 06/17/26 from 11:09 AM through 11:27 AM. Posted on the entry door to Resident #7's room was a sign that read in part, EBP - staff must wear a gown for the following high-contact resident care activities of a urinary catheter. A PPE storage container placed on Resident #7's room entry door contained protective gowns and was available for use. Nurse #1 entered the room, washed his hands, put on a pair of gloves but did not put on a protective gown. Nurse #1 cleaned the catheter insert site and tubing using a wound cleanser moistened gauze and flushed 30 milliliters of acetic acid into the catheter tubing. Nurse #7 removed and discarded his gloves in the trash then cleaned his hands by using sanitizing wipes. During an interview on 06/17/26 at 11:27 AM, Nurse #1 stated he did not wear a PPE gown when providing catheter care for a resident. When asked about the EBP sign posted on Resident #7's door with instructions staff must wear a gown for care of a urinary catheter, Nurse #1 stated he wore a PPE gown if a resident was placed on contact precautions. Nurse #1 further stated he did not wear a gown for a resident on EBP and he was not aware that a PPE gown should be worn when he provided care for a urinary catheter.During an interview on 06/17/26 at 12:53 PM, the Infection Preventionist stated EBPs were utilized for residents with a urinary catheter. She revealed EBP signs were used as a reminder and provided instructions on what type of PPE was required when staff provided high-contact resident care. She revealed an educational in-service on EBP, and other isolation precautions was recently provided to staff and showed Nurse #1 signed the attendance sheet. She revealed the in-service included review of the EBP sign and the instructions and stated Nurse #1 was expected to wear a protective gown when he provided care for a resident's urinary catheter.During an interview on 06/17/26 at 1:12 PM, the Director of Nursing (DON) stated she expected Nurse #1 followed EBPs and wore a gown when he provided catheter care for a resident.An interview was conducted on 06/17/26 at 2:18 PM with the Administrator. The Administrator stated she expected Nurse #1 followed the directions for EBPs and wore a gown when he provided catheter care for Resident #7.

Based on observations and staff interviews, the facility failed to discard expired and spoiled food items from 1 of 1 walk-in cooler. These failures had the potential to affect food served to residents. Findings included: An initial observation of the walk-in cooler on [DATE] at 10:07 AM revealed a plastic bag containing thawed chicken sitting inside a metal pan with a date of [DATE] sitting on a bottom shelf. A box ,d+[DATE] full of green peppers with a delivery date of [DATE] was sitting on a top shelf. An observation of the green peppers at the same date and time revealed the peppers were shriveled and contained multiple brown spots. An interview with the Dietary Manager on [DATE] at 10:10 AM revealed it was her responsibility to check for spoiled and expired food items on a daily basis. She stated the green peppers should have been used or discarded before showing signs of spoilage and she just overlooked them. The Dietary Manager stated she thought raw chicken was good for 7 days after being thawed but she would check. A follow-up interview with the Dietary Manager on [DATE] at 2:35 PM revealed raw chicken was good for 3 days after being thawed. She stated the chicken should have been used or discarded by [DATE]. An interview with the Administrator on [DATE] at 1:01 PM revealed she expected food to be used or discarded before showing signs of spoilage, and the guidelines for thawed chicken should be followed.

Based on observations, record review, and resident and staff interviews, the facility failed to secure medications stored in a resident room for 1 of 1 resident reviewed for medication storage (Resident #103). Findings included: Resident #103 was admitted to the facility 03/22/25 with a diagnosis including acute (sudden onset) metabolic encephalopathy (a condition which occurs when problems with metabolism causes brain dysfunction). Review of a Nurse Practitioner (NP) note dated 03/23/25 revealed Resident #103 was cognitively intact. The admission Minimum Data Set (MDS) assessment dated [DATE] was documented as in process. An observation of an uncovered clear plastic storage bin sitting on the counter beside the sink in Resident #103's room on 04/01/25 at 8:44 AM revealed a bottle of eye multivitamin pills, a bottle of Fluticasone nasal spray, and a bottle of Azelastine (antihistamine) nasal spray in the bin. In an interview with Resident #103 at the same date and time he confirmed the medications in the plastic bin belonged to him. He stated he took the eye multivitamins, but he could not remember the last time he took them. Resident #103 stated his family brought the eye multivitamins to him from home and he thought the nasal sprays came from the hospital. He stated he had not been using the nasal sprays since admission to the facility. An observation of an uncovered plastic storage bin sitting beside the sink in Resident #103's room on 04/02/25 at 8:27 AM revealed a bottle of eye multivitamin pills, a bottle of Fluticasone nasal spray, a bottle of Azelastine nasal spray, and two bottles of Ammonia Lactate 12% lotion (topical medication used to treat dry or scaly skin) were in the bin. In an interview with Resident #103 at the same date and time he stated he had not used the ammonia lactate lotion in a while, and he wasn't sure where it came from. An observation of a plastic storage bin sitting beside the sink in Resident #103's room on 04/03/25 at 8:18 AM revealed two bottles of Ammonia Lactate 12% lotion, a bottle of Fluticasone nasal spray, and a bottle of Azelastine nasal spray were sitting in the bin. An interview with Nurse #1 on 04/03/25 at 8:29 AM revealed she had been caring for Resident #103 from 04/01/25 through 04/03/25 on the 7:00 AM to 3:00 PM shift. She stated she had not noticed medications in the bin in Resident #103's room and if she had she would have removed the medications, placed them in a plastic bag, labeled the medications with Resident #103's name, and stored them in the medication room until they could be sent home with family or until he was discharged . She stated unless a resident had a Physician order to self-administer their medications, they should not be stored in a resident's room. An interview with the Director of Nursing (DON) on 04/03/25 at 1:05 PM revealed families brought medications to residents without staff's knowledge and when staff found them, they removed them from the room and sent them home with family. She stated unless a resident had a Physician order to administer their own medication, medications should not be stored in a resident's room.

Based on observations and staff interviews the facility failed to date an open food item in 1 of 1 walk-in cooler and remove expired food items from 1 of 1 reach-in cooler and 1 of 1 nourishment refrigerator (main dining room). This practice had the potential to affect food and beverages served to the residents. Findings included: 1. An initial tour of the walk-in cooler on [DATE] at 9:52 AM revealed an opened and undated 5-pound container of pimento cheese. An interview with the Certified Food Manager (CFM) at the same date and time revealed all food should have an open date and the person who opened the item was responsible for dating it. An interview with the Administrator on [DATE] at 5:50 PM revealed all food should be dated when opened. 2. An observation of the reach-in cooler on [DATE] at 9:58 AM revealed a half-gallon of orange juice with an expiration date of [DATE]. An interview with the CFM at the same date and time revealed the orange juice should have been used or discarded on or before the expiration date. She stated it was all staff's responsibility to check for expiration dates. An interview with the Administrator on [DATE] at 5:50 PM revealed all food should be used or discarded before the expiration date and expiration dates should be checked daily. 3. An observation of the nourishment refrigerator in the main dining room on [DATE] at 10:02 AM revealed 6 cartons of milk with an expiration date of [DATE]. An interview with the CFM at the same date and time revealed she was responsible for checking expiration dates of food and beverages in the nourishment refrigerator and she last checked the refrigerator on [DATE]. She stated the milk should have been used or discarded before the expiration date. An interview with the Administrator on [DATE] at 5:50 PM revealed all food should be used or discarded before the expiration date and expiration dates should be checked daily.

