Every finding on record at Piedmont Gardens Health Facility

Based on observation, interview and record review, the facility failed to ensure food are prepared under sanitary conditions when:-Ice machine had brownish material build up on the water bin and tubing on the inside area of the machine where water was present.- Kitchen [NAME] (CK) did not cover beard with hair restraint.- Kitchen floor and tiles with cracked areas and brownish buildups.- Kitchen vents with dusty blackish materials- Food shelves and trays with debris.- Two hot boxes (Food warmer) with food debris.- Broom with dustpan were stored in the dry food storage room.- Kitchen wall had cracked and chipped paint and blackish discoloration.- Equipment's air-gaps drainage pipe-basin areas had yellowish brown buildup.- Chemical and cleaning agents were stored in open area next to clean pots and pans.- Floor sink area next to clean pots and pans had yellowish black buildup. These failures had the potential for contamination of food resulting in food borne illness for the residents who consumed meals prepared at the facility. Findings: During a kitchen tour on 6/2/26 at 8:15 a.m. with Food Service Director/Registered Dietician (FSD/RD) the followings were observed:Ice machine had brownish material build up on the water bin and tubing on the inside area of the machine where water was present. [NAME] (CK) did not cover beard with hair restraint. Floor and tiles with cracked areas and brownish buildups. Vents had dusty blackish materials. Food shelves and trays with debris. Two hot boxes (Food warmer) with food debris. Broom with dustpan were stored in the dry food storage room. Kitchen Wall had cracked and chipped paint and blackish discoloration. Equipment's air-gaps drainage pipe-basin areas had yellowish brown buildup. Chemical and cleaning agents were stored in open area next to clean pots and pans. Floor sink area next to clean pots and pans had yellowish black buildup.During an interview on 6/2/26 at 8:15 a.m. FSD/RD stated ice machine sanitization was contracted to outside contractor for cleaning and sanitized twice a year. FSD/RD stated kitchen staff wiped down the outside of ice machine daily. RD stated facility had plan to replace the kitchen flooring this year. RD stated kitchen staff clean the kitchen daily. RD stated that chemicals and cleaning agents should be stored in a locked area. RD said hot boxes are stationed in the kitchen and used to keep food hot. RD stated kitchen staff clean the ice machine monthly. During a concurrent observation and interview on 6/2/26 at 8:42 a.m. with [NAME] (CK), CK used a face mask, and had beard on side of his face that was not all covered. CK's face mask did not cover all his facial hair. CK stated he will go ahead and cover all his beard. During an interview on 6/2/26 at 10:44 a.m. with Executive Chef (EC), EC stated kitchen floor was cleaned daily. EC stated staff assigned to dishwashing cleaned the ice machine monthly. EC stated it's okay to keep cleaning materials in an area that is not secured next to kitchen area clean pots and pans. During an interview on 6/2/26 at 10:47 a.m. with Dietary Staff (DS 1), DS 1 stated he was assigned to clean the ice machine monthly. DS 1 stated he wash the ice bucket and ice scope and did not touch the upper area of the ice machine. During a concurrent observation and interview on 6/2/26 at 11:27 a.m. with FSD/RD and Service Provider (SP), the kitchen ice machine was opened inside of ice machine bin and tubing had brownish material build up to the water bin and water tubing that goes into the ice making area. SP stated he will order and replace water tubing. RD stated it's important to have clean ice machine because the ice is used in preparing residents food. During a review of facility document, titled, Work Order Report dated 1/8/26, the work order report indicated kitchen ice machine was clean and sanitized on 1/8/26. During an interview on 6/3/26 at 1:37 p.m. with Administrator (Admin), the inside of kitchen ice machine's brownish material buildup on water bin and tubing concerns was reviewed. Admin stated facility used outside contractor to sanitize the ice machine. Admin said facility will stop using the kitchen ice machine until its sanitized and cleaned. During a review of the facility's policy and procedure (P&P) titled, Cleaning Procedures Ice Machine, dated 2017, the P&P indicated, Exposed areas of ice bin/ice chute interior and exterior bi-annually: ice machine cleaning/service. Complete ice bin cleaning and sanitizing. During a review of the facility's policy and procedure (P&P) titled, Cleaning of Food and Nonfood Contact Surfaces, undated, the P&P indicated, Food Contact Surfaces are cleaned and sanitized between uses or at least every four hours during continuous use.

Based on observation, interview, and record review, the facility failed to ensure two of 21 sampled residents (Residents 18 and 90) were served food in a dignified manner and one of 21 sampled residents (Resident 90) was groomed in a dignified manner when: 1. Resident 90 waited 16 minutes, and Resident 18 waited 27 minutes after other residents at their table were served food, to get their food. 2. Resident 90 was not offered facial hair grooming. This failure resulted in Resident 90 feeling upset and had the potential to cause Residents 18 and 90 to feel insignificant, embarrassed and undignified. During a review of Resident 90's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of moderate impairment.), dated 5/29/26, the record indicated Resident 90's BIMS score was 15, indicating intact mental status. 1. During a review of Resident 90's Care Plan, revised 5/26/26, the Care Plan indicated, The resident has an ADL self-care performance deficit. During a review of Resident 90's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 5/29/26, the MDS indicated, Eating. Setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.). During a review of Resident 18's Care Plan, revised 6/3/26, the Care Plan indicated, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia. The resident is able to. feed self with queuing. During a concurrent observation and interview on 6/1/26, at 12:00 p.m. in the dining room, residents 90 and 61 sat at a dining table together for lunch. At 12:20 p.m. Resident 61 received lunch and started to eat. At 12:36 p.m. Resident 90 stated they wanted to know when they would get their food. At 12:38 p.m. Resident 90 received their food and started to eat. During an observation on 6/1/26, at 12:00 p.m., in the dining room, Residents 15, 50, 72 and 18 sat at a dining table together for lunch. At 12:25 p.m. Resident 15 received their lunch and started to eat. At 12:27 p.m. Resident 50 received their lunch and started to eat with staff assistance. At 12:26 p.m. Resident 72 received their lunch and started to eat. At 12:52 p.m. Resident 18 received their lunch and Certified Nursing Assistant (CNA) 1 assisted Resident 18 with eating. During an interview on 6/1/26, at 3:59 p.m., Resident 90 stated food took a long time for staff to serve, and it made them feel upset. During an interview on 6/4/26, at 11:33 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was important for residents sitting at the same table to eat at the same time for respect and dignity. During an interview on 6/4/26, at 12:02 p.m., with the Director of Staff Development (DSD), DSD stated residents sitting at the same table should be served food and eat at the same time for dignity. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times . When assisting with care, residents are supported in exercising their rights. For example, residents are. provided with a dignified dining experience. 2. During a concurrent observation and interview on 6/1/26, at 3:59 p.m., Resident 90 was observed with facial hair. Resident 90 stated when they were at home, they removed their facial hair, and staff has not offered to remove it. Resident 90 stated facial hair bothered them. During an interview on 6/4/26, at 11:51 a.m., with Registered Nurse (RN) 1, RN 1 stated razors were stored in the utility room and not in resident rooms. RN 1 stated CNAs were supposed to offer facial hair removal to female residents, so they felt clean and it was important for their dignity. During an interview on 6/4/26, at 12:02 p.m., with the Director of Staff Development (DSD), DSD stated staff should have offered female residents to remove facial hair and it was important for grooming and their dignity. During a review of Resident 90's Care Plan, revised 5/26/26, the Care Plan indicated, The resident has an ADL self-care performance deficit. During a review of Resident 90's MDS, dated 5/29/26, the MDS indicated, Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving. Setup or clean-up assistance. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times . When assisting with care, residents are supported in exercising their rights. For example, residents are. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).

