Every finding on record at Pruitthealth - Sylvester

Based on observations, staff interviews, and review of facility policy titled, Medication Storage Policy, the facility failed to ensure medications were secured for one of four medication carts reviewed. Findings include:The facility policy titled Medication Storage Policy, dated 11/10/2025, revealed under Policy Statement: . It is the policy of [facility] to ensure all medications are stored, secured, and maintained in accordance with federal, state, and facility standards to promote patient safety and regulatory compliance. Medication storage areas including medication and treatment carts, medication rooms, and refrigerator must be clean, organized, and properly secured at all times.Observation on 07/18/2026 at 9:25 AM until 9:31 AM revealed medication cart unlocked and left unattended located in between two resident rooms on Hall -Wing One. LPN AA was in R38's room performing g-tube treatment with the door open and the privacy curtains closed preventing line of sight to the hallway and the medication cart. R80 was observed in the hallway within proximity to the med cart. Interview and confirmation on 03/07/2026 at 9:25 AM with Licensed Practical Nurse (LPN) AA, confirmed that the medication cart was unlocked and unsupervised. She confirmed that she was in R38's room performing g-tube treatment with the privacy curtains pulled which prevented her from seeing the medication cart. She identified the resident who was standing on the hall within proximity to the cart as R80.Interview on 07/18/2026 at 10:01 AM with the Director Health Services (DHS) reviewed the photographic evidence which was a photo of medication cart being unsupervised and not locked. She verified that R80 was standing in the hall within proximity to the cart. The DHS stated that the photo taken showed LPN AA did not have line of sight of the medication cart. She reported that her expectation is that nursing staff ensure that medication cart is locked.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that three of 27 residents (R) (R81), (R2), and (R41) receiving oxygen were administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R81, at risk for respiratory complications and a diminished quality of life. Findings include: Record review of the facility policy titled, Oxygen Administration, documented it is the policy of (facility) to provide oxygen safely and accurately to appropriate patients/residents. 4. Regulate liter flow to ordered/desired flow rate. Review of the electronic health record (EHR) for R81 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), chronic diastolic (congestive) heart failure, morbid (severe) obesity, and hypertension. Review of the Quarterly Minimum Data Set (MDS) for R81, dated 04/21/2026, revealed that Section O (Special Treatment Procedures, Program) revealed the resident received oxygen therapy. Section C (Cognitive Patterns) revealed a Brief Interview Mental Status Score (BIMS) of 12, which indicates cognitive awareness with little to no period of confusion. Review of the physician orders for R81 revealed an order dated 04/30/2024 for oxygen at two liters per minute (2 LPM) via (by) nasal cannula prn (as needed) for SOB (Shortness of Breath) or SAT (saturation) lower than 92% every day, every night. Observations on 07/17/2026 at 12:20 PM to 12:35 PM, 07/17/2026 at 3:49 PM, and 07/18/2026 at 9:07 AM revealed R81 lying in bed and receiving oxygen by nasal cannula with the flowrate set to one and half liters (1.5 LPM). During an observation on 07/18/2026 at 4:15 PM, with the Licensed Practical Nurse (LPN), the LPN AA confirmed that the oxygen was set to 1.5 LPM and adjusted it to 2 LPM. She reported being unaware that resident flowrate was set on the wrong liter. She confirmed that R81 requires a Hoyer lift due to being non-ambulatory and was unable to get out of bed to adjust his flowrate setting without staff assistance. Interview with Director of Health Services (DHS) on 07/18/2026 at 10:03 AM, the DHS reported that her expectations are for her nursing staff to ensure that all resident oxygen is set according to physician order. She reported being unaware that R81 's oxygen flowrate was set incorrectly. Interview on 07/19/2026 at 12:52 PM with the Administrator reported being unaware that R81 's oxygen flowrate was set on the incorrect setting. She reported that once the deficient practice was identified by the survey team for all the residents (R81), (R2), (R41), she provided education to her staff on ensuring correct oxygen flowrate. The Administrator reported that her expectation is that her nursing staff check the resident oxygen every two hours to ensure flowrate is accurate. Review of the electronic health record (EHR) for R41 revealed diagnoses including, but not limited to, Chronic diastolic (congestive) heart failure, Chronic respiratory failure with hypoxia, and chronic respiratory failure with hypercapnia. Review of the Quarterly Minimum Data Set (MDS) for R41, dated 4/16/2026, revealed that Section C (Cognitive Patterns) revealed that her BIMS (Brief Interview of Mental Status) score was 10. Section O (Special Treatment Procedures, Program) revealed that the resident received oxygen therapy. Review of the physician orders for R41 revealed an order dated 06/09/2026 for oxygen at 2 liters per minute (LPM) via (by) nasal cannula PRN. Observations on 07/17/2026 at 3:50 PM revealed R41 lying in bed receiving oxygen by an oxygen concentration via a nasal cannula with the flow rate set to three LPM. Observations on 07/18/2026 at 9:03 AM revealed R41 lying in bed receiving oxygen by an oxygen concentration via a nasal cannula with the flow rate set to three LPM. During an observation on 07/19/2026 at 10:06 AM, with Registered Nurse (RN) CC, R41 was lying in bed receiving oxygen by an oxygen concentration via a nasal cannula with the flow rate set to three LPM. RN CC confirmed that the oxygen was set to three LPM and adjusted it to two LPM. Interview with Director of Health Services (DHS) on 07/19/2026 at 11:30 AM, the DHS reported that her expectations are for her nursing staff to ensure that all resident oxygen is set according to physician order. Interview on 07/19/2026 at 1:05 PM with the Administrator revealed that she expected staff to check the resident oxygen every two hours to ensure the flowrate was accurate. Review of the electronic health record (EHR) for R2 revealed diagnoses including, but not limited to, Atherosclerotic heart disease of native coronary artery without angina pectoris (Primary, Admission), Unspecified osteoarthritis, unspecified site, Chronic obstructive pulmonary disease, unspecified, Hypertensive heart disease without heart failure, Review of the Quarterly Minimum Data Set (MDS) for R2, dated 04/10/2026, revealed that Section C (Cognitive Patterns) revealed that her BIMS (Brief Interview of Mental Status) score was 9. Review of the physician orders for R2 revealed an order dated 05/12/2026 for oxygen at 2 liters per minute (LPM) via (by) nasal cannula PRN. Observations on 07/17/2026 at 3:15 PM revealed R2 lying in bed receiving oxygen via a nasal cannula with the flow rate set to three LPM. Observations on 07/18/2026 at 10:03 AM revealed R2 lying in bed receiving oxygen by an oxygen concentrator via a nasal cannula with the flow rate set to three LPM. During an observation on 07/19/2026 at 10:15 AM, with Registered Nurse (RN) CC R2, was observed lying in bed receiving oxygen by an oxygen concentration via a nasal cannula with the flow rate set to three LPM. RN CC confirmed that the oxygen was set to three LPM and adjusted it to two LPM. RN CC confirmed that R2 was unable to change the oxygen setting Interview with Director of Health Services (DHS) on 07/19/2026 at 11:30 AM, the DHS reported that her expectations are for her nursing staff to ensure that all resident oxygen is set according to physician order. Interview on 07/19/2026 at 1:05 PM with the Administrator revealed that she expected staff to check the resident oxygen every two hours to ensure the flow rate was accurate.