Based on record review and staff interviews the facility failed to ensure recommendations made by the Register Dietitian were implemented for 1 of 3 residents reviewed for nutrition (Resident #193). Findings included: Resident #193 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition and history of a cerebrovascular accident (stroke). Resident #193 expired in the facility on [DATE]. Review of the documented weights revealed from [DATE] through [DATE] Resident #193 had 18.48 % weight loss. The care plan focus area started on [DATE] identified Resident #193 had suboptimal oral intake and needed increased protein related to wounds and being at risk for further skin breakdown. The care plan indicated Resident #193 had unavoidable weight loss due to the refusal for placement of a feeding tube and included the intervention to obtain dietary consults and follow the recommendations. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #193's cognition was moderately impaired and extensive assistance was needed with eating. Review of the Registered Dietitian (RD) weight review dated [DATE] revealed Resident #193 had significant weight loss of 18.5% over the past 156 days; had a non-pressure wound on the right elbow; and received protein shakes twice a day and liquid protein daily for wound healing and weight loss. The RD note revealed the Medication Administration Records showed Resident #193 frequently refused the protein shakes and liquid protein and recommended discontinuing those. Meal intakes were noted to range between 0 and 100% but mostly less than 50% and the placement of a feeding tube was declined by family. The RD made new recommendations to add fortified breakfast cereal and double meat proteins to the meal tray and a trial period for a protein dense ice cream as morning snack for 14 days. Review of the physician orders included the following: liquid protein 30 milliliters daily to meet protein needs started on [DATE] and discontinued on [DATE]; protein shake twice daily for prevention of weight loss and malnutrition started on [DATE] and discontinued on [DATE]; regular diet to include finger foods when available started on [DATE]: and protein dense ice cream daily in the morning started on [DATE]. There was no physician's diet order for fortified breakfast cereal and double meat proteins started on [DATE]. During an interview on [DATE] at 1:13 PM the Director of Nursing (DON) explained the process in place for implementing the RD recommendations was for the RD to enter her recommendations into the facility's computer system as a physician's diet order and also send the recommendations to her email for review. During the morning meeting the Interdisciplinary Team reviewed the new RD recommendations and the DON would activate the recommendation as a new physician's diet order. After reviewing the diet orders for Resident #193 the DON revealed she could not find a physician's order Resident #193 was to receive fortified breakfast cereal and double meat proteins per the RD recommendation made on [DATE]. The DON revealed she could not find the email sent by the RD for recommendations made on [DATE] and indicated it was sometime ago and she could have deleted the email. A telephone interview was conducted with the RD on [DATE] at 4:08 PM. The RD revealed she was included in the morning meeting with the Interdisciplinary Team and had discussed Resident #193 was not eating much and the placement of a feeding tube was refused. The RD revealed the facility's process for her to add diet recommendations for residents into the facility's computer system as a physician's order was a new process and she did not recall the date it started but her recommendations were also sent to the DON and Dietary Manager via email that included Resident #193 receive fortified breakfast cereal and double meat portions. The RD revealed she would expect the recommendations made on [DATE] for Resident #193 to receive fortified breakfast cereal and double meat proteins to be included on the meal tray and provided to the resident. During an interview on [DATE] at 5:05 PM the Certified Dietary Manager (CDM) revealed the RD sent her and the DON an email that listed diet recommendations for residents. The CDM explained she did not add recommendations to the resident's meal ticket until there was a physician's order in place. She explained after she received the physician's order, she updated the resident's meal ticket to ensure the new recommendations were included on the meal tray and provided to the resident. After review of her email the CDM confirmed she received the recommendation made by the RD on [DATE] for Resident #193 to receive fortified breakfast cereal and double meat proteins. She revealed an active physician's order would need to be in place before the meal ticket was updated to ensure Resident #193 received fortified breakfast cereal and double meat proteins on the meal tray. During an interview on [DATE] at 6:14 PM the Administrator confirmed the process was for the RD to add recommendations as a diet order and were reviewed by the Interdisciplinary Team prior to being added as an active order and recommendations were also sent via email to the DON and CDM. The Administrator stated she thought the process for implementing the RD recommendations for Resident #193 to receive fortified breakfast cereal and double meat proteins were not added to the resident's diet order due to human error.