Based on observation, interview, and record review, the facility failed to ensure the safe and secure storage of medications when:A damaged/crushed plastic, orange colored medication bottle containing crushed pills, for Resident 32, was kept in the medication cart. An expired bottle with Calcium 600 milligrams (mg) tablets was kept in the medication cart.The central supply/over the counter (OTC) medication storage room doors (entry door and inside door) were left unlocked and unattended.These failures resulted in unsafe medication storage practices, had the the potential for medication errors and unauthorized access to OTC medications and supplies.Findings:1. During a concurrent observation and interview on [DATE] at 2:05 p.m. with Registered Nurse (RN) 2, the 2nd floor medication (med) cart 2 was checked. There was a damaged/crushed plastic bottle with crushed/damaged medication (in a pills form) for Resident 32 kept in the medication cart. The crushed plastic bottle with Resident 32's name and dosage information contained Finasteride (used to treat enlarged prostrate) 5mg tablets. RN 2 stated it was collected from Resident 32 upon admission and they did not use it. RN 2 stated it should not be stored in the med cart.During an interview on [DATE] at 11:50 a.m. with Director of Nursing (DON), DON stated the damaged bottle with medications was not supposed to be there in the med cart and should be discarded as per their policy.2. During a concurrent observation and interview on [DATE] at 2:56 p.m. with Licensed Vocational Nurse (LVN) 1, the 3rd floor medication (med) cart 2 was checked, there was an over the counter (OTC) Geri Care calcium 600 mg med with pills inside, with an opened date of [DATE] and expiration date of 2026/05 on the bottle. LVN 1 stated it expired last month. She stated they don't normally use it but it should not be there. LVN 1 stated that someone might get sick with expired meds, and she couldn't think of anything else when asked about the other risks.During an interview on [DATE] at 3:41 p.m. with DON, DON stated they were supposed to remove the expired med from the med cart because the efficacy is not the same or good after it expires.During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 2007, the P&P indicated, .Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, . are immediately removed from stock, disposed of according to procedures for medication disposal.3. During a concurrent observation and interview on [DATE] at 3:24 p.m. in the storage room (central supply room), the lockable coded entry door was left wide open and the lockable caged room door inside was left unlocked. There were multiple OTC medications on the shelves in the caged room that lead to an inner caged room with medical supplies. LVN 1 stated the door had a lock and was supposed to be locked because they have meds stored there. She stated they have things like nutrition supplements, briefs, general supplies stored in main room and also needed to be locked.During an interview [DATE] at 8:30 a.m. with DON, DON stated the door like a cage door should at least be locked because it has medications. DON stated residents can go there and get some meds and take it, so it becomes a safety issue. During a concurrent observation and interview on [DATE] at 9:25 a.m. with the Central Supply Director/Health Center Coordinator (HCC), HCC stated the supply room door always have to be locked. She stated the gated door also had to be locked all the time. She stated it could remain unlocked if someone was there. HCC stated they forgot to lock it yesterday and it was important to lock them because residents can come in and grab medications that they are not supposed to take.During a review of the facility's P&P, titled, Medication Storage dated 2007, the P&P indicated, .Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized .

Based on observation, interview, and record review, the facility failed to follow infection prevention and control practices when Certified Nursing Assistant (CNA) 3 and CNA 4 did not wear a Personal Protective Equipment (PPE, specialized gear-such as gloves, masks, gowns, face shields, and respirators-used to protect healthcare workers and patients from infectious agents) gown, while providing activities of daily living (ADL) to one of 21 sampled residents (Resident 48). This failure has the potential for cross contamination and compromise the health and safety of the residents. Findings:During a record review of Resident 48's admission Record (AR), printed on [DATE], the AR showed that Resident 48 was admitted on [DATE]. The AR indicated Resident 48 had a history of a chronic ulcer of the right foot with necrosis (necrosis means that part of the body's tissue has died. It happens when the tissue doesn't get enough blood, oxygen, or has been damaged by infection or injury. Once tissue becomes necrotic, it cannot heal on its own and usually needs medical treatment to remove or manage it) of bone.A review of Resident 48's physician order, placed on [DATE] and reviewed on [DATE] at 12:33 PM, the order indicated the staff was to follow Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs)) for right foot wound (ordered [DATE]) and Enhanced Barrier Precautions for right foot neuropathic ulcer (ordered [DATE]).During observation on [DATE] at 10:05 AM, an Enhanced Barrier Precautions (EBP), sign was posted at the head of the bed for Resident 48. EBP precautions involves the use of gowns and gloves during high-contact resident care activities to prevent the spread of infections in healthcare settings, particularly in nursing homes. CNA 3 and CNA 4 were observed performing activities of daily living (ADL) care and transferring Resident 48 from bed to wheelchair without wearing the required PPE, an isolation gown.During an interview on [DATE] at 11:22 AM, CNA 3 stated that the facility's expectation is for staff to wear PPE when providing care to residents on Enhanced Barrier Precautions (EBP). CNA 3 stated that proper PPE for an EBP resident includes disposable gloves and a gown.During an interview on [DATE] at 2:06 PM with Registered Nurse (RN) 3, RN 3 stated the expectation for staff providing care to EBP residents are to wear disposable gowns and gloves. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised February 10, 2026, the P&P indicated, Contact precautions apply, when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contaminated.PPE USE: examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: Dressing, bathing or showering, providing hygiene or grooming, transferring, changing of briefs or assist with toileting, provide bed mobility, device care or use and prolonged high contact items in the residents room, with residents equipment or with residents clothing or skin.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 77) was prescribed Azithromycin (an antibiotic used to treat various bacterial infections) for cough and shortness of breath with an appropriate indication for use.This failure had the potential for Resident 77 to receive unnecessary medications and to suffer adverse side effects. Findings:During a review of Resident 77's admission Record (AR), printed on 6/3/26, AR indicated Resident 77 was admitted to the facility on [DATE], with diagnoses that included heart failure and acute respiratory failure with hypercapnia (a condition when the body cannot expel carbon monoxide through normal breathing).During a review of Resident 77's record titled, Antibiotic Time Out, dated 5/13/26, indicated, Resident 77 was started on antibiotic Azithromycin for shortness of breath (SOB) and wheezing. Record indicated Resident 77 had no fever, no symptoms, no further sign of infection noted, antibiotic order reviewed with physician with order to continue administering antibioticsDuring a review of Resident 77's Order Summary (OS) dated 5/13/26, the OS indicated physician prescribed Azithromycin 250 mg one tablet by mouth every day in the morning for pneumonia.During a review of Resident 77's Medication Administration Record (MAR), dated 5/1/26 to 5/31/26, indicated Resident 77 was administered Azithromycin 250 mg one tablet in the morning for 7 days.During a concurrent interview and record review on 6/4/26 at 2:30 p.m. with Registered Nurse/Infection Preventionist (RN/IP) and Licensed Vocational Nurse (LVN/IP), Antibiotic Use Report (AUR) was reviewed. AUR indicated Resident 77 had Healthcare-Associated Infection (HAI). AUR indicated Resident 77 was started on Azithromycin for 7 days for SOB and wheezing. RN/IP stated Resident 77 had no SOB, no wheezing, no symptoms of pneumonia. RN/IP stated Resident 77 symptoms did not meet infection control criteria for infection. RN/IP stated Resident 77's physician was informed that Resident 77 had no SOB, no wheezing or symptoms of pneumonia. RN/IP stated physician ordered to continue to administer Azithromycin because Resident 77 chest Xray showed opacity.Healthcare-Associated Infection (HA1) refers to an infection a resident develops while receiving medical treatment or care in a long-term care facility.During a review of Resident 77's Medical Doctor Progress Notes (PN) dated 5/13/26, PN indicated Resident 77 had cough, no SOB or fever. Chest Xray showed right lung opacities and on Azithromycin.During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 8/6/2025, the P&P indicated Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotics use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotics for the right indication, dose and duration.

Based on observation, interview and record review, the facility staff did not have comprehensive care plan for bed alarms and chair alarm as fall prevention for 3 out of 8 sampled residents(Resident 36, 55 and 44.) The failure to not care plan interventions for bed alarm use under fall risk for Resident 36, 55 and 44 has the potential to not provide direct or limited staff supervision for resisdents and also to not accurately monitor, provide care, and reassess the effectiveness of the bed alarms. Findings: During an observation on 1/27/25 at 10:15 a.m. in Resident 44's room, Resident 44 was had a bed alarm strapped to the siderail of her bed while she was asleep in bed. During an observation on 1/27/25 at 10:27 a.m., in Resident 55's room, Resident 55 was up in a wheelchair with family husband and daughter visiting at her bedside. Resident 55 had a white portable position alarm on her wheelchair and a green portable bed alarm strapped to the siderail of Resident 55's bed. During an observation and an interview with Resident 36 on 1/27/25 at 10:43 a.m. in Resident 36's room, Resident 36 was laying in bed resting. Resident 36 had a green portable bed alarm strapped to her bed. Resident 36 stated she gets Physical therapy (PT )in bed in bed for now and she has to be repositioned by staff. During an interview on 1/27/25 on 11:09 a.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated bed alarms are used on Residents with high risk fall. LVN 3 stated facility should inform the family about the use of bed alarms and document it in the care plan and discuss it in Interdisciplinary Treatment (IDT) together with Social Worker, Case Manager, and Director of Staff Development (DSD). During an interview on 1/27/25 at 11:22 a.m. with Director of Nursing (DON), DON stated bed alarms or position change alarms are only used on residents on high risk falls and falls with injury. During a record review on 01/28/25 of Resident 44's Care Plan, Care plan indicated a fall risk was initiated on 7/2/24 with a targeted date of 1/30/24 and was last revised on 7/2/24. Care Plan also indicated Resident 44 is at moderate risk for falls. The Care plan does not include the use of bed alarms or position alarms. During a record review on 01/28/25 of Resident 55's Care Plan, Care plan indicated a fall risk initiated on 12/27/24 with a targeted date of 3/24/25 and was last revised on 1/16/25. Care Plan also indicated Resident 44 is at moderate risk for falls. The Care plan does not include the use of bed alarms or position alarms. During a record review on 01/28/25 of Resident 36's Care Plan, Care plan indicated a fall risk was initiated on 10/29/24 with a targeted date of 1/29/24 and was last revised on 11/14/24. Care Plan also indicated Resident 36 is at moderate risk for falls. The Care plan does not include the use of bed alarms or position alarms. During an interview on 1/30/25 at 09:30 a.m. with DON DON stated bed alarm should be in the care plan because the care plan is what the facility follow to care for the residents. The DON further stated that the care plan should be updated quarterly, when the residents are due for MDS assessment every three months. During an interview on 1/30/25 at 10:11 a.m. with Minimum Data Set Coordinator (MDSC), MDSC stated it is important for facility to have acre plan for use of bed alarms as it shows the bed alarm is one of the intervention being used and is one of the care plan facility uses for resident safety. During a review of Facility Policy and Procedure (P and P), titled 'Bed and chair Alarm for Fall Prevention, dated 1/29/2025, pg 1, indicated, it is policy of HumanGood to establish guidelines for the appropriate use of bed and chair alarms as part of a comprehensive fall prevention program, ensuring resident safety while adhering to federal and state regulations and promoting dignity and independence. These alarms are to be used as part of a multifacted fall prevention strategy and must not be used as restraints or as substitute for direct supervision and other fall prevention interventions. Procedure: Assessment and indications for Use: Conduct a comprehensive fall risk assessment for each resident upon admission, after any fall, quarterly, and with any significant change in condition. Reassess the necessity of alarms and discontinue use when they are no longer needed, documenting the rationale for continuation or discontinuation.