Based on observations, staff interviews, record review, and review of the facility policy titled Care Plans, the facility failed to follow care plans for two of 32 sampled residents (R) (R81) and (R41). This deficient practice had the potential to place R81 at risk of not receiving treatment and/or care in accordance with their needs.Findings include: Record of the facility policy titled Care Plan dated 10/21/2025 3. The comprehensive person-centered care plan is developed to include measurable goals and time frames to meet a patient/resident 's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive care plan should describe the following (4). The care plan will contain 4 main components: Problem, Goal, Approaches and Role or Accountability The care plan approach serves as instructions for the patient/resident 's care and provides continuity of care by all partners. Review of the electronic health record (EHR) for R41 revealed diagnoses including, but not limited to, Chronic diastolic (congestive) heart failure, Chronic respiratory failure with hypoxia, and chronic respiratory failure with hypercapnia. Review of the Quarterly Minimum Data Set (MDS) for R41, dated 04/16/2026, Section O (Special Treatment Procedures, Program) revealed that the resident received oxygen therapy. R41 physician order dated 06/09/2026 for oxygen at two liters per minute (LPM) via (by) nasal cannula PRN (as needed). for SOB (Shortness of Breath) or SAT (saturation) lower than 92% every day, every night. Observations on 07/17/2026 at 3:50 PM, 7/18/2026 at 9:03AM, and 07/19/2026 at 10:06 AM revealed R41 was lying in bed and receiving oxygen by oxygen concentrator by nasal cannula with the flowrate set to three liters (3 LPM) instead of 2 LPM per physician order. Review of the care plan (last revised) for R41 revealed a Problem area which stated R41 is at risk for impaired gas exchange R/T CHF (related to congestive heart failure) and COPD (Chronic Obstructive Pulmonary Disease. R41 has PRN (as needed) O2(oxygen). The Goal was Resident will have an effective gas exchange as evidenced by clear breath sounds, mental status within normal limits, skin color within normal limit. The approaches stated Administer oxygen as ordered. Observe oxygen precautions. Interview with MDS Director on 07/19/2026 at 2:15 PM revealed when it comes to care plans, she expects staff to follow the care plans. She stated she reviews changes every morning in clinical meetings and then care plans are updated. Those changes are communicated to staff when they occur. Record review of R81's electronic health record (EHR) revealed the following diagnoses but not limited to chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and morbid (severe) obesity. Record review of R81's Quarterly Minimum Data Set (MDS) dated [DATE] for Section O (Special Treatment Procedures, Program) assessed R81 for oxygen therapy. R81's physician order dated 04/30/2024 stated oxygen at two liters per minute (2 LPM) via (by) nasal cannula prn (as needed) for SOB (Shortness of Breath) or SAT (saturation) lower than 92% every day, every night. Observations on 07/17/2026 at 12:20 PM to 12:35 PM, 07/17/2026 at 3:49 PM, and 07/18/2026 at 9:07 AM revealed R81 lying in bed and receiving by nasal cannula with the flowrate set to one and half liters (1.5 LPM) instead of 2 LPM per physician order. Record review of the care plan (last revised) for R81 revealed a Focus area which stated R81 requires oxygen therapy PRN for shortness of breath r/t (relate to) CHF and COPD has altered respiratory status/difficulty breathing related to anxiety, asthma, and COPD. The Goal was for the resident to have no complications related to shortness of breath. The Interventions/approaches documented administered oxygen as order. Observe oxygen precautions. Interview on 07/19/2026 at 12:47 PM with MDS Case Mix Director (CMD), (CMD DD) reported that her expectations are for the nursing staff to administer the oxygen as ordered.

Based on observations, staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents the facility failed to ensure two of 32 sampled residents (R) (R58) and (R67) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility. A review of the facility policy titled, Self-Administration of Medications by Patients/Residents dated 12/11/2025 documented, Each patient/resident who desires to self-administer medication is permitted to do so if the health care center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients /residents of the healthcare center. Medication self administration also applies to family members who wish to administer medication.3. If the Licensed nurse determines the patient /resident or family member to be capable of self -administration of medications, the attending physician must write an order to that effect that includes the specific medications based off of the Self Administration Medication Observation. A review of clinical records for R58 revealed the following diagnoses, but not limited to, type 2 diabetes mellitus without complications, peripheral vascular disease, unspecified, unspecified systolic (congestive) heart failure, hypertension, and chronic kidney disease, stage 3. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R58 presented with a Brief Interview Mental Status Score (BIMS) of 15, indicating little to no cognitive impairments. An observation on 07/17/2026 at 12:25 PM of R58's room revealed the following over-counter medications, a jar of VapoRub cough cold medication and a container (medication) fluid ease leg therapy edema cream sitting on resident's bedside table. R58 reported that a nurse had given her the pills to take later. Further interview on 07/17/2026 at 1:10PM, R58 reported purchasing the cream herself and using the leg cream daily with the help of certified nursing assistant (CNA) and that nurse authorized her to self-administer the VapoRub medications as needed. A review of clinical records for R58 revealed an omission of a completed assessment to determine whether or not the resident was capable of Self-Administration of Medications. A review of R58 's care plan revealed no focus area for self-administration of medications. During an interview at the time of observation of resident R58's room on 07/17/2026 at 5:15 PM with the Director of Health Service (DHS), the DHS confirmed the medications in the resident room. DHS reported that resident was not capable of self-administering the medications without supervision. She reported being unaware of medications in the resident room and described the incident with medications as most likely being brought into the facility by the resident or her family. The DHS removed the medications from the room. During a later interview on 07/18/2026 at 10:20 AM with the Administrator, the Administrator reported being unaware of the medications at the R58 's beside. She confirmed that this was a deficient practice and in-services would be provided to her nurses. She reported that her expectations were that any unauthorized medications needed to be confiscated by the nurses and disposed of properly. The Administrator categorized the deficient practice of unsupervised medications as being a risk to resident safety for residents who wander and residents who may have allergies. An observation on 7/17/2026 at 10:48 AM of R67's room revealed R67 sitting up in bed with a bedside table in front of him. A a plastic 30 ml medicine cup with one (1) white round pill and one half (1/2) tab white pill inside the cup was observed on the table. R67 stated that he did not know what was in the cup, he did not know how long it was there, and he does not know who put it there. Surveyor exited R67 room and asked Licensed Practical Nurse (LPN) BB if she was the nurse for R67. LPN BB stated that she was R67 nurse, and she asked the surveyor if she could answer any questions about R67 for her. During an observation and interview with LPN BB on 7/17/2026 at 10:17 AM, LPN BB entered R67 room, picked up the medicine cup and looked at the pills in the cup. LPN BB confirmed the pills in the cup sitting on R67's bedside table. LPN BB stated that R67 was dumping all of his pills in his mouth as she was walking off, she stated that she thought that he had swallowed them. LPN BB apologized for R67 not taking all of his medications. LPN BB handed the medicine cup containing the pills to R67 and instructed him to take his pills. R67 took the cup, put the pills in his mouth, took a sip of water, and placed the cup on the bedside table. Interview on 07/10/2026 at 11:40 AM with the Director of Nursing (DON) revealed R67 had a history of spitting out his medications. The DON revealed the resident's care plan was updated to include this behavior. The DON revealed she expected the administering nurse to complete the medication pass by staying in the room until the resident swallowed all medications. Review of R67's annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIM) score of 12. A BIM score of 12 indicating moderate cognitive impairment. Review of progress notes for the last year revealed there was no documentation of R67 spitting out medications. Review of R67 care plan revealed care plan with a revision date of 7/19/2026 at 11:51 am.