Based on record review, family interviews, and staff interviews, the facility failed to create a record of an oral grievance from an interested family member in accordance with the facility policy for 1 of 2 sampled residents (Resident #4) who were reviewed for social services. Findings included: Resident #4 was admitted to facility on 9/14/20 and had a quarterly Minimum Data Set (MDS) assessment dated [DATE] that indicated she had moderate cognitive impairment. Review of the Grievance Log from September through February 2023 revealed no grievances had been reported on behalf of Resident #4's family member. A review of the Grievance Policy 11/28/2016 revealed the facility would assist residents, their representatives, other interested family members or resident advocates in filing grievances or complaints when such requests are made. Grievances may be submitted orally, in writing, or anonymously. The administrator would be designated as the grievance official and responsible for overseeing the grievance process; receiving and tracking through their conclusion; leading any necessary investigations; and issuing written grievance decisions. The grievance official would assign the investigation to the appropriate department manager, who would investigate and submit findings to the administrator within five (5) working days of receiving the grievance. The grievance official would take immediate action to prevent further potential violations of any resident rights while the alleged violation was being investigated. The person filing the grievance on behalf of the resident, would be informed of the findings of the investigation and the actions that would be taken to correct any identified problems. All grievance reporting forms would be maintained for 3 years from date of the resolution of the grievance. An interview with a family member on 2/21/23 at 10:45 AM revealed she was very upset when she complained to Nurse #1 that Nurse Aide #1 took advantage of Resident #4 by leaving her personal cell phone and charger plugged into Resident #4's plug outlet by her bed and stashed supplies and/ or personal items in the closet. The family member further revealed Resident #4 stated the Nurse Aide usually sits in the chair beside her bed to talk on the cell phone. She also expressed her frustration to the receptionist who coordinated an apology from the Nurse Aide. She was unaware that she could file a grievance. During an interview on 2/21/23 at 4:48 PM the Staff Development Coordinator indicated she was made aware that Resident #4's family member was upset and crying about an incident that took place on 2/15/23, whereas Nurse Aide #1's belongings were found in the Resident's room. The Staff Coordinator further indicated she did not speak to the family member because she had already left the building. She stated that she educated the Nurse Aide on the cell phone policy and having belongings in the room that did not belong to the resident. She further stated she should have followed up with the family member to file a written grievance. During a phone interview on 2/22/23 at 10:15 AM Nurse #1 indicated she was assigned to Resident #4 and heard loud yelling coming from a family member. She then went down the hall and approached the family member to calm her down to ask her what was wrong. She heard the family member yelling and insisting that she wanted to talk to the owner or manager and that this was unacceptable. She further indicated the family member was upset that she saw Nurse Aide #1 sitting in a chair and talking on her cell phone and found other items in the room that did not belong to the Resident. Nurse #1 stated she removed the chair located next to Resident #4's bed and items from the room that the family member identified as not belonging to the resident. She stated she addressed the issue with Nurse Aide #1 and later informed the Director of Nursing (DON) about the incident. She further stated she did not write a grievance because she felt she handled the situation. She was unaware the family member spoke with other staff members about the incident. During a phone interview on 2/22/23 at 10:34 AM the Social Worker stated she was responsible for coordinating the grievance process after a staff member completes and submits it to her. According to the facility's Grievance Policy, she would then add the grievance to a log and place a follow-up call to the family to let them know the issue would be addressed by the department head. She further stated she would place another follow-up call to ensure the family member received an outcome to the grievance. She also indicated she was made aware of the incident on 2/22/23. A phone interview on 2/22/23 at 10:37 AM with the DON revealed she was made aware of the incident details on 2/21/23. She stated she may have been dealing with other family issues during the week the incident took place and could not recall the details. She was unaware Resident #4's family member was upset. She further revealed a grievance should have been submitted but was not. She expected a formal grievance to be submitted and discussed in morning meeting, assigned to the appropriate department who would then follow up with the family within 5 days with a resolution or status update. If the family member was not satisfied with the outcome, the grievance is escalated to the Administrator. An interview with the Administrator on 2/21/23 at 4:33 PM revealed she was made aware there were items found in Resident #4's room that belonged to Nurse Aide #1 and that the family member was upset. She further revealed a grievance was not submitted because she believed it was handled that day, by the Staff Development Coordinator. She stated she was not aware the family member interacted with other staff who also did not escalate the incident to a written grievance. Her expectation was for grievances to be completed, reviewed in morning meeting, and assigned to a department head for investigation.

Based on record review and staff interviews, the facility failed to make a referral for re-evaluation after a change in mental health status for 1 of 2 residents (Resident #25) reviewed for Pre-Admission Screening and Resident Review. Findings included: A review of the North Carolina Department of Health and Human Services, Division of Medical Assistance, Preadmission Screening and Annual Resident Review (PASRR) application, dated 1/31/22, revealed Resident #25 had no mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #25 was moderately cognitive impaired and had not been considered by the State Level II PASRR process to have a serious mental illness. The MDS indicated Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's Care Plan, last revised 4/25/22, revealed Resident #25 had been care planned for use of [CONDITION(S)] medications and risk for adverse reactions/side effects related to psychiatric disorder and having a mental illness/intellectual disability. During an interview with the Administrator on 6/09/22 at 9:45 a.m., the Administrator stated she was aware of the PASRR not being updated and the staff would update it immediately. The Administrator explained there had been a vacancy in the social work position, but PASARR would be corrected immediately. She expected PASRRs to be completed timely as per federal regulations. During an interview with the MDS Nurse Consultant on 6/09/22 at 10:00 a.m., the MDS Nurse Consultant stated the PASRR would be resubmitted for Resident #25 immediately. She explained it was overlooked.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 2 of 35 resident assessments reviewed (Resident #25 and Resident # 87). Findings included: 1. Resident # 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #25 was moderately cognitive impaired. The MDS indicated Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #25's Care Plan, last revised 4/25/22, revealed Resident #25 had been care planned for use of [CONDITION(S)] medications and risk for adverse reactions/side effects related to psychiatric disorder and having a mental illness/intellectual disability. During an interview with the MDS Nurse Consultant on 6/09/22 at 10:00 a.m., the MDS Nurse Consultant stated the psychotic disorder was an error and was keyed in the system accidentally. Interview with the Administrator on 6/09/22 at 2:22 PM revealed she expected all MDS documentation be coded correctly. 2. Resident #87 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #87's discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #87 was discharged to an acute hospital. Review of the medical record dated 4/22/22 indicated Resident #87 was discharged to the community with home health services not to an acute hospital. During the interview on 6/09/22 at 11:50 AM, Minimum Data Set (MDS) nurse reviewed Resident #87 discharge MDS and confirmed it was inaccurately coded. The MDS nurse explained it was coded in error as Resident #87 was discharged to the community not to an acute hospital. During an interview on 6/09/22 at 2:19 PM with the Director of Nursing (DON) she acknowledged Resident #87 discharge MDS was inaccurately coded. She indicated that Resident #87 was discharged to the community to assisted living and the MDS dated [DATE] should have been coded to community not to acute hospital. Interview with the Administrator on 6/09/22 at 2:22 PM revealed she expected all MDS documentation be coded correctly.