Based on observation ,interview record review, facility staff including Certified Nursing Assistant (CNA), Licensed Nurses (LNs), and Maintenance Staff did not perform hand hygiene while providing care to one of five sampled residents (Resident 42) when : 1.CNA 3 did not perform hand hygiene before and after putting in hearing aides in Resident 42 's ears and before donning gloves for incontinence care. 2.LNs did not sanitize/disinfect glucometer and flat surfaces to keep medication tray during medication administration. This failure placed all residents at risk for spread of in infection. 1. Findings: During an observation on 01/29/25 at 09:45 a.m. without performing hand hygiene, CNA 3 entered Resident 42's room, placed Resident 42's hearing aid in both ears with bare hands, without performing hand hygiene, CNA 3 donned gloves and provided incontinence care to Resident 42. During an interview on 01/29/25 at 12:07 p.m. CNA 3 stated hand hygiene includes gel in, gel out and hand washing with soap and water when hands or gloves are visible soiled. CNA 3 stated should have completed hand hygiene before donning gloves to perform incontinence care for Resident 42. CNA 3 stated it is important to perform hand hygiene to reduce transfer of infection. During an interview on 01/29/25 at 12:20 p.m. with Infection Preventionist (IP), IP stated hand hygiene should be done before and after donning gloves when providing direct resident care, and hand washing especially if hands are visibly soiled. IP stated staff should complete proper hand hygiene in before performing incontinence care to prevent spread of germs and infection. During record review of the 'Handwashing/Hand hygiene' policy and procedure (P&P), dated 08/2019, indicated, wash hands with soap and water for the following situations: a. when hands are visibly soiled and use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; e. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident. 43771 2.During an observation and an interview on 01/29/25 at 08:44 a.m the glucometer was stored in the med cart with three spots of blood stains on the back of it. LVN 1 stated she was supposed to have cleaned the glucometer for infection control prevention. LVN 1 further stated the glucometer was supposed to be cleaned after every resident use. During an interview on 01/29/25 at 08: 48 a.m. with Infection Preventionist (IP), the IP stated glucometer needs to be disinfected after each use to prevent infection. During an observation on 1/29/25 at 08:51a.m. with LVN 2, LVN 2 came out of Resident 36' s room, and was wiping her hands with two paper towels. LVN 2 placed used paper towels on top of the med cart after wiping her hands with it. LVN 2 did not sanitize the contaminated med cart prior to prepping meds for Resident 42. During an interview on 1/29/25 at 08:53 a.m. with LVN 2, LVN 2 stated the paper towel on top of the med cart was the paper towel she had used to wipe her hands after she had washed her hands. LVN 2 further stated she was supposed to have thrown the used paper towel in the trash instead of placing it on the med cart and sanitize the med cart in between patients for cross contamination. During a review on 01/29/25 of facility ' s Policy and Procedure (P and P) titled Hand Hygiene Program, dated 2010, the P & P indicated, Rationale for hand hygiene: Prevent transmission of infectious agents. Hand hygiene Hand hygiene should be performed in the area where the hands were contaminated (this may be done in the resident ' s bathroom if the resident or the environment/equipment of the resident was handled). Indications for performing hand hygiene before and after contact with resident or their environment, before and after glove use, before handling clean linen, and after disposal of soiled linen. After touching items that are likely to be contaminated (bedpans, urinal), Note: gloves should always be changed between residents and between clean and contaminated sites on the same resident. Gloves use not preclude the need for hand hygiene after removing gloves.

Based on observation, interview and record review facility did not promptly investigate and act upon complaints of one of one sampled resident's (Resident 11) missing personal belongings (sweatpants). This failure resulted in the Resident 11 feeling angry. Findings: During a record review of Resident 11's Admission record, the Admission record indicated, Resident 11 was admitted to the facility in August 2024 and family representative (FR1) was the responsible party. During record review of Resident 11's Inventory of Personal Effects, dated 08/20/24,the record indicated two pair of sweatpants were listed as items acquired. During an interview on 01/28/25 at 09:40 a.m. FR1 stated, Resident 11 had lost around two- three sweatpants over time, since admission. FR1 stated he had made one or two Certified nursing assistants (CNA) aware of missing items at the time items went missing. During an observation on 01/28/25 at 10:04 a.m. FR1 gave CNA1 a verbal description of two missing sweatpants. During an interview on 01/30/25 at 09:31 a.m. CNA1 stated she told the SSD about Resident 11's missing personal belongings, on the week of 01/13/25 when FR1 initially reported loss personal belongings (three sweatpants). CNA1 stated she and SSD looked for pants together on week of 01/13/25 and did not find any. CNA1 also stated when a resident reports missing items, staff was to report that to SSD, and if facility could not locate the missing belongings, the facility needed to replace the item. CNA1 stated she was unaware of where theft and loss reports were located as she typically only made the reports to the SSD verbally. During an interview on 01/30/25 at 09:35 a.m. with CNA1 and SSD, SSD stated she remembered when CNA1 initially reported missing sweatpants for Resident 11 on the week of 01/13/25. SSD stated they searched for Resident 11's sweatpants on both floors but could not find them. SSD stated, they should have documented a loss report to properly and promptly investigated Resident 11's complaint of missing items. During an interview on 01/30/25 at 09:42 a.m. Resident 11 stated she felt upset the facility could not locate her personal property sooner. FR1 stated facility makes me angry when Resident 11 does not have sweatpants returned from laundry for dressing and feeling forced to report missing personal property multiple times. FR1 stated Resident 11 was still missing one pair of sweatpants, and he had discussed matter with SSD. During an interview and concurrent record review on 01/29/25 at 10:01 a.m. Social Services Director/Case Manager (SSD) stated when residents reported missing belongings to CNA's, clinical staff, and anyone on the care team, staff were to complete a theft and loss report to initiate further investigation. SSD stated she had no theft and loss reports for Resident 11 from 08/2024 till date. During an interview on 01/30/25 at 10:19 a.m. Director of Nursing (DON) stated if a resident reported missing personal belongings all staff were alerted, including the laundry staff, staff were to search room to room on both floors and a loss report was to be completed by resident and/or family and SSD follows up to replace or reimburse. DON stated,SSD is primarily responsible for investigating loss report once completed. During record review of ' Personal Property ' policy and procedures (P&P) indicated, The facility promptly investigates any complaints of misappropriation or mistreatment of resident property.