Based on observation, record review, and interview, the facility failed to ensure bathing and personal hygiene assistance were provided for one of three residents (Resident (R) 92) reviewed for bathing out of 32 sample residents. This failure had the potential to cause residents' bathing and personal hygiene preferences not to be met. Findings include: Review of R92's Face Sheet located in the resident's electronic medical records (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included bilateral above-the-knee amputations. Review of R92's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/2025 and located in the resident's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out 15 points which indicated the resident was cognitively intact. The MDS indicated the resident did not exhibit any behaviors such as resisting care. The resident was assessed to require substantial to maximal assistance with personal hygiene. Review R92's Care Plan revised on 4/9/2025and located in the resident's EMR under the Care Planning tab revealed the resident needed assistance with activities of daily living (ADLs). Interventions included checking nails and assisting with care as tolerated and resident requires assistance with bathing. Observation and interview on 4/22/2025 at 10:28 am, R92 was lying in bed wearing a green tee shirt and an adult brief. The resident's hair was matted and uncombed, and his face was unshaven. The resident had long discolored fingernails with brown colored matter underneath the nails. R92 stated had not received a bath or shower since his admission to the facility. The resident stated that he was left lying wet, in urine, for long periods. The resident also stated that he did not like long fingernails and wished the staff would trim and clean his nails. Observation on 4/22/2025 at 1:30 pm revealed R92 was lying in bed and still wearing a green tee shirt and an adult brief. The resident remained unshaven, and his hair matted and uncombed. The resident's fingernails were long and discolored with brown matter underneath the nails. Observation on 4/23/2025 at 8:56 am revealed R92 was lying in bed and still had on the same green shirt as the day before and an adult brief. The resident's hair remained uncombed, and his face unshaven. The resident's fingernails were trimmed, but still had brown colored matter underneath the nails. Observation and interview on 4/23/2025 at 11:44 am, R92 was lying in bed with the same green shirt on as in the previous observations and in a freshly changed adult brief. The resident's hair remained matted and uncombed, and his face was unshaven. R92's fingernails had brown residue underneath the nails. R92 stated the staff had just changed his brief; however, the staff did not offer to bathe him or wash his face. The resident stated the staff did trim his nails, but that stuff remained under his nails. The resident stated the staff did not offer to soak his hands to clean under the nails. Observation on 4/23/2025 at 3:00 pm revealed R92 was still wearing the same green shirt in only a brief, his hair matted and uncombed, and his fingernails with brown matter underneath the nails. Interview on 4/24/2025 at 10:10 am with Licensed Practical Nurse (LPN) 5 revealed R92 had never requested to have a shower. The LPN stated R92 would take bed baths but had a habit of refusing the bed bath at times. LPN5 stated the resident's refusal for bed baths was never documented. LPN5 stated the resident's tasks had to be segmented, meaning the staff had to perform the care in segments and not all at once. LPN5 also stated the resident was particular about nail care because the fingers were tender. LPN5 stated that she did not know if this was documented in his care plan. An interview on 4/24/2025 at 10:10 am with a Certified Nursing Assistant (CNA) 4 revealed she provided R92 with a complete bed bath, nail care, and encouraged the resident to be out of bed on this date. CNA4 stated that she was able to trim R92's fingernails on 4/23/2025, but really cleaned them today. CNA4 also stated the resident refused to take a bed bath yesterday, and she notified the nurse. Interview on 4/24/2025 at 2:30 pm with the Director of Nursing (DON) revealed R92 would at times refuse care; however, she was unaware that the resident's MDS and care plan did not reflect his refusal of care. The DON was unable to provide documentation of the resident's refusal of personal hygiene care. The DON stated the facility did not have a policy for ADL care or shower/bath.