Based on observations, staff interviews and record reviews, the facility failed to follow infection control policies when two housekeepers entered and exited resident rooms for cleaning (Housekeeper #1 and #2) without changing gloves or performing hand hygiene and when a nurse aide (Nurse Aide #1) performed incontinence care and exited the room without removing her gloves or performing hand hygiene. In addition, Housekeeper #2 was observed using the same cleaning cloth to clean multiple surfaces in a resident's bathroom and room. The observations occurred for 3 of 4 staff members reviewed for infection control practices. Findings included: A review of the facility's infection control policy dated 05/24/21 under the heading Standard Precautions indicated standard precautions are the minimum infection prevention practices that apply to all patients regardless of suspected or confirmed infection status of the resident which include hand hygiene, use of personal protective equipment, cleaning and disinfecting environmental surfaces. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub when hands are not visibly soiled. Always change gloves between residents and perform hand hygiene before and after donning gloves. A review of the facility document titled, Healthcare Services Group (HCSG) Infection Control Overview and Policy revised 09/05/17 indicated preventing the spread of infection is the core of our environmental services department to include implementation of hand hygiene practices to improve infection control processes and outcomes by ensuring that all HCSG employees wash their hands after contact with any potentially infected resident, linens, or personal belongings. HCSG employees can be exposed to or expose residents to diseases through improper hand hygiene and improper glove use (e.g., utilizing a single pair of gloves for multiple tasks, or multiple residents). The document further indicated gloves are to be worn and changed after each use will help reduce the spread of microorganisms. An in-service record titled Infection Control and Hand Hygiene dated 09/09/21 and ongoing revealed a signature for Housekeeper #1 and Housekeeper #2. 1.a. A continuous observation and interview on 10/7/21 beginning at 10:00 AM and ending at 10:10 AM revealed Housekeeper #1 outside room [ROOM NUMBER] obtaining supplies from her cart. Housekeeper #1 was observed to be wearing a face mask, face shield, and a pair of gloves. The housekeeper was then observed to enter room [ROOM NUMBER] with her supplies where she emptied the trash cans, brought the bag of trash to the housekeeping cart, obtained the broom and dustpan from the cart and re-entered the room. Housekeeper #1 was observed to sweep the floor before again returning to the cart in the hallway where she emptied the dustpan and placed it and the broom on the cart. Housekeeper #1 then entered room [ROOM NUMBER] where she began emptying the trash cans and replacing them with fresh liners. After discarding the trash, Housekeeper #1 grabbed a mop and went back into room [ROOM NUMBER]. When Housekeeper #1 was finished mopping, she returned the mop to the cart to replace the mop. She opened the lid on the housekeeping cart and placed a roll of unused bags in the compartment when she was stopped and asked about the observation. Housekeeper #1 was not observed to remove her gloves or perform hand hygiene between housekeeping tasks in resident rooms before proceeding to the next room or prior to being interviewed. Housekeeper #1 stated she should have not touched the cart with gloves, she should have changed gloves and performed hand hygiene before entering back into a room or before going to another room. An interview with the Housekeeping Manager on 10/07/21 at 12:30 PM revealed he had provided his housekeeping staff with monthly in-service training on infection control practices, PPE, and hand hygiene. The Housekeeping Manager stated he expected Housekeeper #1 to remove her gloves between tasks within the resident's room and when exiting a resident's room and perform hand hygiene and don clean gloves before entering the next resident room. An interview with the Infection Control Nurse (IC Nurse) on 10/08/21 at 1:30 PM revealed all staff had received ongoing training in hand hygiene, PPE and infection control. She indicated all staff were to perform hand hygiene after each contact with a resident or environmental surface in a resident care area. The IC nurse also stated all staff were to remove their gloves each time they exited a resident's room. The IC Nurse elaborated staff were aware of the facility's infection control policies and were expected to follow them to prevent further spread of infections in the facility. b. A continuous observation on 10/7/21 beginning at 10:15 AM and ending at 10:18 AM revealed Housekeeper #2 exit room [ROOM NUMBER] wearing a face mask, face shield, and a pair of gloves. She approached the housekeeping cart located in the hallway and retrieved a mop before entering back into room [ROOM NUMBER]. Housekeeper #2 then exited the room [ROOM NUMBER] carrying the mop, placed the mop on the cart, and entered room [ROOM NUMBER]. Housekeeper #2 was not observed to doff her gloves or perform hand hygiene between resident rooms. An observation on 10/07/21 at 10:24 AM and ending at 10:35 AM revealed Housekeeper #2 pushing her cart down the hallway wearing gloves on both hands when she parked the cart outside room [ROOM NUMBER] and entered the room carrying an unidentified bottle of a chemical spray and an orange cloth rag. Housekeeper #2 then entered the rooms restroom where she cleaned the commode, and a toilet was overheard being flushed. Housekeeper #2 exited the restroom carrying the soiled rag and walked over to the overbed table placed between the two resident beds located in the room. Housekeeper #2 then was observed to wipe the soiled orange rag across the overbed table and continue cleaning at the vanity/sink area before exiting the room and approach her housekeeping cart. An interview with Housekeeper #2 on 10/07/21 at 10:35 AM revealed she was the routine housekeeper on the 300-hall. She indicated she was instructed to wear gloves when cleaning in resident care areas; however, Housekeeper #2 elaborated to include she believed if the resident rooms were not under isolation precautions, she could clean more than one resident room without changing gloves or performing hand hygiene. Housekeeper #2 acknowledged she cleaned the base of the toilet bowl with the orange rag, followed by the overbed table and the mirror and light fixtures in the room. An interview with the Housekeeping Manager on 10/07/21 at 12:30 PM revealed he had provided his housekeeping staff with monthly in-service training on infection control practices, PPE, and hand hygiene. The Housekeeping Manager stated he expected Housekeeper #2 to remove her gloves between tasks within the resident's room and when exiting a resident's room and perform hand hygiene and don clean gloves before entering the next resident room. The Housekeeping manager indicated Housekeeper #2 should not have cleaned any surfaces in the bathroom with the same rag as used on other surfaces within a resident's room. He further elaborated to reveal Housekeeper #2 should have performed hand hygiene and changed gloves between cleaning in the bathroom and the resident's bedroom areas. An interview with the Infection Control Nurse (IC Nurse) on 10/08/21 at 1:30 PM revealed all staff had received ongoing training in hand hygiene, PPE and infection control. She indicated all staff were to perform hand hygiene after each contact with a resident or environmental surface in a resident care area. The IC nurse also stated all staff were to remove their gloves each time they exited a resident's room. The IC Nurse elaborated staff were aware of the facility's infection control policies and were expected to follow them to prevent further spread of infections in the facility. The IC Nurse stated Housekeeper #2 should never clean the bedside table with a rag used to clean other surfaces in the resident's room to include the toilet or sink areas. c. A continuous observation and interview began at 10:19 AM and ended at 10:35 AM revealed Nurse Aide (NA #1) entered room [ROOM NUMBER] bed A wearing a face mask, face shield, and a pair of gloves. NA #1 exited the room holding a bag of soiled linens and proceeded down the hallway to the soiled linen receptacle where she opened the lid with her gloved hand and tossed the dirty linens. NA #1 began walking towards room [ROOM NUMBER] when a female resident was standing in the doorway of room [ROOM NUMBER] hollering for assistance. NA #1 approached the female resident in the doorway touched her shoulder and followed her to her bed at 304 B bed where she touched items on the bed of the resident. NA #1 then exited room [ROOM NUMBER] and re-entered room [ROOM NUMBER] where she picked up a bag of trash and again exited room [ROOM NUMBER]. NA #1 then proceeded back down the hallway to the trash receptacle, lifted the lid with her gloved hand and discarded the trash. NA #1 then walked into room [ROOM NUMBER] where she discarded the soiled gloves and performed hand hygiene at the resident's sink. NA #1 was not observed to remove gloves between contact with residents or objects in multiple resident's room nor perform hand hygiene. NA #1 stated she had performed incontinence care for 303A and went to discard the linen in the receptacle. NA #1 indicated she was sidetracked when the female resident in room [ROOM NUMBER] B asked for assistance and entered the room without changing gloves or performing hand hygiene. NA #1 also elaborated to say she had been taught she should remove her gloves and perform hand hygiene between each task and before contact with another resident but got in a hurry and forgot. An interview with the Infection Control Nurse (IC Nurse) on 10/08/21 at 1:30 PM revealed all staff had received ongoing training in hand hygiene, PPE and infection control. She indicated all staff were to perform hand hygiene after each contact with a resident or environmental surface in a resident care area. The IC nurse also stated all staff were to remove their gloves each time they exited a resident's room. The IC Nurse elaborated staff were aware of the facility's infection control policies and were expected to follow them to prevent further spread of infections in the facility. The IC nurse explained NA #1 should not wear two gloves in the hallway, should not have touched the linen or trash receptacle with a gloved hand, nor wore the same gloves into another resident's room used for any reason to include incontinence care.