Based on observation, interviews, and record review, the facility failed to ensure adequate supervision and implement interventions for one (Resident 1) of three sampled residents. Resident 1 was found on the dining room floor and sustained a skin tear on the left leg . The interventions to prevent future falls was not implemented as instructed by the Interdisciplinary Team (team members from different departments for collaboration of care). This deficient practice caused Resident 1 a skin tear on the left leg and had the potential to cause repeated falls and or injuries. Findings: Review of the clinical notes dated 12/18/22 indicated Resident 1 was found on the floor with the left arm under his body. Further review indicated that before the fall, Resident 1 was sitting in the dining room watching TV when the wheelchair alarm sounded and the nurse responded and found Resident 1 on the floor. Resident 1 sustained a skin tear on the left leg. Review of the Minimal Data Set (MDS - an assessment screening tool used to guide care) dated 11/11/22, indicated Resident 1 ' s Basic Interview of Mental status (BIMS) score was 9 (meaning moderate long and short term memory). Resident 1 had vision impairment with vision and used a wheelchair for mobility that required two-person physical assistance with movement to and from lying position, moves to and from wheelchair, including physical limitation impairment to the lower extremity (hip, knee and ankle). Also, Resident 1 was always incontinent of urine. Resident 1's diagnoses included anxiety disorder and heart failure (a condition in which the heart doesn ' t pump blood as well as it should). Review of the risk for fall care plan updated 12/18/22, indicated Resident 1 was a high risk for falls related to weakness, blind right eye, history of falls and poor safety awareness. Resident 1 had an unwitnessed fall in the dining room. During an interview on 12/29/22 at 11:00 a.m., the Certified Nursing Assistant (CNA 1) stated she was assigned to Resident 1 when he fell . CNA 1 stated she was on her break time and had informed the Registered Nurse (RN 1) that she was going on break when Resident 1 fell . During an interview on 12/29/22 at 4:29 p.m., RN 1 stated CNA 1 informed her she was going on break. RN 1 further stated she left the dining room area to attend to another resident that was screaming. RN 1 stated she heard the chair alarm beep from the dining room and found Resident 1 on the floor. During an interview on 12/29/22 at 9:50 a.m., CNA 2 stated Resident 1 slides from the wheelchair while sitting and had to be repositioned at times. Review of the clinical notes dated 12/19/22 indicated the IDT met and discussed the fall and instructed staff to apply a dycem (non -slip pad to hold wheelchair cushion in place} prevent from slipping. During an observation on 12/29/22 at 11:10 a.m., and accompanied by the Assistant Director of Nursing (ADON), ADON stated the dycem was not applied to the wheelchair cushion. During an interview on 12/29/22 at 11:45 a.m., the Administrator (Admin) stated she thought the dycem was ordered and will follow up on the order. The facility ' s policy and procedure titled, Fall Prevention and Management Program dated 8/4/2020, indicated for staff to refer to the interdisciplinary treatment team to review fall prevention interventions and modify care-plans as appropriated.

Based on observation, interviews, and record review, the facility failed to implement their policy and procedure for reporting allegation of abuse for one (Resident 1) of three sampled residents when the Administrator (Admin) did not report to the Department, the Certified Nursing Assistant (CNA 1) had allegedly roughed up and hit Resident 1 while providing care at night. This failure had the potential for mistreatment or injury and delayed the Department's investigation of alleged abuse. Findings: Review of the Minimal Data Set (MDS - an assessment screening tool used to guide care), dated 11/11/22, indicated Resident 1 ' s Basic Interview of Mental status (BIMS) score was 9 (meaning moderate long and short term memory). Resident 1 misses some part/intent of conversations but usually comprehends most conversation. Resident 1 had visual impairment. Resident 1 used a wheelchair for mobility, and required two-person physical assistance with movement to and from a lying position, and to move to and from the wheelchair, including physical limitation impairment to the lower extremity (hip, knee and ankle). Resident 1 was incontinent (loss of bladder control) of urine. The diagnoses included anxiety disorder and heart failure (a condition in which the heart doesn ' t pump blood as well as it should). During an observation and concurrent interview on 12/7/22 at 10:20 a.m., Resident 1 was sitting up in wheelchair in the dining room on oxygen via nasal cannula (tube with prongs that deliver oxygen via the nares). Resident 1 was alert but made incomprehensible sounds and was non-interviewable. During an interview on 12/7/22 at 10:54 a.m., the Assistant Director of Nursing ADON) stated Resident 1 ' s daughter complained CNA 1 was rough with Resident 1 at night. ADON stated during the facility's investigation, Resident 1 stated he was roughed up at night by CNA 1. ADON further stated CNA 1 was reassigned and was provided with in-service training. During an interview on 12/8/22 at 10:50 a.m., CNA 1 stated she changed Resident 1 ' s incontinent brief and was not rough with him. CNA 1 stated Resident 1 was a nice man and was surprised by the allegation. During an interview on 12/8/22 at 11:38 a.m., Admin stated Resident 1 said CNA 1 was strong as a man, and Resident 1 ' s daughter alleged CNA 1 hit him. During an interview on 12/8/22 at 11:38 a.m., Admin stated she did not report the allegation that CNA 1 roughed up or hit Resident 1 at night to the Department because the facility investigated the allegation and concluded that it was not abuse. The facility ' s policy and procedure, Elder Abuse Prevention, Identification response and reporting indicated, if an allegation or witnessed event involves alleged abuse by a team member, he or she will be removed from the assigned worksite immediately, the Director of Human Resources shall be notified and the team member sent home and may not return until instructed to do so by human Resources. The appropriate community leader makes any required verbal and written report to the local law enforcement and to the Department of Public Health. The community leader shall report allegations as dictated by state or local agencies including to the state survey agency and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with State Law through established procedures

Based on interview and record review, for one of five (Resident 259) sampled residents reviewed for unnecessary medications, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan when the physician was not notified as ordered when Resident 259's blood sugar level exceeded 400 milligrams per deciliter (mg/dL). This failure increased the risk for Resident 259 of developing complications related to severely elevated blood glucose levels, like diabetic ketoacidosis (life-threatening complication of diabetes when the build-up of acids in the body occurs when the blood sugar is too high for too long) or coma. Findings: Review of Resident 259's Face Sheet indicated Resident 259 was admitted to the facility with diagnoses that included diabetes mellitus with hyperglycemia (condition of uncontrolled, elevated blood glucose levels). Review of Resident 259's Physician's Orders dated 7/2/22 indicated to administer insulin (treats diabetes) lispro per sliding scale ( insulin dosage varies based on blood glucose level) before every meal and to notify the physician if the blood glucose was higher than 400 mg/dL. Review of Resident 259's undated, insulin use care plan indicated staff were to monitor the blood sugar as ordered by provider and to report to the physician signs of hyperglycemia (high blood sugar). During an interview and concurrent review of Resident 2's clinical records with the Director of Nursing (DON), on 11/16/22 at 9:03 a.m., DON stated, Resident 259 was sent to the hospital on 8/27/22 for hyperglycemia and fainting and returned to the facility with instructions to adjust the insulin dose. Further record review with DON of the physician order dated 9/7/22 indicated an order for admelog (treats diabetes) insulin lispro per sliding scale and to notify physician if blood sugar level was more than 400 mg/dL. DON stated, on 9/7/22 and 9/8/22, Resident 259's clinical record indicated physician was notified of the blood sugar result higher than 400 mg/dL and extra insulin was administered. DON stated in October 2022, Resident 259's clinical record indicated staff had notified the physician of Resident 259's high blood sugar level two times on 10/1/22 and 10/26/22. Review of Resident 259's Medication Administration Record (MAR) for October 2022 indicated Resident 259's blood sugar exceeded 400 mg/dL 28 times. MAR for November 2022 indicated Resident 259's blood sugar level exceeded 400 mg/dL 18 times. DON stated the clinical record indicated the physician notification occurred four times on 11/1/22, 11/5/22, 11/13/22 and 11/15/22. Further review of Resident 259's MAR for November 2022 indicated the following; - 11/10/22, Resident 259's blood sugar reading was 481 mg/dL at 6:30 a.m The clinical record did not indicate the physician was notified, until a few hours later at 11:30 a.m. On the same day, Resident 259's blood sugar remained elevated at 485 mg/dL. - 11/12/22, Resident 259's blood sugar reading was 463 mg/dL at 6:30 a.m., and at 11:30 a.m., the blood sugar reading was 590 mg/dL. - On 11/14/22, Resident 259's blood sugar reading was 560 mg/dL at 6:30 a.m., later at 11:30 a.m., Resident 259's blood sugar was 581 mg/dL. On the above dates, the clinical record did not reflect the physician was notified by licensed staff about the high blood sugar levels as ordered.