Based on observation, interview, and record review, the facility failed to ensure call devices were accessible for one of 33 residents (Resident (R) 68) observed for call light accessibility. This failure had the potential to place R68 at risk of accident, injury, or unmet needs related to an inability to call for staff assistance. Findings include: Review of R68's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including diabetes, dementia with agitation, insomnia, dizziness and giddiness, anxiety, lack of coordination, muscle weakness, and orthostatic hypotension. Review of R68's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/7/2025 and located under the MDS 3.0 Assessments tab of the EMR, revealed she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The MDS also revealed R68 was independent with bed mobility and transfers, and required setup/clean up assistance with using the bathroom. She used a wheelchair for locomotion. Review of R68's Care Plan, dated 4/9/2025 and located under the Care Plan tab of the EMR, revealed, [R68] is at risk for falls related to chronic orthostatic HTN [hypertension], dementia, hx [history] of CVA [stroke], and syncope. The approaches included: encourage resident to call for assistance with mobility and place call light within reach. During observations on 4/22/2025 at 10:08 am and 11:56 am in R68's room, the resident was lying in bed. Her call light cord was coiled and hanging on the call box on the wall behind the head of her bed, approximately three feet away. During an observation on 4/22/2025 at 1:57 pm in R68's room, the resident was lying in bed awake. Her call light cord was coiled and still hanging on the wall behind the head of the bed. During a concurrent interview, R68 stated the call light button was not in a place where she could reach it and stated she needed it to be within reach to call for help. She stated, They were cleaning, and they forgot to move it back, and added that it should be on her bed. During an interview and concurrent observation on 4/22/2025 at 2:03 pm, Licensed Practical Nurse (LPN) 4 stated R68 was able to use her call light, and it should be placed within reach. LPN4 entered R68's room and confirmed the call light was not within the resident's reach. LPN4 moved the call light from the wall to R68's bed, and R68 was grateful. During an interview on 4/22/2025 at 2:05 pm, Certified Nurse Aide (CNA) 2 stated she typically placed the call light on R68's bed; however, sometimes the housekeeping staff moved it for cleaning and forgot to return it to the bed. CNA2 stated R68 would not be able to coil up her call light cord and hang it on the wall; she did not know how it got there. During a concurrent interview on 4/25/2025 at 11:25 am with the Administrator and Director of Nursing (DON), the DON stated all staff in-service trainings were held periodically, which included housekeeping staff, regarding the placement of call lights within resident reach. The DON stated that the training and her expectation were that the call light should be within reach of residents while they were in bed. The Administrator stated the facility did not have a policy addressing call light accessibility.

Based on observation, interview, record review, and review of the facility's policy titled Enteral Nutrition (Tube Feeding), the facility failed to ensure gastric residual was checked prior to administering enteral nutrition via gastrostomy tube (G-Tube) for one of two residents (Resident (R) 65) reviewed for G-Tubes out of 36 sampled residents. The failure to check R65's gastric residual increased the risk that the resident could experience health complications associated with the stomach not digesting the contents as expected. Findings include: Review of the facility's policy titled, Enteral Nutrition (Tube Feeding), reviewed 9/12/2024, revealed, .Procedures .2. The physician writes orders prescribing the formula, rate, route of administration, and flush orders for the individualized resident/patient. Review of R65's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 2/26/25 and located in the Aspen MDS Viewer, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE]. The MDS also revealed the resident was assessed as having a feeding tube (G-Tube) and received 51 percent or more of her calories via tube feeding for seven of seven days of the seven-day assessment period. Review of R65's Physician Orders found in the electronic medical record (EMR) under the Orders tab revealed an order dated 4/9/2025 of G-Tube: Check for residual before feeding. If residual is greater than 100 mL [milliliters], hold feeding and call MD [medical doctor] for further orders. Observation on 4/24/2025 at 2:10 pm, Licensed Practical Nurse (LPN) 2 approached R65 to start the G-tube feeding. LPN2 flushed the resident's G-tube with 30 mL of water. LPN2 then connected the line coming from the nutritional supplement and enteral feeding pump to the resident's G-tube and started the feeding. The LPN did not check the resident's gastric residual prior to the start of the enteral feeding pump. During an interview 4/24/2025 at 3:55 PM, LPN2 confirmed she did not check the resident's gastric residual per R65's physician's order. During an interview on 4/24/2025 at 4:45 pm, Registered Nurse (RN) 1 was asked to describe the process for checking a resident's gastric residual. RN1 stated that a clear syringe with a plunger should have been connected to the resident's G-tube, and the nurse should have slowly pulled out on the plunger to check and see if there was any gastric residual from the resident's last feeding. RN1 stated the nurse should have measured the amount of residual (if any) to ensure it was 100 mL or less prior to starting the resident's feeding.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Enhanced Barrier Precautions, the facility failed to maintain their infection control and prevention program related to Enhanced Barrier Precautions (EBP) and hand hygiene for two of 15 residents reviewed for EBP (Resident (R) 211 and R65). Staff failed to wear the required personal protective equipment (PPE) while providing care to both residents. Additionally, nursing staff failed to perform hand hygiene in between glove changes when providing care to R65. These failures placed the residents at an increased risk of developing an infection. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, revised 4/30/2024 indicated .Enhanced Barrier Precautions refers to an infection control interventions designed to reduce transmission of multi-drug resistant organism that employs targeted gown and gloves use during high contact resident care activities .wounds (i.e chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (i e. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes even if the resident is known to be infected or colonized with a multi-drug resistant organism (MDRO) . 1. Review of R211's Face Sheet located in the resident's electronic medical records (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarct with right side hemiplegia and hemiparesis; dysphagia, and post-gastrostomy. Review of R211's Physician's Order dated 4/3/2025, located in the resident's EMR under the Orders tab, revealed the resident was ordered Jevity 1.5 calorie (a nutritional supplement used for enteral feeding) feeding at 57 milliliters (mL) per hour for 20 hours. The order also indicated Enhanced Barrier Precautions. Observation on 4/22/2025 at 11:00 am revealed signage on R211's room door that indicated the resident was on EBP precautions. The signage directed staff to wear a gown and gloves when providing resident care. During an observation on 4/22/2025 at 1:55 pm, Licensed Practical Nurse (LPN) 5 entered R211's room carrying tube feeding supplies without donning a gown or gloves. LPN5 then exited the resident's room carrying an old tube feeding. Observation on 4/22/2025 at 2:05 pm revealed LPN5 entered R211's room again with tube feeding supplies and the LPN did not don a gown or gloves. Continued observation of the nurse in R211's room revealed LPN5 connected the resident's Gastronomy Tube (G-tube), and she did not have on a gown or gloves. During an interview on 4/22/2025 at 1:57 pm, Family Member (F) 211 stated she was in the room when LPN5 was working on the resident's feeding tube, and the LPN was not wearing a gown or gloves. During an interview on 4/22/2025 at 2:20 pm, LPN5 stated R211 was on EBP because he had a gastrotomy tube with a dressing. LPN5 acknowledged that she failed to follow the facility's EBP protocol for donning a gown and gloves when providing care for this resident. During an interview on 4/25/2025 at 10:00 am, the Assistant Director of Nursing (ADON), who was also the facility's Infection Preventionist, stated LPN5 had made her aware that she failed to follow the EBP guidance for PPE. 2. Review of R65's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 2/26/2025 and located in the Aspen MDS Viewer, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE]. The MDS also revealed the resident was assessed as having a feeding tube (gastronomy tube [G-Tube]) and received 51 percent or more of her calories via tube feeding for seven of seven days of the seven-day assessment period. Review of R65's Physician Orders found in the electronic medical record (EMR) under the Orders tab revealed an order dated 4/9/2025 of G-Tube: Check for residual before feeding. If residual is greater than 100 mL, hold feeding and call MD [medical doctor] for further orders. Observation on 4/22/2025 at 10:25 am revealed signage posted outside of R65's door, which indicated the resident was on EBP and directed that the personal protective equipment (PPE) of a gown and gloves was to be worn when staff were providing care to the resident. Continued observation revealed R65 was lying in bed in her room, being administered an enteral feeding, and her enteral feeding pump was sounding an audible alarm. R65 was receiving enteral feeding via her G-tube. During an observation and interview on 4/22/2025 at 10:27 am, Registered Nurse (RN) 2 entered R65's room to respond to the resident's enteral feeding pump alarm. The RN stated the alarm was informing her that the feeding was complete. RN2 then disconnected the feeding tube line from the resident's G-tube. Observation and interview on 4/24/2025 at 2:10 pm revealed LPN2 entered R65's room to restart the resident's enteral feeding pump. LPN2 performed hand hygiene and then donned a gown and gloves. Prior to approaching the R65, LPN2 doffed her gloves, adjusted her eyeglasses, rubbed her eye, and then donned new gloves. LPN2 then flushed R65's G-tube with water, attached the tubing to the G-tube, and started the enteral feeding pump. LPN2 did not perform hand hygiene prior to placing new gloves on after adjusting her glasses and rubbing her eye. LPN2 acknowledged that hand hygiene should have occurred between glove changes.