Based on observations, record reviews, and staff interviews, the facility failed to implement their infection control policies and procedures when 1 of 14 residents positive for COVID-19 did not have signage on the door for enhanced droplet contact precautions and when 1 of 3 staff members (Nurse Aide #3) was observed not sanitizing her hands after handling dirty linen and before donning a clean gown to go into another room to answer a call light for 1 of 2 residents (Resident #17) observed for infection control practices. This occurred during a global pandemic. The findings included: The Centers for Disease Control and Prevention (CDC) guideline entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated on 09/10/21 revealed the following: under the section Infection Prevention and Control Program - Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices: Ensure Healthcare Personnel (HCP) have access to all necessary supplies including alcohol-based hand sanitizer with 60-90% alcohol, personal protective equipment (PPE), and supplies for cleaning and disinfection o Put FDA-approved alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym). Hand Hygiene o Require HCP to perform hand hygiene in accordance with CDC recommendations: o Immediately before touching a patient o Before performing an aseptic task o Before moving from work on a soiled body site to a clean body site on the same patient o After touching a patient or the patient ' s immediate environment o After contact with blood, body fluids or contaminated surfaces. o Immediately after glove removal o Ensure that HCP perform hand hygiene with soap and water when hands are visibly soiled. o Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. A review of the facility's Infection Prevention and Control Program dated 05/2020 under section Transmission Based Precautions read in part: Transmission-Based Precautions shall be used when caring for resident who are documented or suspected to have communicable diseases or infections that can be transmitted to others. The facility will use current CDC guidelines for all precautions as they apply to long term care. The facility shall make every effort to use the least restrictive approach to managing individuals with potentially communicable infections. The categories include: o Contact o Droplet o Airborne o Enhanced Barrier Precautions (not mandated at this time) o Enhanced Droplet-Contact Precautions The Infection Preventionist/Director of Nursing, in collaboration with the Attending Physician, will determine the need for precautions and when precautions may be discontinued. Upon entry to the facility on [DATE], during the entrance conference the Director of Nursing (DON) identified the 400 hall as the COVID-19 positive hall with the 200 hall as the COVID-19 positive overflow hall. The 100 hall was off isolation effective 09/09/21 for COVID-19. 1. a. Upon entry to the 400 hall the double doors were closed, and clean PPE supplies readily available outside the doors. There was signage on the double doors which indicated the unit required the donning of Personal Protective Equipment (PPE) prior to entering the hallway. A continuous observation was made of the 400 hall on 09/09/21 from 10:48 AM to 11:20 AM. There were 2 private rooms and 14 semi-private rooms. There were 24 residents on the unit. Resident #13 resided in room # 411-2 and was identified as unvaccinated and positive for COVID 19 without a sign on his door indicating he was on enhanced droplet-contact precautions. Staff were observed going in and out of rooms providing care and treatment and utilizing appropriate full PPE. An interview with the Staff Development Coordinator/Infection Preventionist (SDC/IP) on 09/09/21 at 5:03 PM revealed Resident #13 ' s door did not have a sign on it indicating he was on enhanced droplet-contact precautions. The IP stated she had overlooked putting the sign on the door and said the resident should have had a sign with PPE on his door. b. A continuous observation was made on 09/10/21 from 9:05 AM to 9:48 AM on the 400 hall. At 9:17 AM Nurse Aide (NA) #3 donned full PPE and went into a room to provide care. NA #3 was observed coming out of the room at 9:25 AM with bagged linen in her right hand. She proceeded down the hall to the dirty linen bin and placed the bagged linen in the dirty linen bin. She proceeded back up the hall and obtained a clean gown from a supply cabinet, donned the gown, and went into another room to answer the call light. NA #3 did not sanitize her hands after handling the dirty linen and before donning the gown to go into another resident room. An interview on 09/10/21 with NA #3 revealed she had been educated at the facility regarding COVID-19, signs and symptoms, protocol for wearing PPE, testing and education was provided continually with updates. NA #3 recalled not sanitizing her hands after putting the linen in the bin and before donning a new gown to go into another room. NA #3 stated she knew better and should have sanitized her hands after handling dirty linen. She further stated she had been educated to sanitize her hands after handling dirty linen and/or trash and said she must have gotten in a hurry and forgot to do it. An interview on 09/10/21 with the Director of Nursing (DON) revealed she was not aware of NA #3 not sanitizing her hands after handling dirty linen and donning a new gown and going into another room to answer a call light. The DON stated all employees were provided education on a continual basis and every employee should be aware of the need to sanitize their hands after handling dirty linen.

Based on observations and facility staff interviews the facility failed to label and date food items and remove expired milk which were all available for resident use stored in 1 of 1 walk-in refrigerators and 1 of 1 dry storage areas in the facility's kitchen. Findings Included: A observation of the facility's walk-in refrigerator on [DATE] at 9:40 AM revealed a half bag of chopped lettuce with no date to indicate when it was opened, an undated half onion wrapped in clear plastic wrap, and a half empty gallon of whole milk with an expiration date of [DATE]. An observation of the facility's dry storage area on [DATE] at 9:46 AM revealed an opened and undated bag of spaghetti noodles and egg noodles. There was no date to indicate when either had been opened. The Dietary Manager (DM) was present during the observations of the walk-in refrigerator and dry storage area and immediately removed the opened, undated food items and milk and discarded them. She reported the facility was without some scheduled staff but there was no excuse why there were opened, undated and expired food found in the refrigerator or dry storage room. During a follow up interview with the DM on [DATE] at 10:06 AM, she reported she could not determine where the breakdown occurred but stated there was a new dietary aide working over the weekend. The DM stated she typically came in on Monday mornings and would immediately check the storage areas for any foods that may have expired and not been removed or foods that had not been dated. She reported her staff knew the correct process for storing food and that the opened food items should have been placed in zip closure bags and dated before being stored. The DM explained she had placed flyers throughout the kitchen to serve as a reminder. The interview further revealed she did not know about the expired gallon of milk in the refrigerator and was uncertain how it ended up in there as the facility did not receive whole gallons of milk. She indicated their milk supplier only delivered individual use cartons. During an interview with the Administrator on [DATE] at 11:38 AM she reported she often audited the kitchen and storage areas and had not had an issue with kitchen staff not storing and dating food items correctly. She reported all open food items should be dated but felt it was an isolated incident. She also stated that expired food and milk should be removed from the storage areas when they reach their use by or expiration date.