Based on observation, interviews, and record review, the facility failed to follow proper sanitation and food storage practices when: - The High temperature dishwasher was not within the required temperature range - Kitchen floor tiles had brownish residual discoloration, - Two food steamers had brownish food debris on the bottom shelf and around the steamer areas - Bowl of lettuce, bowl of tomatoes in refrigerator were not labeled or dated - Two opened milk cartons in the walk in refrigerator were not label or dated - Bowl of sliced ham in the refrigerator had use by date 11/10/22 -Two food mixers had brownish discoloration and debris around the edges - Plate covers were faded and discolored - Three compartment sink air gap drain area had yellow residue - Ice machine cover had debris and crumbs - Ice machine air-gap drain area with yellowish residual - Cook trays with thick blackish brown crusts around the edges - Double door panel to the kitchen/dumpster area with black discoloration on the surface These deficient practices had the potential to result in foodborne illness. Findings: During the initial tour of the kitchen on 11/14/22 at 9:15 a.m., accompanied by the Chef (CF1) and Registered Dietician (RD), the following were observed: High temperature dishwasher was not within the required temperature range, Kitchen floor tiles had brownish residual discoloration, two food steamers with brownish food debris on bottom shelve and around the steamer areas Bowl of lettuce , bowl of tomatoes in refrigerator not label or dated, two opened Milk cartons in walk in refrigerator not label or dated, bowl of sliced ham in refrigerator with use by date 11/10/22, two food mixer with brownish discoloration and debris around the edges, plate covers with faded discolored appearance, 3 compartment sink air gap drain area with yellowish residual, Ice machine air-gap drain area with yellowish residual. Ice machine cover with debris and crumbs, cooking trays with thick blackish brown crusts around the edges, double door panel to the kitchen/dumpster area with blackish discoloration on the surface. During an observation on 11/14/22 at 10:49 a.m., in the presence of CF1 and RD, the high temperature dishwasher was operated to wash dishes. The final rinse temperature was at 60 degrees Fahrenheit (F). RD operated the dishwasher three times and the final rinse temperature gauge was at 60 (degrees F). During an interview on 11/14/22 at 10:54 a.m., RD stated the dishwasher had to be run three times for the temperature to be at the required range. RD operated the dishwasher several times and the final rinse temperature gauge was at 60 degrees F. During an interview on 11/15/22 at 8:56 a.m., RD stated a work order was placed for the contractor to visit and check the dishwasher temperature gauge for proper functioning. During an interview on 11/15/22 at 11:55 a.m., the Executive Chef (EC) stated he was aware the dishwasher temperature gauges was not at the required range when the heat booster was not operated at the same time. EC stated the dietary staff needs to use the heat booster when operating the dishwasher for the temperature to reach the required final rinse temperature. EC further stated the staff assigned to clean and sanitize the dishwasher and floor were out on family leave vacation. EC said staff needed to be trained to start the heat booster with the dishwasher. The Dishwasher Installation & Operation Manual indicated the Final rinse temperature and flow pressure gauges are accurate only when a rack enters the final rinse area and water is flowing. Acceptable temperature range is 180 - 195 degrees Fahrenheit and pressure should be 20 psi (pounds per square inch). The facility's policy and procedure titled, Sanitation and Infection Prevention Control, revised 1/21' reflected, Assigns daily cleaning responsibilities in each position workflow.

Based on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for infection) for one of five residents reviewed (Resident 27) when they did not monitor appropriate use and improved outcomes. This failure had the potential for Resident 27 to take unnecessary antibiotics which could lead to antibiotic resistance. Findings: During a concurrent interview and record review, on 11/16/22 at 10:43 a.m., with the Infection Preventionist (IP), Resident 27's Physician Order Sheet (POS), dated November 2022 was reviewed. The POS indicated an order start date of 06/28/21, for Keflex (an antibiotic), indicated for urinary tract infection (UTI) prophylaxis (action taken to prevent disease). IP stated, there was no documentation on the POS dated November 2022 that indicated Resident 27's Keflex had a stop date. During an interview and concurrent record review, on 11/16/22 at 10:43 a.m., IP stated she could only find documentation that their antibiotic stewardship for Resident 27 was done in February, May and November of 2022. IP stated she could not find the antibiotic stewardship documentation that was done for Resident 27 on the other months of 2022. During a review of Resident 27's laboratory tests indicated Resident 27's urinalysis (test that can also detect urine infection or evaluate antibiotic effectiveness), was last done on 7/12/21. During an interview on 11/17/22, at 11:07 a.m., with the Director of Nursing (DON), DON stated, the facility should have followed up about the stop date for Resident 27's Keflex because the resident has been on the antibiotic since last year. DON stated the risk of long-term antibiotic usage is for Resident 27 to acquire another form of infection that is resistant to antibiotics. Review of the facility's policy and procedure titled, Antibiotic Stewardship, revised December 2016 indicated, If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the . duration of treatment: stop and start date or number of days of therapy .

Based on observation, interview, and record review, for one of two sampled residents (Resident 2), the facility failed to provide devices to ensure Resident 2's activities of daily living (ADL) did not diminish when Resident 2 was not provided with an assistive device to stay upright during meals. This failure resulted in Resident 2's inability to feed self independently and had the potential to result in decreased oral intake. Findings: Review of Resident 2's Face Sheet indicated Resident 2 had been known to the facility since 1/20/21 with diagnoses that included acute transverse demyelinating disease (inflammation of both sides of the spinal cord) of the central nervous system, spinal stenosis (narrowing of the spinal canal which then puts pressure on the spinal cord) of the cervical (neck) region, and need for assistance with personal care. Review of Resident 2's comprehensive Minimum Data Set (assessment tool used to direct resident care) assessment dated [DATE] indicated Resident 2 required staff supervision for set up help with meals (if a resident is provided with devices necessary to perform the ADL independently) and extensive staff assist for bed mobility (staff providing weight-bearing support; bed mobility is how one positions body while in bed). Review of Resident 2's bed mobility care plan effective 4/16/21 indicated to use pillows and foam wedges to maintain position while in bed. During an observation on 11/14/22 at 10:04 a.m., Resident 2 was eating breakfast while in bed. Resident 2 leaned to the right side, completely pinning the right hand under the right shoulder. There was one small pillow on the right side of the bed and no foam wedges. Resident 2's breakfast tray was on the over-bed table and placed higher than Resident 2's eye level. A small pillow was on the right side of the bed. Resident 2 attempted to pick up a cup of tea from the tray with the left hand but struggled and spilled the tea all over the tray. Resident 2 stated not knowing why the staff would not help her. There was no staff present in the room. During an interview with Certified Nurse Assistant (CNA) 2 on 11/14/22 at 10:25 a.m., CNA 2 stated the tray was set up and checked on Resident 2 once in a while. CNA 2 also stated, Resident 2 had the tendency to lean towards the right side and a pillow was placed to prevent that. During an interview with the Director of Rehabilitation (DOR) on 11/16/22 at 2:27 p.m., DOR stated while Resident 2 is in bed, the most important thing was correct positioning, with support on both sides to maintain an upright position, and position the over-bed table at the right height where Resident 2 could see the tray. DOR also stated Resident 2 would be re-evaluated to see if a wedge would be ordered and staff training would be provided.

Based on interviews and record review, the facility failed to ensure the Consultant Pharmacist's (CP) monthly Medication Regimen Review (MRR) reported a medication irregularity for two (Residents 18 and 27) sampled residents. For Resident 18, CP did not address the duration for the administration of Macrobid (antibiotic medication) for the prevention of Urinary Tract Infection (UTI). For Resident 27, the duration of Keflex (antibiotic) for UTI was not identiied for more than one year. These deficient practices had the potential for residents to receive unnecessary drugs and future antibiotic resistant infections due to prolong use Findings: Review of the physician order dated 8/16/22 indicated Resident 18 was to receive Macrobid 100 mg (milligram) capsule every morning for UTI prophylaxis, indefinite. Review of Resident 18's Medication Administration Record (MAR) for October 1 through November 16, 2022, indicated Resident 18 was administered Macrobid 100 mg capsule by mouth every morning as ordered by the physician. During an interview on 11/17/22 at 8:08 a.m., the Director of Nursing (DON) stated she had not received CP's recommendations for Resident 18's use of Macrobid for the prevention of UTI indefinite. During an interview on 11/17/22 at 9:17a.m., CP stated she did not address the duration for Resident 18's administration of Macrobid 100 mg capsule every morning for the prevention of UTI, or report any irregularities to DON and Resident 18's physician. Review of the Nitrofurantoin (Macrobid) literature, revised April 2022, indicated using antibiotics when it is not needed can cause it to not work for future infections. According to the pharmacy professional reference resource, Lexicomp for Macrobid indicated the optimal duration has not been established; duration ranges from 3 to 12 months, with periodic reassessment (Ref). Prolonged use (>6 months) of Macrobid has been associated with diffuse interstitial pneumonitis (inflammation of the lining of the lung) and/or pulmonary fibrosis, chronic hepatitis (liver inflammation), and the development of neuropathy (nerve pain). The facility's policy and procedure titled, Consultant Pharmacist Services Provider Requirement dated 10/07, indicated, The consultant pharmacist, or designee, provides pharmaceutical care services including Medication Regimen Reviews (MRR) for each resident at least monthly, or more frequently under certain conditions, incorporating the federally mandated standards of care in addition to other applicable professional standards. 46487 During a review of Resident 27's active physician orders for November 2022, indicated an order start date of 06/28/21 for Keflex (antibiotic), indicated for UTI prophylaxis (action taken to prevent disease). During an interview on 11/17/ 22, at 10:00 a.m., CP stated, she did not send monthly recommendations for Resident 27's prophylactic antibiotic use to the physician. CP acknowledged no recommendation to verify the duration of Resident 27's Keflex and that long-term antibiotic usage should be evaluated every six months. CP also stated the risk of long-term antibiotic usage for Resident 27 was to have another form of infection. During an interview on 11/17/22, at 11:07 a.m., DON stated, the facility should have verified with the physician the duration of Resident 27's Keflex because the resident has been on the antibiotic since last year. DON further stated the risk of long-term antibiotic usage could result in another form of infection that is resistant to antibiotics. During a review of Resident 27's laboratory tests indicated Resident 27's urinalysis (test to also detect urine infection) was last done on 7/12/21. During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements, dated 10/07 indicated to, Communicate to the responsible prescriber and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication therapy and the monitoring of medication therapy.