Based on interview, record review, and policy review, the facility failed to ensure that an allegation of abuse and misappropriation of property was reported to the State Survey Agency in a timely manner for one resident (A) from a total sample of 19 residents. Findings include: The facility had a Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy, last revised 7/29/2019. The policy documented that any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator. The policy also included that the Administrator or his or her designee should notify the appropriate state agency of any allegation or incident previously described and of the pending investigation. During an interview on 3/7/2022 at 10:53 a.m. Resident (R) A alleged that she was fearful of Licensed Practical Nurse (LPN) DD because the nurse purposely removed three medications ([MEDICATION(S)], Requip and [MEDICATION(S)]) from her medication packs on 1/8/2022. RA stated that she reported her concerns to the Administrator and Director of Nursing (DON). During an interview with the Administrator and DON on 3/8/2022 at 9:50 a.m., the DON stated, when she was making rounds, RA reported that she was afraid LPN DD was going to stab her with an insulin needle and she accused the nurse of stealing her medications. The DON stated that she immediately notified the Administrator and LPN DD was suspended that same day also. The DON stated that RA reported the allegations to her on 1/16/2022. However, although the Administrator and DON were made aware of RA's allegations and began an investigation on 1/16/2022, a report to the State Survey Agency was not initially sent until 1/18/2022. A review of the Facility Incident Report Form, initially submitted to the State Survey Agency by the Administrator, is dated 1/18/2022. The form includes that RA accused LPN DD of administering insulin in an inappropriate manner and taking her medications. The report documents that an investigation was started and LPN DD was suspended pending the investigation results. A Follow Up Report submitted to the State Survey Agency, dated 1/26/2022, indicated that the facility could not substantiate RAs allegations, but that LPN DD received in-service education on insulin administration and was assigned to a different area of the facility. During the interview on 3/8/2022 at 9:50 a.m. the Administrator stated she could not recall why the allegation was not reported earlier. The Administrator provided additional information on 3/10/2022 at 11:47 a.m., via email correspondence, that she was out of town on 1/16/2022 and unable to travel to the facility due to snow. She called and spoke with RA and let her know she would see her on Tuesday morning (1/18/2022), which is when the initial report to the State Survey Agency was submitted.

Based on interviews, record review, and policy review, the facility failed to ensure that medications were administered as ordered and accurately documented in the clinical record for one resident ( RA) from a total sample of 19 residents. Findings include: During an interview on 3/7/2022 at 10:53 a.m. Resident (R) A stated that last Friday (3/4/22) Licensed Practical Nurse (LPN) BB came into her room and told her she had no medications for the day and she would try and get the medications out of the machine (faclity's medication dispensing system). RA stated that LPN BB was able to get all but two of her (9 a.m.) medications; [MEDICATION(S)] and [MEDICATION(S)]. RA further stated that her blood sugar was 246 around 4:00 p.m. and she received insulin. During an interview on 3/8/22 at 9:50 a.m. the Director of Nursing (DON) stated that the pharmacy did not run Thursday night (3/3/22) as usual. She found out about it on Friday morning and called the pharmacy and they said they would send out medications on the evening delivery and any medications needed before then could be pulled from the CubeX (the facility's medication dispensing system). Review of the clinical record revealed RA had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, a review of pharmacy report from 3/4/22 for the medication dispensing system onsite at the facility, revealed the [MEDICATION(S)] (also known as [MEDICATION(S)]) was not signed out until 4:36 p.m. During an interview on 3/9/22 at 12:50 p.m. LPN BB confirmed that she signed out the [MEDICATION(S)] late on 3/4/22 because she initially overlooked it earlier that morning due to it being listed under the generic name of [MEDICATION(S)]. RA had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, during an interview on 3/8/22 at 11:21 a.m. the DON stated that LPN BB told her that RA received all of her 9:00 a.m. medications on 3/4/22 except the [MEDICATION(S)] and that she signed the medication as being administered in error. During an interview on 3/9/22 at 12:50 p.m. LPN BB confirmed that RA did not receive [MEDICATION(S)] as ordered and documented on 3/4/22 because it was not available in the medication dispensing system or on the medication cart. RA had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN BB recalled the 4:30 p.m. blood sugar level being 219 or 220 and administering 2 units of insulin coverage. During the interview, the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, there was no documentation in the clinical record of RA receiving 2 units of insulin coverage on 3/4/22 at 4:30 p.m. for a blood sugar level of 219 or 220. During a subsequent interview on 3/9/22 at 1:15 p.m. LPN BB stated RA did not have an physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review, and policy review, the facility failed to ensure the medication error rate was less than 5%. A total of 38 opportunities were observed with nine errors for three residents (R#5, R#6, and R#7) for an error rate of 23%. Findings include: The facility had a Medication Administration: General Guidelines policy. The policy documented that if the facility receives its medications packed with the AdvantageRx system the authorized personnel will compare the AdvantageRx bag to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At the end of each medication pass, the person administering the medications reviews the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, during medication administration observations on 12/1/21, Licensed Practical Nurse (LPN) BB failed to access the electronic MAR's, to ensure all necessary medication doses were administered as ordered and scheduled, for R#5, R#6 and R#7, resulting in nine medication omission errors. On 12/1/21 at 9:35 a.m. the computer tablet on one of the two Wing 2 medication carts was observed not working. LPN BB, who was working on the medication cart confirmed that the tablet was not working. When LPN BB was questioned about how she confirmed medication orders before administering medications, she stated that she reviewed all the MAR's before starting (medication administration) and received order changes from the shift report and that she was already familiar with the cart and the residents. She did not use an alternate method to confirm medications as she administered medications to each resident. Record review revealed R#5 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications were scheduled to be administered at 9:00 a.m. However, during an observation of medication administration on 12/1/21 at 9:42 a.m. for R#5, LPN BB failed to include and administer the medications as ordered. Record review revealed R#6 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications were scheduled to be administered at 9:00 a.m. However, during an observation of medication administration on 12/1/21 at 9:48 a.m. for R#6, LPN BB failed to included and administer the medications as ordered. Record review revealed R#7 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications were scheduled to be administered at 9:00 a.m. However, during an observation of medication administration on 12/1/21 at 10:02 a.m. for R#7, LPN BB failed to include the medications and administer as ordered. During a follow up interview on 12/1/21 at 11:02 a.m., in response to the omission errors for R#5, R#6 and R#7, LPN BB stated that all she could go by was what was in the packets (pre-packaged medication packets from the pharmacy) and that yes, there would be oversights but what could she do when the pharmacy already knows that the computer does not work. During interviews on 12/1/21 at 12:30 p.m. and 3:05 p.m. the Director of Health Services (DHS) stated that if the computer on the medication cart was not working, LPN BB should have obtained another tablet to use to look at orders when administering medications. The DHS stated that the pharmacist was not aware the computer tablet on the cart was not working.