Based on record review and staff interviews the facility failed to accurately code a fall with a major injury on the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for accidents (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #61 was discharged on [DATE] to the hospital and readmitted to the facility on [DATE] after receiving surgical repair for a fractured left hip. The hospital discharge summary revealed Resident #61 was admitted on [DATE] and discharged back to the facility on [DATE] after receiving surgical repair for a left [MEDICAL CONDITION]. The summary included admitting and discharge [DIAGNOSES REDACTED]. The annual MDS dated [DATE] assessed Resident #61's fall history under section J1800 and revealed no falls occurred after being readmitted to the facility on [DATE]. During an interview on 02/20/19 at 8:47 AM, the MDS Coordinator stated she completed Resident #61's annual MDS dated [DATE]. After she reviewed the hospital discharge summary's admitting [DIAGNOSES REDACTED]. A second interview on 02/20/19 at 10:29 AM, the MDS Coordinator revealed she modified section J1800 of the annual MDS assessment to show yes, a fall occurred upon reentry to the facility. When corrected she revealed section J1900 was available which she coded 1 fall occurred since readmission which identified a major injury due to a bone fracture. During an interview on 02/21/19 at 1:02 PM, the Director of Nursing (DON) explained the regional nurse reviewed and corrected the MDS assessments. All admissions were reviewed during the morning staff meetings and she didn't know why the fall was incorrectly coded by the MDS Coordinator. The DON revealed it was her expectation the MDS assessments would be coded correctly to reflect the resident.

Based on observation, record review, and staff and physician interviews the facility failed to implement an identified care plan intervention for 1 of 1 resident reviewed for urinary catheter (Resident #80). The findings included: Resident #80 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#80 was to have a #20 French 30 cubic centimeter (cc) indwelling catheter, secured with a strap, placed in a privacy bag, and monitored every shift. The 5 day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 was cognitively intact, was total dependent for transfers, toileting, and personal hygiene, and required an indwelling catheter. A review of Resident #80's current care plan addressed a problem of urinary incontinence with a revision date of 12/28/18 which indicated Resident #80 had an indwelling urinary catheter related to [MEDICAL CONDITION] bladder, impaired activities of daily living (ADL) function, and mobility. The goal specified Resident #80 would have catheter managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. The approaches included staff were to provide catheter care per physician orders [REDACTED]. An observation was conducted on 02/20/19 at 12:12 PM of Nurse Aide #1 providing urinary catheter care for Resident #80. Resident #80 was observed without a catheter strap in place to secure the catheter tubing to prevent tension on the urethral meatus and prevent kinking and dislodging of the catheter. Resident #80 did not have any observed signs of bleeding or trauma from the absence of a catheter strap. Nurse Aide #1 immediately obtained a catheter strap and secured the catheter tubing. On 02/20/19 at 1:07 PM a telephone interview was conducted with the physician who stated his expectation was that staff would have placed a catheter strap on Resident #80 to secure the indwelling catheter tubing to prevent tension and pulling on the catheter that could cause trauma to the urethral meatus. On 02/20/19 at 1:25 PM an interview was conducted with the Director of Nursing (DON) who stated her expectation was that Resident #80 would have had a catheter strap in place to secure the indwelling catheter tubing to prevent pulling and tension on the urethral meatus. On 02/20/19 at 1:35 PM an interview was conducted with the Administrator who stated her expectation was that Resident #80 would have had a catheter strap in place per clinical policy.

Based on observation, record review, staff, and physician interviews the facility failed to secure indwelling urinary catheter tubing for 1 of 2 resident reviewed for urinary catheter (Resident #80). The findings included: Resident #80 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#80 was to have a #20 French 30 cubic centimeter (cc) indwelling catheter, secured with a strap, placed in a privacy bag, and monitored every shift. The 5 day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #80 was cognitively intact, was total dependent for transfers, toileting, and personal hygiene, and required an indwelling catheter. A review of Resident #80's current care plan addressed a problem of urinary incontinence with a revision date of 12/28/18 which indicated Resident #80 had an indwelling urinary catheter related to [MEDICAL CONDITION] bladder, impaired activities of daily living (ADL) function, and mobility. The goal specified Resident #80 would have catheter managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. The approaches included staff were to provide catheter care per physician orders [REDACTED]. An observation was conducted on 02/20/19 at 12:12 PM of Nurse Aide #1 providing urinary catheter care for Resident #80. Resident #80 was observed without a catheter strap in place to secure the catheter tubing to prevent tension on the urethral meatus and prevent kinking and dislodging of the catheter. Resident #80 did not have any observed signs of bleeding or trauma from the absence of a catheter strap. Nurse Aide #1 immediately obtained a catheter strap and secured the catheter tubing. An interview was conducted on 02/20/19 at 12:15 PM with Nurse Aide #1 who stated Resident #80 should have had a catheter strap in place to secure the indwelling urinary catheter. Nurse Aide #1 stated she did not know how long Resident #80 had been without a catheter strap. An interview was conducted 02/20/19 at 12:18 PM with Nurse #1 who stated Resident #80 should have had a catheter strap in place to secure the urinary catheter tubing to prevent tugging and tension on the catheter to prevent trauma to the urethral meatus. Nurse #1 verified that Nurse Aide #1 had applied a catheter strap to secure the indwelling catheter tubing for Resident #80 after the catheter strap was noted as absent. On 02/20/19 at 1:07 PM a telephone interview was conducted with the physician who stated his expectation was that staff would have placed a catheter strap on Resident #80 to secure the indwelling catheter tubing to prevent tension and pulling on the catheter that could cause trauma to the urethral meatus. On 02/20/19 at 1:25 PM an interview was conducted with the Director of Nursing (DON) who stated her expectation was that Resident #80 would have had a catheter strap in place to secure the indwelling catheter tubing to prevent pulling and tension on the urethral meatus. The DON stated her expectation was that Nurse Aide #1 would have immediately placed a catheter strap to secure the indwelling catheter tubing in place. The DON stated her expectation and process was that Nurse Aide #1 would have informed Nurse #1 that Resident #80 did not have a catheter strap in place to secure the indwelling catheter tubing. On 02/20/19 at 1:35 PM an interview was conducted with the Administrator who stated her expectation was that Resident #80 would have had a catheter strap in place per clinical policy. The Administrator stated her expectation was that Nurse Aide #1 would have immediately placed a catheter strap on Resident #80 to secure the indwelling catheter tubing.