Based on interviews and record reviews, the facility failed ensure professional foot care was delivered to one (Resident 1) when they did not follow up and obtain podiatry (foot) services in a timely manner. This failure resulted in Resident 1's toenails remaining uncut and extremely overgrown for four months, and had one toe that was inflamed. FINDINGS: During an interview with Resident 1 on 3/18/19 at 11:09 a.m., the resident indicated her toenails had not been cut in four months. Resident 1 stated her toenails had gotten so long they lifted up from the nail bed, and were catching on her socks and shoes, and now one toe was red and swollen. Resident 1 stated a day-shift registered nurse looked at her inflamed toe and long toenails, and had Resident 1 soak her toes, and staff pushed down on her nails and taped the nails so they would not catch on her socks. Resident 1 indicated she was supposed to have her toenails cut every two months by a podiatrist (specializes in foot disorders/care). After learning the podiatrist was not coming in January, Resident 1 repeatedly asked the facility to arrange for a podiatrist to come to the facility or arrange a podiatry appointment with an outside podiatrist service. During a second interview with Resident 1 on 4/8/19 at 10:38 a.m., the resident indicated on 3/20/19 her son-in-law took her to an outside podiatrist. Resident 1 stated the outside podiatrist said four months was too long between toe nail cuttings. A record review on 3/29/19 of Resident 1's medical record showed a physician's orders [REDACTED]. Further record review indicated Resident 1 was last seen by a podiatrist in the facility on 11/14/18. At that time, the podiatrist's evaluation and treatment documentation indicated, At risk foot care needed The record review of the Health Status progress note, dated 3/15/19 at 8 a.m., indicated the second toe of Resident 1's right foot was red, and the toenail was overgrown, but there was no swelling or drainage. Furthermore, the note indicated the SW was informed that a podiatry consult was needed and Resident 1's physician was made aware. The Health Status progress note dated 3/15/19 at 7:24 p.m., indicated Resident 1's physician ordered Resident 1's toes to be soaked in Epsom salts for 15 minutes every day. A record review of the Social Services progress note dated 3/15/19 at 8:56 a.m., 9:44 a.m. and 3:30 p.m., indicated the facility would not be able to provide podiatry services at the facility, until 3/27/19 which was four months after the most recent podiatrist visit to the facility. Resident 1 was advised to see if family will take her to private Podiatrist if necessary. Further review of the notes indicated Resident 1 was upset by this information regarding further delays in podiatry services and was told that in order for her to see a podiatrist sooner, the facility would have to arrange an appointment with an outside podiatrist and she would have to pay for the outside podiatrist's visit herself, if not covered by insurance. The Social Services progress note dated 3/18/19 at 3:26 p.m., indicated the SW had attempted to arrange for an outside podiatrist to come to the facility to see Resident 1 but the outside podiatrist was not able to do so. The record review of the Health Status progress note dated 3/16/19 at 7:46 a.m., indicated Resident 1 was complaining about her toenails. At 7:20 p.m., the note indicated Resident 1 refused to have the bandages holding her toenails down removed in order to soak her toes in Epsom salts. A record review of the Weekly Progress Summary note dated 3/18/19 at 11:50 p.m., indicated a referral to an outside podiatrist was made for Resident 1. A record review of the Conversation progress note in Resident 1's medical record dated 3/19/19 at 12:15 p.m., indicated the Administrator (ADMIN) met with Resident 1 to explain why there was a delay in podiatry services, and had met with Resident 1's son-in-law later that day at 1:30 p.m. Resident 1's son-in-law notified the facility he had found an outside podiatrist who would be able to see Resident 1 the next day. The record review of the Health Status progress note dated 3/20/19 at 12 p.m., indicated Resident 1 was picked up that day by her son-in-law and transported to the outside podiatry appointment in her wheelchair. The facility did not accommodate Resident 1's urgent need for podiatry service or assist in arranging for an outside podiatry appointment, including transportation. Further record review on 3/29/19 of Resident 2 and Resident 3's medical records indicated they also did not receive any podiatry care in (MONTH) as scheduled. During an interview with the facility's Social Worker (SW) on 4/11/19 at 10:18 a.m., SW indicated the organization providing podiatry services at the facility but was unable to provide those services as scheduled in (MONTH) due to staffing issues. The SW stated the organization kept telling her they were sending someone, and no one came. Furthermore, SW indicated most of these promises were made over the telephone and provided one documented instance where the organization told her they were going to get a podiatrist from another area of the state to come to the facility that week. SW stated due to these promises by the organization, she kept expecting someone, so she did not try to find an outside podiatrist to come to the facility and deliver podiatry care to Resident 1 and all the residents who required it. A record review of the contract between the facility and organization providing podiatry care at the facility, and signed 8/12/15, indicated the provider shall provide podiatry services to FACILITIES residents in accordance with any applicable requirements of federal, state or local laws, rules and/or regulations . and that the provider shall respond to FACILITIES request for services in a timely manner . The provider did not provide podiatry services as agreed and did not respond in a timely manner to the facility's request for services. A record review of the facility's Quality of Life - Accommodation of Needs policy dated (MONTH) 2009 indicated, the resident's individual needs and preferences shall be accommodated to the extent possible .

Based on observation, interview, and record review, the facility failed to ensure drugs used in the medication room were not expired when one Ekit (An emergency container with equipment, supplies, and medications needed to provide care and manage life-threatening conditions) had expired medications in the refrigerator. This deficient practice had the potential to affect the potency and safety of the medication that could have harmful effects for all 70 residents in the facility. Findings: During an observation of the third floor medication room, on 04/10/19 at 12:55 P.M., an Ekit inside the medication's refrigerator included three tablets of [MEDICATION NAME] (antianxiety) 2 mg/ml (milligram/milliliter) that expired on 12/18 (December (YEAR)). During an interview with the Registered Nurse 1 (RN 1) on 04/10/19 at 12:55 P.M., RN 1 confirmed the expired Ekit and stated the expired medication should not be stored in the medication room and they (staff) forgot to return the Ekit to the pharmacy. During a review of the policy and procedure, DISPOSAL OF MEDICATIONS dated 2007 indicated: . 8. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed .

Based on interview and record review, the facility failed to update the plan of care for two of two sampled residents (Residents 47 and 62). Resident 47's hearing aids were missing and Resident 62 had untreated pain with movement. These failures resulted in a lack of comprehensive care plans for hearing and pain management that did not meet resident care needs. Findings: 1. Record review of the Admission Record showed the facility admitted Resident 47 on 2/8/19. Record review of Resident 47's plan of care dated 1/23/19 showed, The resident has a communication problem r/t (related to) hearing deficit .Hearing Aid provided .hearing aids are kept with the nurses cart and given to resident each morning. In an interview on 4/8/19 at 10:34 a.m., Resident 47 stated she has difficulty hearing and wanted to know where her hearing aids were located. In a concurrent interview, Registered Nurse 1 (RN 1) stated Patient 47's hearing aids were lost during the time she was in and out of the hospital and were not stored in the medication cart. There was no updated care plan and interventions for the missing hearing aids. 2. Record review of the Admission Record showed the facility admitted Resident 62 on 3/9/19. The [DIAGNOSES REDACTED]. In an interview on 4/8/19 at 10:42 a.m., Resident 62 stated he has significant amount of shoulder pain when staff assists him with activities of daily living (ADL, consists of bathing, toileting, eating etc.) and turning in bed. In an interview on 4/9/19, at 2:30 p.m., the Physical Therapist 1 (PT 1) stated Resident 62 reported to him that he had pain in his shoulders whenever staff turned him. In an interview on 4/9/19 at 2:45 p.m., the Certified Nursing Assistant 1 (CNA 1) stated when assisting Resident 62 with care, she asks another staff person for help because Resident 62 was hesitant to turn. Record review of Patient 62's plan of care, Needs assistance with ADL . dated 4/6/19 did not identify pain with movement. In an interview on 4/10/19 at 11:19 a.m., the Director of Nursing (DON) confirmed Resident 62's pain with movement was not in his plan of care. Review of the policy and procedure, Care Plans, Comprehensive Person-Centered dated (MONTH) (YEAR), showed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility did not manage the pain for one (Resident 62) of two sampled residents in a timely manner. Resident 62 complained of pain when staff turned him in bed and during assistance with activities of daily living (or ADLs: bathing, toileting, feeding). This failure resulted in Resident 62 experiencing unnecessary pain and discomfort. Findings: Record review of theAdmission Record showed the facility admitted Resident 62 on 3/9/19. The [DIAGNOSES REDACTED]. Record review of the Minimum Data Set - Resident Assessment and Care Screening, dated 3/16/19, showed Resident 62 had clear speech, understood what others said to him, and was able to express his ideas and wants. In an interview on 4/8/19 at 10:42 a.m., Resident 62 stated he had a significant amount of pain in his shoulders when staff assisted him with his ADLs and turning in bed. In an interview on 4/9/19 at 2:30 p.m., the Physical Therapist 1 (PT 1) stated Resident 62 reported to him that he had pain in his shoulders when staff were turning him. In a concurrent interview on 4/9/19 at 2:30 p.m., the Registered Nurse 1 (RN 1) stated she was not aware Resident 62 had pain with movement. In an interview on 4/9/19 at 2:45 p.m., the Certified Nursing Assistant 1 (CNA 1) stated when assisting Resident 62 with care, she asks another staff person to help because Resident 62 was hesitant to turn. Record review of the Medication Administration Record [REDACTED]. There was no Tylenol given to Resident 62 for the month of April. Review of the facility's policy and procedure, Pain Assessment and Management dated (MONTH) (YEAR), showed the purpose was to, Help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under the section, Assessing Pain, staff were to identify Factors that precipitate or exacerbate pain.