Based on observation, interview and record review, the facility failed to ensure that a medication was reordered and administered in a timely manner for one resident ( R A) from a total sample of 13 residents. Findings include: During an interview on 11/30/21 at 1:45 p.m. Resident (R) A stated that her eye drops had not been replaced and she had not received them for a week. Review of the clinical record revealed RA had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of the medication cart on 12/1/21 at 10:05 a.m., with Licensed Practical Nurse (LPN) BB, a prescription bottle of [MEDICATION(S)] 0.025% eye drops were observed in the cart and labeled with RA's name and dated 11/30/21. LPN BB stated that the eye drops had come in yesterday (11/30/21) and that RA had been out of them for four or five days. LPN BB did not know if the medication had not been reordered timely by nursing staff or if the pharmacy was out of the medication. During an interview on 12/1/21 at 2:48 p.m. the Director of Health Services (DHS) stated that RA's eye drops were not reordered timely by nursing staff, they were not reordered until 11/29/21.

Based on observation, interview, record review, the facility failed to maintain kitchen floor clean; area surrounding fryer without grease build up, oven clean, kitchen walls in good condition; and failed to label and discard expired items. Findings include: Observations during the initial kitchen tour on [DATE] at 10:10 a.m. revealed the following: - Brown liquid on the floor by the hand washing sink - Wall behind the soiled dish table had peeling paint throughout multiple areas - Area between the floor and base board underneath the three-compartment sink had black build up - Area underneath deep fryer and gas pipes located next to it had grease build up - Two (2) expired chocolate half pint containers of milk which expired on [DATE] were noted inside the milk carton cooler - Milk carton cooler gasket with black residue and ice buildup throughout interior walls - Two packs of round sandwich meat located inside the three-door reach in refrigerator with a use by date of [DATE] but labeled [DATE] - Frozen liquid buildup (yellow and clear) on the inside bottom of the three-door reach in freezer - Dirty floor including one drinking cup and foam cup under the three cooling/freezer units (three (3) door reach in refrigerator, two (2) door reach in refrigerator, and three (3) door reach in freezer) - Chest freezer had a bag of frozen meat not labeled or dated and one (1) bag of chicken tenders with no label or date. Observation of Wing II Diet Kitchen on [DATE] at approximately 3:31 p.m. revealed the following: - six (6) 4-ounce (oz.) vanilla yogurt containers with an expired date of [DATE], - nine (9) 4 oz. vanilla yogurt containers with an expired date of [DATE], - three (3) 3.25 oz cups of orange/red jello with an expired date of [DATE], - an unlabeled (no name or date) plastic container with some liquid - a plastic shopping bag with some with spoiled food without name or label, - a small 10 oz bag of carrots with an expired date of [DATE] - one (1) 1000 milliliter (ml) bottle of Vital 1.5 calorie an expired date of [DATE]. Interview with Dietary Manager (DM) in the kitchen on [DATE] at approximately 10:40 a.m. revealed the staff have a cleaning schedule and the grease on the fryer was scheduled to be cleaned today. Upon showing her the round sandwich meat, the DM indicated it had a label, but when shown the package she confirmed it did say use by [DATE]. Regarding the meat not labeled or dated in the ice box she acknowledged it should had been labeled and dated. Interview and observations with Unit Manager CC of Wing II Diet Kitchen on [DATE] at 3:38 p.m. in the Wing II Diet Kitchen revealed the Vital 1.5 1000 ml bottle was expired, but it belonged to a resident that was no longer on enteral feedings. Unit Manager CC also confirmed the containers of yogurts and jello were expired; the plastic container was not labeled, and the food was in fact spoiled that was in the bag inside the refrigerator. An additional kitchen observation on [DATE] at approximately 11:22 a.m. revealed the gas pipes and floor area by the gas fryer continued to have grease buildup. During that observation the DM said they were going to clean in it. At approximately 11:23 a.m. a large 50-pound refined sugar bag was noted sitting on the floor by one of the shelfs in the dry storage room. Observation made when the staff opened the right oven door at approximately 11:30 a.m. revealed that half the interior door was covered with black grease buildup. Interview with the DM at 11:48 a.m. revealed a deep cleaning of the ovens was done on Mondays. Review of the housekeeping kitchen cleaning schedule revealed the last deep cleaning was done on [DATE] and the next cleaning was scheduled for [DATE]. Interview with Housekeeping Staff II on [DATE] at 3:08 p.m. in the conference room revealed when they did a deep cleaning of the kitchen they would normally deep clean the floors and use a scraper if needed for the areas by the base boards. Review of the kitchen cleaning schedule for (MONTH) (YEAR) revealed no one signed off at all for cleaning the fryer, stove/grill, or cleaning the base boards weekly all month of (MONTH) (YEAR).