Based on observations, and staff interviews, the facility failed to properly secure a medication on 1 of 2 medication carts reviewed for safe medication storage. Findings included: During an observation of 200 Hall on 02/20/19 at 8:42 AM, Nurse #2 removed a clear plastic bag from the medication cart and placed the plastic bag on top of the medication cart. Further observation indicated the outside of the clear plastic bag displayed a resident's name, medication name, dosage of medication, and date of 02/2020. The inside content of the clear plastic bag contained 9 individually sealed blister packages of [MEDICATION NAME] 18 micrograms (mcg) (medication used to increase airway to the lungs). At 8:43 AM, Nurse #2 left the medication cart with the bag of [MEDICATION NAME] medications still on top of the cart and Nurse #2 went to a resident's room to administer medications. Continuous observations from 8:43 AM to 8:53 AM, revealed Nurse #2 left a resident's room to go to the medication room and upon return to the medication cart, the [MEDICATION NAME] was still sitting on top of the medication cart without Nurse #2 acknowledging the [MEDICATION NAME]. During the continuous observations from 8:43 AM to 8:53 AM, no residents or visitors were observed around or passing by the unattended medication cart with the [MEDICATION NAME] medication on top of the cart. During an interview on 02/20/19 at 8:53 AM, Nurse #2, stated that she made a mistake because the [MEDICATION NAME] should not have been left on top of the unattended medication cart. During an interview on 02/20/19 at 9:16 AM, the Director of Nursing (DON) stated her expectation was that the [MEDICATION NAME] should not have been left on top of the medication cart. She further stated that the medication should have been under the supervision of the nurse and kept locked in the medication cart when not in use. During an interview on 02/20/19 at 9:18 AM, the Administrator stated her expectation was the nurse should have followed the clinical policy regarding safe medication storage.

Based on observations, record review and staff interviews, the facility failed to develop a plan of care with measurable objectives and timetables to address a significant [DIAGNOSES REDACTED]. (Resident #8). Findings included: Resident #8 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. A record review of Resident #8's care plan revealed there was no plan of care in place for the [DIAGNOSES REDACTED]. An interview was conducted with the MDS/Care Plan Nurse on 12/07/17 at 4:30 pm. The MDS nurse stated the facility developed a care plan for every significant diagnosis. The MDS nurse confirmed there was no care plan in place for [MEDICAL CONDITION] for this resident and there should be one. The nurse explained when a resident was admitted , their care plans were initiated based on their diagnoses. The nurse further added the interventions should be listed with a time frame of anticipated resolution and measurable goals. The nurse explained if there were any changes in a resident such as an infection, fall, pressure ulcer or a new diagnosis, the care plan should be updated. The MDS nurse stated it was an over sight that a care plan was not implemented for the [DIAGNOSES REDACTED].#8. An interview with the Director of Nursing (DON) on 12/8/17 at 2:05 pm revealed her expectation was that the care plans should reflect the care that was being provided for the resident.

Based on observation and staff interviews, the facility failed to air dry dishware prior to stacking them on top of one another in storage, during 2 of 2 observations of dishware in the kitchen. Findings included: During review of the kitchen on 10/10/16 at 10:57 AM, staff were observed removing items from the dishwasher. There were 30 of 30 plates stacked on top of one another in the plate warmer while still wet. There were 47 of 47 bowls and 5 of 5 plates with guards that were stacked on top of one another while wet, and they were sitting at the tray service line. Dietary Staff #1, who indicated she had removed the plates and bowls from the dishwasher, was interviewed on 10/10/16 at 11:10 AM. Dietary Staff #1 said, We are told to let them dry but I have to keep up with the dishwasher. I should probably stack them upside down so they dry. On 10/11/16 at 7:59 PM the kitchen was reviewed again and 9 of 15 bowls were found stacked on top of one another with moisture inside them. During an interview on 10/13/16 at 9:00 AM, the District Dietary Manager indicated it was his expectation that dishware be allowed to dry because when stacked wet there is increased risk of bacteria growth.

Based on record review and staff interview the facility failed to code the Minimum Data Set accurately for 3 of 21 sampled residents regarding Preadmission Screening and Resident Review level (Resident #55), and behaviors (Residents #65 and #166). The findings included: 1. Resident #55 had [DIAGNOSES REDACTED]. Review of a letter dated 7/02/15, from the Division of Medical Assistance revealed Resident #55 had PASRR Level I determination. Resident #55's annual Minimum Data Set ((MDS) dated [DATE], indicated he had been evaluated by the State level Preadmission Screening and Resident Review (PASRR) authority, and determined to have a serious mental illness and/or intellectual disability. The MDS specified Resident #55 had a PASRR Level II determination. An interview with Social Worker (SW)#1 was conducted on 10/13/16 at 4:32 PM. SW #1 indicated the SW who had completed the PASRR portion of Resident #55's MDS, was no longer working at the facility. She could not explain why the other SW had coded the resident as Level II PASRR, but it was not correct. SW#1 stated she had checked the database and Resident #55 had a Level I determination. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that the MDS accurately reflect the resident's status. 2. Resident #166 was admitted to the facility on [DATE] and discharged on [DATE]. The admitted d 7/7/2016, indicated the resident was cognitively intact and did not resist care. Record review of a nursing notes dated 7/2/2016, revealed Resident #166 had refused to take a Fish Oil dietary supplement because it was too big and was difficult to swallow. Review of the July 2016 Medication Administration Record [REDACTED]. The Discharge MDS dated [DATE], specified Resident #166 rejected care 4-6 days during the assessment period. An interview with Social Worker (SW) #1 was conducted on 10/13/16 at 6:01 PM. SW #1 stated she had coded the portion of the MDS which indicated the resident was rejecting care She stated the rejection of care coding was based on the refusal of medication and that Resident #166 had no other behaviors. SW #1 indicated it was an error in coding because the resident was cognitively intact and could make her own choices. SW #1 said, I understand that it was her choice. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that the MDS accurately reflect the resident's status. 3. Resident #65 had the [DIAGNOSES REDACTED]. Resident #65's annual Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively impaired. The MDS specified the resident did not have any behavior or verbal symptoms directed towards others. Review of a progress note from 4/2/16 revealed the resident as very agitated and was cursing at a male resident and calling him offensive names. The progress note also revealed the resident acted out aggressively with a female resident. Review of a progress note dated 4/5/16 revealed a behavior team meeting was conducted related to the episodes of agitation, cursing, and aggressive behaviors towards other residents. An interview with Social Worker (SW) #1 was conducted on 10/13/16 at 6:00 PM. SW #1 indicated the SW who had completed the Behavior portion of Resident #65's MDS, was no longer working at the facility. She could not explain why the other SW had not captured the resident's behavior on the MDS. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that the MDS accurately reflect the resident's status.