Based on interview and record review the facility failed to ensure to respect residents' right to refuse the treatment for one of three sample residents (Resident 1) when the facility did a blood test against the power of attorney's request. This failure resulted in Resident 1's unnecessary pain and discomfort from the blood draw. Findings: Review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Further review of the Admission Record indicated Resident 1's husband was indicated as the number one emergency contact person. During an interview with Family Member 1 (FM 1) on 6/12/18 at 12:46 p.m., FM 1 stated they met with Resident 1's physician on 5/21/18 and asked the physician to discontinue the lab and any hospitalization for Resident 1 because the family wanted comfort care for Resident 1. The physician sent an order to the facility to discontinue any lab and hospitalization for Resident 1. Review of the Progress Notes dated 5/21/18 indicated was seen by MD (medical doctor). D/C (Discontinue) all labs and no hospital transfer unless family approves . Review of the physician's orders [REDACTED]. Cancel all future lab work 2. No hospital transfer unless family approves. During a review of a laboratory result's record dated 5/23/18 indicated a a blood collection was done on 5/23/18 at 6:42 a.m. During an interview with the Director of Nursing (DON) on 6/18/17 at 9:35 a.m., DON stated Registered Nurse (RN) 1 did not remove the lab order from the lab book at the time of discontinuation of the lab order from the physician. During a review of the facility's policy and procedure titled Refusal of Treatment revised (MONTH) 2013, indicated .1. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician .

Based on interview and record review, the facility failed to ensure that CNA (certified nurses aide) 2 and RN (registered nurse) 1 implemented their written policy regarding abuse, affecting one of one sampled residents (1). CNA 2 failed to intervene immediately when she witnessed CNA 1 hitting Resident 1 and charge nurse (RN 1) failed reassign CNA 1 to non-resident duties immediately, and allowed CNA 1 to finish providing care, unsupervised, to Resident 1 and other residents, while she telephoned the Director of Staff Development (DSD). This left Resident 1 and other residents unprotected from the potential for further abuse. Findings: On 1/8/15, record review showed Resident 1 was a [AGE] year old woman who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].). According to the most recent Minimum Data Set (assessment tool). dated 11/4/14, Resident 1 needed extensive assistance two persons assisting for transferring from the bed to wheelchair, and one person assisting for dressing, eating, toileting and personal hygiene. A record review of the nurses note dated 1/1/15 at 8:41 a.m. revealed that at 11 p.m. on 12/31/14 the resident's legs were on the edge of the bed and she was trying to get up and disrobing. At 12:30 a.m. on 1/1/15 the bed alarm was beeping and the assigned certified nursing assistant (CNA 1) and an extra CNA (CNA 2) got the resident up into a wheelchair because of her restlessness. Around 12:35 a.m. CNA 2 told the charge nurse (RN 1) that CNA 1 slapped the resident on both of her cheeks, the tops of both hands and punched the resident on the mid chest. RN 1 went to the room and she heard the resident saying "Aw, Aw, AW" repeatedly. The resident was naked, sitting on the wheelchair and CNA 1 went out of the room to get a gown and "other stuff" for the resident. RN 1 was speaking with the resident who only said "Aw, Aw..." and CNA 1 came back into the room and "...was complaining about how the resident was giving her a hard time because she was disrobing...trying to get up..." RN 1 assessed the resident and there were no skin discolorations. RN 1 reported the incident to the Director of Staff Development (DSD). During a telephone interview with CNA 2 on 1/9/15 at 9:30 a.m. he stated that while helping CNA 1 transfer Resident 1 from her bed to the wheelchair. He went to get the wheelchair, which was in front of the bed next to Resident 1's bed, and out of the corner of his eye he saw CNA 1 "slap both hands and both cheeks" of Resident 1. He could hear the slaps. When he helped CNA 1 transfer Resident 1 to the wheelchair he saw CNA 1 "punch" Resident 1 in the chest with her fist, and the Resident kept saying "Ow, Ow, Ow." He didn't say anything to CNA 1 and went out of the room to report what he saw to the charge nurse (RN 1). In a telephone interview with RN 1 on 1/9/15 at 10:30 a.m. she stated that sometime after midnight, CNA 2 came to her and said that CNA 1 was slapping Resident 1 on the face and hands and punched her on her chest. RN 1 went in to check the resident who was unclothed in her room sitting on the wheelchair. She stated that CNA 1 went to get a gown and pads for the resident. RN 1 left CNA 1 in the room to continue caring for Resident 1 while she went to telephone the Director of Staff Development (DSD) to report the incident. RN 1 was not sure if CNA 1 went on to work with other residents while she was speaking with the DSD on the phone. In a telephone interview with CNA 1 on 1/9/15 at 9:36 a.m. she stated that after providing care to Resident 1 she placed her in the T.V. room and she went on to finish her "rounds" and took care of three or four other residents before RN 1 told her to talk with the DSD on the telephone. She stated that the DSD told her "You have abused somebody and leave the building." She didn't know why or what she had done. In an interview with DSD on 1/8/15 at 1 p.m. he stated that he received a phone call from RN 1 on 1/1/15 around 12:45 p.m. to reported that CNA 2 told her that CNA 1 slapped Resident 1. He stated that when he was talking to RN 1, CNA 1 and CNA 2 had already transferred Resident 1 and were taking care of other residents. DSD then spoke with CNA 1 on the phone and told her there was an allegation of abuse and she had to go home. According to the facility's Resident Rights and Abuse Prevention Policy and Procedure Manual dated August 2011, "Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact..."

Based on observation, interview and record review, the facility failed to ensure that one of one sampled resident (Resident 1) was not abused during care. CNA 1 was witnessed by another staff covering Resident 1's mouth, slapping her on the tops of both hands and punching her on the mid chest during carem telling her to be quiet, causing Resident 1, who was restless, to become more agitated and make sounds like "Aw, Aw, Aw." Later, CNA 1 left Resident 1 naked in the wheelchair in her room while she went to get supplies, leaving Resident 1 exposed to anyone entering the room. Findings: On 1/8/15, record review showed Resident 1 was a [AGE] year old woman who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].). According to the most recent minimum data set (assessment tool), dated 11/4/14, Resident 1 needed extensive assistance, requiring two persons to assist transferring from the bed to wheelchair, and one person assist for dressing, eating, toileting and personal hygiene. On 1/8/15 at 12:45 p.m. Resident 1 was observed sitting up in a wheelchair. She did not have any visible injuries did not appear distress and did not respond to questions. Review of the nurses note dated 1/1/15 at 8:41 a.m., revealed that at 11 p.m. on 12/31/14, Resident 1 had her legs on the edge of the bed as she was trying to get up and was disrobing. An hour and half later on on 1/1/15 at 12:30 a.m. ,the bed alarm was beeping and CNA 1 and CNA 2 got the resident up into a wheelchair because of her restlessness. Around 12:35 a.m. , CNA 2 told the charge nurse (RN 1) that CNA 1 slapped the resident on both of her cheeks, the tops of both hands and punched the resident on the mid chest. RN 1 went to the room and heard Resident 1 saying "Aw, Aw, AW" repeatedly. The resident was naked, sitting on the wheelchair and CNA 1 went out of the room to get a gown and "other stuff" for the resident. As RN 1 was speaking with the resident, CNA 1 came back into the room and "...was complaining about how the resident was giving her a hard time because she was disrobing...trying to get up..." RN 1 assessed the resident and there were no skin discolorations. RN 1 reported the incident to the Director of Staff Development (DSD). In a telephone interview on 1/9/15 at 9:36 a.m., CNA 1 stated that when she arrived on her shift on 1/1/15, RN 1 told her to get Resident 1 up in the wheelchair. She asked CNA 2 to help her. The resident was full of feces and she went to get warm water to clean her. The Resident was not cooperative because "she doesn't like to be washed." CNA 1 bent down to clean the resident and she reached out and grabbed CNA 1's uniform top with her hand and was hanging on. CNA 1 stopped her and tried to remove her hand. CNA 1 then put her hand over Resident 1's mouth and told her, "Be quiet, it's the middle of the night, people are sleeping." During a telephone interview on 1/9/15 at 12:30 p.m. the Administrator stated that CNA 1 had told him during the investigation that she put her hand over Resident 1's mouth to quiet her and that was the basis for CNA 1's termination because he considered that abuse.