Based on observations, staff and resident interviews, and record review, facility failed to allow resident group known as the Resident Council to meet without the presence of staff. This had the potential to affect census of 99 residents in the facility at the time of this survey. Findings include: Review of facility policy titled Patient/Resident Council policy and procedure (P&P) effective 3/1/08, reviewed 10/20/17, and revised 10/20/17 revealed the Recreation Services Director or Social Services Director will assist in the coordination of the council meetings as requested by the group President . Also, the P&P revealed that Minutes will be taken by the Council Secretary or designated staff liaison (at the request of the Council). On 8/20/18 at 11:00 a.m., a request was made of the Social Services Director (SSD), in her office, for arrangements to be made to conduct a Resident Council Meeting. The SSD stated she coordinates the Resident Council Meetings each month with the Recreation Services Director. SSD stated she attends the Meetings each month to write the minutes. Resident Council meeting was held on 8/21/18 at 3:00 p.m. with ten (10) residents and Social Services Director present. SSD was asked to leave the meeting, so residents could freely voice their opinions. She complied by leaving the room. Interview conducted with R#90 during the Resident Council Meeting held on 8/21/18 at 3:00 p.m. revealed that resident does wish to have a Resident CouncilePresident voted in, so the meetings could be held without the attendance of staff. And the members could have more freedom to discuss what they wanted. During the group meeting R#99 also expressed a desire to have a Resident Council President voted in so the meetings could be held without staff attendance. During the continued group meeting, R#7, R#30, R#35, R#39, R#45, R#52, R#65, R#90, R#99, and R#104 voiced they would like to hold meetings without staff being present. The Council Members all agreed they did not request for the SSD to attend the meetings or to take minutes during the meetings. They stated the SSD set the agenda and the tone for the meeting. The group also agreed that they are not able to speak freely so they meet in one of the resident's rooms for privacy. Interview conducted on 8/23/18 at 4:45 p.m. with the Administrator in his office. The Administrator stated the facility Resident Council currently does not have a President. The Social Worker attends and leads each meeting and takes minutes. He also stated the Resident Council has not had a person in President position since he started working at the facility. Review of written statement, undated, provided by the Administrator during this survey revealed(NAME)Health(NAME)does not have a resident council president.

Based on observation, record review and interview, the facility failed to ensure opened food items in the dry storage area were securely wrapped, labeled and dated; failed to ensure the microwave oven was clean from food debris; failed to discard food items by expiration date; failed to maintain proper cooler temperature for the milk cooler; failed to provide hot water in the kitchen for handwashing; and failed to demonstrate the usage of the three compartment sink to prevent food borne illness. In addition, the facility failed to maintain sanitary conditions of the Diet Kitchens on two of two units. The census was 106 and the sample size was 35. Findings Include: 1. During observation on 9/25/17 at 11:04 a.m., revealed an opened, undated gallon container of Tartar Sauce in the cooler with slimy, yellow substance around the rim of the container and lid, an opened, unlabeled and undated bag of pasta noodles, instant mashed potato bag with no open or use by date, and a box of croutons with three large bags of croutons with an expiration date of 6/1/16. Interview with Dietary Manager (DM) on 9/27/17 at 7:57 a.m., verified the jar of tartar sauce in the cooler did have slimy substance around the rim and lid, as well as opened and undated pasta noodles, instant potatoes and expired box of croutons in the dry storage. 2. During observation on 9/25/17 at 8:45 a.m., revealed the microwave oven in the main kitchen with dried food particles on round glass tray, both interior sides, roof and the inside of door. 3. During observation on 9/25/17 at 11:18 a.m., revealed the temperature of the milk cooler at 50 degrees Farenheit (F). The rubber seal from the lid of the chest cooler was hanging apart from the lid. One hour later the temperature was 46 degrees F. Interview with DM on 9/27/17 at 7:59 a.m., revealed the temperature of the milk cooler was 44 degrees F. She stated she was not aware the rubber seal on the cooler lid was broken. She stated she would call someone to come look at the milk cooler. Interview with DM on 9/27/2017 at 12:10 p.m., stated that she had put in service order with Mayfield to service the milk cooler. 4. During observation on 9/25/17 at 11:04 a.m., revealed there was no hot water at the handwashing station in the kitchen for two full days. Interview with DM on 9/27/17 at 7:59 a.m., stated she was not aware that the hot water at the handwashing station in the kitchen was not working. She attempted to turn the hot water on, but noted that the hot water knob was stuck and unable to turn on. She stated she would get maintenance department to look at the sink. 5. During observation on 9/27/17 at 8:48 a.m., dietary cook, GG washed dishes at 3 compartment sink. She first washed dirty dishes in first sink well with soap and water. She then placed the washed dishes directly into third sink well with sanitizing water. The sanitizing water tested to 200 ppm (Quaternary system). The second sink well was full with dirty pots and pans. 6. During observation on 9/26/17 at 11:59 a.m., revealed Diet Kitchens on two units to have temperature checklist posted on the door of the refrigerator indicating the temperature range to be between 36-46 degrees. No thermometer in the freezer and no freezer temps recorded for the month of September for either unit. Both Diet Kitchens revealed dried food particles in refrigerator and microwave oven, opened and unlabeled food items in refrigerator and personal items (purse, backpack and insulated lunch pack) stored in the diet kitchens. Interview with LPN unit manager II on 9/26/17 at 4:47 p.m., revealed that she believed it was the dietary departments responsibility to keep the diet kitchen clean. She further stated that no staff items are to be kept in the diet kitchen. There is a staff break room for staff to keep their items in. She stated she would have to find out how to get a thermometer for the freezer. Interview with LPN unit manager DD on 9/26/17 at 5:01 p.m., stated she believed that the housekeeping department was responsible for keeping the diet kitchen clean, but that it was her responsibility to make sure that the fridge is cleaned out with unlabeled items. She further stated that staff do not store their personal items in the diet kitchen. She stated she did not know the refrigerator temp had to be 40 degrees or below, since temp on check sheet stated temperature range from 36-46 degrees F. She further stated she did not know where to get a thermometer for the freezer, but she would find out. Interview with DM on 9/27/17 at 5:30 p.m., stated it was the responsibility of the dietary department for keeping the diet kitchens on the units cleaned, including making sure foods are discarded if not labeled with residents name or with use by dates. She further stated that staff are aware they are not to put their personal food items in the diet kitchen fridge/cabinets. Interview with Nurse Consultant HH on 9/26/17 at 5:15 p.m., stated she would make a new refrigerator check list with correct temperature range on it. She further stated would also add column for checking freezer temps. She stated she would get some additional thermometers for the freezers on both units.