Based on observation, record review and staff interviews, the facility failed to provide Care Area Assessment summaries which included underlying causes, risk factors, and factors to be considered in developing individualized care plan interventions for 4 of 21 sampled residents ( Residents #55, #85, #102 and #166) with comprehensive assessments. The findings included: 1. Resident #55 had [DIAGNOSES REDACTED]. Resident #55's Annual Minimum Data Set ((MDS) dated [DATE] indicated his long-term memory was intact but he was moderately cognitively impaired for daily decision making. The MDS specified the resident required extensive staff assistance for bed mobility, transfers, dressing, and toilet use. It indicated the resident was short-tempered and easily annoyed several days during the assessment period. The MDS indicated the resident displayed verbal behaviors like yelling and cursing as well as self-directed behaviors, rejection of care. It also specified the resident had received antipsychotic, antianxiety and antidepressant medications during the week of the assessment. Record review also revealed the resident was being see by a psychiatrist. The 05/05/2016 Behavior Care Area Assessment (CAA) was reviewed. The CAA included an Analysis of Findings which indicated there would be a description of the problem, causes and contributing factors, and risk factors related to the care area. The CAA summary stated, Resident has displayed behavioral symptoms as evidenced of refusal of meds, yelling/cursing at staff. Contributing factors include possible side effects of medications, mental health disorders, and hearing impairment. Staff will need to redirect and encourage compliance as needed. The CAA did not contain a clear description of the behaviors, underlying causes, contributing factors, or approaches specific to this resident to consider in developing an individualized care plan. An interview was conducted on 10/13/16 at 6:01 PM, with Social Worker (SW) #1 who indicated she was responsible for writing the Behavior CAA summary for Resident #55. The SW stated, I thought we were just supposed to summarize what was in the CAA checklist. SW#1 indicated she was aware it did not give a description of Resident #55's concerns, underlying causes or risks related to his behaviors. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that CAA summaries would include supporting documentation to reflect the resident's status. 2. Resident #166 was admitted to the facility on [DATE] and discharged on [DATE]. The Admission Minimum Data Set ((MDS) dated [DATE], indicated the resident was cognitively intact and did not resist care. The MDS specified the resident was visually impaired but did not wear her glasses for the vision assessment. The 07/07/2016 Vision Care Area Assessment (CAA) was reviewed. The CAA included an Analysis of Findings which indicated there would be a description of the problem, causes and contributing factors, and risk factors related to the care area. The CAA summary stated, Resident has impaired vision. Contributing factors [MEDICAL CONDITION] and anxiety. Activity department have(sic) large print materials available for use. Staff to assist resident as needed. The CAA did not contain a clear description of the underlying causes, contributing factors, if the resident had glasses or not, or approaches specific to this resident to consider in developing an individualized care plan. An interview with Social Worker (SW) #1 was conducted on 10/13/16 at 6:01 PM. SW #1 stated she had conducted the vision test and coded the portion of the MDS which indicated the resident was not using glasses for the assessment. SW#1 stated Resident#166 told her she had glasses in her room at the facility and that her vision had been affected by the [MEDICAL CONDITION]. The Social Worker was asked why the resident had not used her glasses for the vision test. SW#1 said, I didn't ask her to use them. and wasn't sure how or when the resident used the glasses. After reading the CAA summary she had written, SW#1 stated, I should have put the information in the summary. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that the MDS accurately reflect the resident's status. 3. Resident #102 had [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) dated ,[DATE]//2016 revealed Resident #102 was severely cognitively impaired Review of Resident #102's clinical record revealed he received continuous oxygen at 2 liters and staff checked his oxygen saturation level every shift. The 06/14/2016 Cognition Care Area Assessment (CAA) was reviewed. The CAA included an Analysis of Findings which indicated there would be a description of the problem, causes and contributing factors, and risk factors related to the care area. The CAA summary stated, Resident is out of his bed daily to his wheelchair interacting with others. Resident can verbally communicate some of his simple needs. Since admission resident is dependent on staff to cue him to get to his destinations and daily ADL (activities of daily living) care. Resident has a dx (diagnosis) of Alzheimer's diesease. The CAA did not contain a clear description of the underlying causes, contributing factors, or approaches specific to this resident to consider in developing an individualized care plan regarding his cognition. An interview was conducted on 10/13/16 at 6:28 PM, with Social Worker (SW) #1. She stated the Social Worker who completed Resident #102's CAA summary no longer worked in the facility. SW#1 did not know why the CAA summary did not consider the resident's use of oxygen, medications or other factors impacting cognition. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that CAA summaries would include supporting documentation to reflect the resident's status. 4. Resident #85 was admitted to the facility 7/28/2011with [DIAGNOSES REDACTED]. Resident #85's annual Minimum Data Set ((MDS) dated [DATE] indicated he was moderately cognitively impaired. The MDS specified the resident required extensive assistance with activities of daily living including bed mobility, transfers, dressing, and toileting. The MDS indicated the resident displayed behaviors such as yelling and cursing as well as hitting and spitting at staff. It also indicated that the resident had received antipsychotic, antianxiety, and antidepressant medications during the assessment review date. Medical record review also revealed the resident was being seen by a psychiatrist. Resident #85 was observed on 10/12/2016 at 6:30 AM, lying in bed yelling, I am ready to get up and cursing at times. The 6/9/2016 Behavior Care Area Assessment (CAA) was reviewed. The CAA included an Analysis of Findings which indicated there would be a description of the problem, causes and contributing factors, and risk factors related to the care area. The CAA summary stated, Resident has displayed behavioral symptoms as evidenced by yelling/cursing, contributing factors include hearing/vision impairments, mental health problems and use of antihypertensive medication, staff to redirect and encourage resident to display appropriate behavior. The CAA did not contain a clear description of the behaviors, underlying causes, contributing factors, or approaches specific to this resident to consider in developing an individualized care plan. An interview was conducted on 10/13/16 at 6:20 PM, with Social Worker (SW) #1 who indicated she was responsible for writing the Behavior CAA summary for Resident #85. The SW stated, I thought we were just supposed to summarize what was in the CAA checklist. SW#1 indicated she was aware it did not give a description of Resident #85's concerns, underlying causes, or risks related to his behaviors. During an interview on 10/13/2016 at 7:04 PM, the Director of Nursing stated it was her expectation that CAA summaries would include supporting documentation to reflect the resident's status.