Based on observation, interview and record review, for one (10) of 15 onesampled residents, the facility failed to provide supervision and assess for appropriate devices to prevent accidents. 1. Resident 10 was assessed and identified by the facility as high risk for falls. Resident 10 was also known to the facility and staffs to slide, cross her leg over the pommel cushion and lean forward while seated in a wheelchair. Resident 10 was left unattended, seated in a wheelchair with a pommel cushion (made of dense foam to keep the patient from sliding out of the wheelchair). Resident 10 fell forward and sustained facial, nose, and mouth injuries. Definitions: Alternating pressure pad - APP - mattress covering connected to a pump that alternately inflates and deflates air cells at variable pressure settings. Pain scale - standardized scale used for pain assessment and documentation of assessments. A scale of 0 (no pain) -10 (worst hurt) is used for verbal description or facial grimace evaluation to determine pain levels. The scores are stated as 4/10, 5/10, etc. Findings: 1. Clinical record review on 12/11/12, of Resident 10 showed that she was an [AGE] year old initially admitted to the facility on [DATE] with history of falls, and Alzheimer's Disease. The Facility's fall risk assessment dated [DATE], 5/16/12, and 8/1/12 showed that Resident 10 was at high risk for falls. The initial PT (Physical Therapy) assessment, dated 7/18/12, showed that Resident 10 had constant tremor (shakiness) on both hands wrists and more pronounced on right side. According to the PT notes, Resident 10 required 100% physical assistance by one or more persons to position , even with constant cueing , resident was unable to sustain and perform each gross motor action of the positioning. PT was discontinued on 8/2/12. The PT note reflected, "Pt. (patient) will be monitored by staff for proper positioning in wheelchair. Precaution: High risk of fall." The Rehab (Rehabilitation) Director was interviewed on 12/12/12, at approximately 10 a.m.. He stated that Resident 10 was known to the PT department and staff were well aware of her care. Rehab Director stated that Resident 10 tended to slide out of the wheelchair while seated up in spite of the pommel cushion and known to lean forward when seated in wheelchair. His instruction and recommendation to prevent Resident 10 from leaning forward while seated in the wheelchair was, that the staff should position resident properly, seated back in the wheelchair and recommended that the facility should use a wedge cushion in her wheelchair (a cushioned seating device wherein the front part cushion is higher than the back). In an interview on 12/11/12 at 3:40 p.m., (Certified Nurse Assistant ) CNA 3 stated he was assigned to Resident 10 regularly on the days that he was on schedule, and the day Resident 10 fell . CNA 3 stated that routinely he set up and got Resident 10 ready for dinner at approximately 10 minutes before 5 p.m.. CNA 3 described Resident 10 as high risk for falls, and needed to be watched constantly. Staff were to keep an eye on her when she was seated in wheelchair. CNA 3 further stated that Resident 10 was not steady and not able to sit upright, she slipped and leaned on her right side or forward. Resident 10 crossed her legs over the pommel cushion. CNA stated that on 11/16/12, after he seated Resident 10 in her wheelchair, CNA 3 left the floor. Resident 10 was by herself in the room unattended. According to CNA 3, on the day of the incident he was assigned to take care of more residents on another floor. The DSD ( Director of Staff Development) was interviewed on 12/12/12 at 4:35 p.m.. During the interview the DSD stated, "I felt that there was not a high risk resident under his care." DSD was not aware that Resident 10 had a positioning problem of leaning forward, not steady, not able to sit upright. CNA 4 was interviewed on 12/12/12 4:05 p.m.. He stated that he was the first one who responded and found Resident 10 down on the floor, he saw the Resident 10 face down on the floor and there was, "Lots of blood" He called RN 2 for help. CNA 4 stated that he knew CNA 3 left Resident 10 alone in the room seated in the wheelchair, but he was not aware that CNA 3 was out on another floor. RN 2, the licensed nurse in charge, on 11/16/12. In an interview on 12/12/12 at 4:05 p.m., he stated that Resident 10 was well known to him, Resident 10 could slide out of her wheelchair and even when she was in bed. RN 2 further stated, "Resident 10 crossed her legs over the pommel cushion, and had the tendency to lean forward, that was why we have to keep constant eye on her". (Rehabilitative Nursing Assistant) RNA 1 was interviewed on 12/12/12 at 10 a.m.. She took care of Resident 10 after PT discharged her from their services and therapy. RNA 1 stated that Resident 10 was not able to follow instructions, she moved a lot, and needed constant supervision. The facility's full comprehensive assessment dated [DATE], reflected that she was totally dependent in most of her activity of daily living. On 10/10/12 an initial assessment was done by the hospice agency, reflected that Resident 10 had constant motion of upper and lower extremities and shifting of body. During an observation of Resident 10's care on 12/12/12 at 9:50 a.m., with CNA 2, who was regularly assigned to resident on day shift, Resident 10 was in a low bed. (bed positioned at its lowest close to the floor) There were two landing pads (padded mats) on each side of her bed. Resident 10's left arm had involuntary movements. She was awake, and verbally unresponsive. Resident 10's wheelchair with a pommel cushion was in the room. There was no Dycem (slip resistant usually made of rubber material) on the wheelchair. In an interview with the DON ( Director of Nursing) and Corporate Nurse Consultant on 12/13/12 at approx 4 p.m., both stated that the facility did not have a policy and procedure for the use of pommel cushion. A care plan for Resident 10's problem of high risk for fall dated and revised on 10/12/12 reflected, "Fall r/t (related to ) unaware safety needs. Confusion, incontinence. Dycem (slip resistant usually made of rubber material) and Pommel cushion on w/c (wheelchair for positioning)." One of the goals was, "The resident will be free of minor injury through the review date." Some of the interventions were: a. Anticipate and meet the resident's need. b. Ensure that the resident is wearing appropriate footwear non-skid when mobilizing in wheelchair. c. The resident has been evaluated for and supplied a pommel cushion for positioning due to her medical condition . Re-evaluate every shift and as needed for continued appropriateness and to ensure least restrictive device or restraint. The facility did not care plan and did not include Resident 10's problem of constant tremors, constant motion of upper and lower extremities and shifting of body, slipping and sliding out of the wheelchair, leaning forward when seated in the wheelchair and resident's crossing her legs over the pommel cushion when seated in wheelchair. On 11/16/12 at about 5:15 p.m. Resident 10 had a fall while seated in a wheelchair left alone and unsupervised in her room. According to the nurses progress notes, CNA 4 found Resident 10 on the floor face down, there was bleeding from resident's face. 911 was called and Resident 10 was transported to the acute care hospital's emergency room in a backboard with cervical neck collar. In an interview with Licensed nurse (RN 2), on 12/12/12 at 4:05 p.m., he stated that he was called by CNA 4 , he described and found Resident 10 down on the floor face down and bleeding, "Moderately", the pommel cushion was on top of resident's lower back her feet was crossed and under the wheelchair. Review of the acute hospital record indicated that Resident 10 sustained the following injuries : a. upper outer lip laceration ( cut or jagged wound) 1 cm ( centimeter) size. b. upper inner lip laceration 1 cm x 2 cm. ( both lacerations were repaired under anesthesia) c. dental trauma ( mildly displaced left incisor (tooth) ). d. bilateral ( both) nasal bone fractures ( a bone break). e. left frontal, periorbital ( around eye) and nasal soft tissue swelling. f. fracture of upper alveolar ridge ( Reference: Mosby's Medical Dictionary, 8th edition. the bony ridge of the jaw that contains the teeth). The DON was interviewed on 12/12/12 at 4:49 p.m.. There was no post fall assessment done for Resident 10. A blank post fall assessment form was presented to the surveyor. On 12/14/12 at approximately 9:30 a.m. during a visit to Resident 10's room, CNA 7 was observed attending to the resident. CNA 7 stated that after she did Resident 10's morning care, she sat her up in her wheelchair, and placed a bedside table in front of Resident 10 to prevent her from falling forward. According to CNA 7, while she was changing Resident 10's bed, Resident 10 fell forward and hit her head on the bedside table which was placed in front of Resident 10. CNA 7 reported this incident to RN 3 and MD 2.