Based on observation, record review, and staff interview, the facility failed to ensure that all components of the nurse call system in six resident bathrooms shared by 18 residents, and one of one women's common shower room on one of two units (Unit 1) were fully functional. Three of these 18 residents could use the bathroom independently. The facility census was 106 residents, and the sample size was 35 residents. Findings include: Observation on 9/25/17 at 3:20 p.m. revealed that the call light in the bathroom for rooms 22 and 23 shared by four residents did not work when pressed. This was verified during interview with Licensed Practical Nurse (LPN) Unit Manager DD at this time. Observation on 9/25/17 at 4:10 p.m. revealed that the bathroom call light for rooms 26 and 27 shared by four residents did not work. This was verified during interview with LPN Unit Manager DD at this time. On 9/26/17 at 9:40 a.m., the call light in the bathroom for rooms 11 and 12 shared by three residents was observed not to work when pressed. This was verified during interview with the Maintenance Director on 9/26/17 at 11:32 a.m. During observation on 9/26/17 at 3:30 p.m., all of the bathroom call lights on Unit 1 were checked with LPN EE, and the following call lights were noted to not work: Room 25 (private room): When the bathroom call light was pressed, the light above the door in the hall was observed to flicker weakly and then go off. During interview with LPN EE at this time, he stated that the call light would not stay pressed in when activated. Resident Women Bath: The light outside the door was observed to not illuminate when the call light was activated, but it did alarm at the nurse's station, and the location of the alarm was labeled and lit up on the call light console. Rooms 9 and 10 (shared by two residents): During observation at 3:48 p.m., an alarm at the nurse's station sounded when the call light was activated, but the location did not display on the console, and there was no light in the hallway outside the room. During interview with the Maintenance Director at this time, he stated that if this ever happened, staff would go room to room until they found the resident that activated the alarm. During further observations, all of the non-functional call lights were noted to be working within a few minutes after reporting the concern to the Maintenance Director. During interview with LPN FF on 9/27/17 at 2:04 p.m., she stated that one of the three residents that shared the bathroom in rooms 11 and 12 could independently use the bathroom. She stated during further interview that one of the two residents that currently shared the bathroom in rooms 9 and 10 could independently use the bathroom. During interview with LPN Unit Manager DD on 9/27/17 at 2:10 p.m., she stated that one of the four residents that shared the bathroom in rooms 30 and 31 could independently use the bathroom. She stated during further interview that none of the four residents that shared the bathroom in rooms 22 and 23, and 26 and 27 could independently use the bathroom. LPN DD added that the resident in room 25 could not independently use his bathroom.

Based on resident and staff interview the facility failed to ensure that residents receive delivered mail promptly within twenty (24) hours of delivery to the facility unopened, and on the weekends to include Saturdays. This deficiency has the potential to cause low morale and affect all residents who receive mail. The Census sample was 106. Findings Include: 09/28/2017 10:18 a.m. interview with the Town Hall representative resident (R) 43 revealed residents do not receive mail on Saturdays due to the persons who sort and deliver the mail after arrival to the facility on Saturday are not working. Although, residents are able to get their mail during the week, the mail is not delivered to the residents on Saturdays. Residents are required to wait to receive their mail on Mondays when the Bookkeeper and Activity director return. 09/28/2017 10:38 a.m. interview with the Activities Director revealed some of the residents' mail comes to the facility mail box, and some mail is delivered to the post office box at the post office. The weekend Supervisor/Manager are supposed to get the mail out of the facility mailbox and deliver the mail to the residents who received mail. 09/28/2017 11:29 a.m. interview with the Bookkeeper, revealed when mail is delivered to the facility she is responsible for sorting out the residents mail and the facility's mail from both the facility mailbox and the post office box. Interview revealed the mail is not delivered to the residents on Saturdays because she is only scheduled to work Monday's through Friday's, and to her knowledge there is not a designated person to deliver mail to the residents on the weekends. Any mail delivered on Saturday will wait until Monday to be delivered to the residents upon her return. During the interview the Bookkeeper revealed she was not aware that residents were to receive their mail on the weekends to include Saturdays. 09/28/2017 1:43:07 p.m. Administrator reported that mail delivery should be delivered to residents daily. If mail is delivered on Saturdays it should be delivered to the residents on and the RN supervisor should be responsible for this. The Facility failed to ensure residents were able to receive their mail on Saturday's without having to wait more than 24 hours for delivery.

Based on observation and interviews the facility failed to assure the maintenance and upkeep of resident wheelchairs related to buildup, chipped and stained floor tiles, and rust discoloring in the sinks. This affected 8 resident rooms and 5 residents (R#1, R#51, R#71, R#76, R#120, and R#121). The sample size was 35. Findings include: 1. Observation on 9/26/17 8:42 a.m. in room 9 the ceiling tile above the sink was water stained and has a crack in it. 2. Observation on 9/26/17 9:06 a.m. in room 56 there is white build up around faucet on sink in room 3. Observation on 9/26/17 9:30 a.m. in room 28 Flooring in bathroom to the right of the commode is stained light brown. 4. Observation on 9/26/17 9:39 a.m. in room 11 there was a Grayish-brown discolored flooring surrounding and behind commode. 5. Observation on 9/26/17 9:41 a.m. R#51 observed sitting in activity room in wheelchair and wheelchair noted to have buildup on the wheels. 6. Observation on 9/26/17 9:48 a.m. in room 29 revealed there was a brownish-yellow discoloration of the flooring behind and to the right of the commode. Five slats of the venetian blinds on the lower right side are bent outward. Light over the head of the bed does not work when the short cord is pulled. In addition, a resident in that bed would not be able to turn the overbed light on or off due to the cord extending only approximately four inches below the light. 7. Observation on 9/26/17 9:53 a.m. in room 52 revealed there are chipped pieces on the floor, white build up on sink fixtures, and yellow staining on floor tiles between the sink and closet. 8. Observation on 9/26/17 10:13 a.m.in room 31 revealed there was rust coloring around sink, staining on floor under sink, and staining on floor tile in bathroom around the toilet. 9. Observation on 9/26/17 11:54 a.m. in room 63 revealed there was staining on the floor tiles between the sink and closet. 10. Observation on 9/26/17 at 12:20 p.m. There was black stripping on the floor separating independent from dependent dining rooms that was cracked and curled. 11. Observation 9/27/17 9:52 a.m. in the activity room revealed that the wheelchairs for R#76, R#120, and R#51 all were observed to have buildup on the wheels of the wheelchairs. 12. Observation on 9/28/17 10:18 a.m. revealed that R#51 was being pushed by a CNA in hallway and build up was observed on the wheelchair. 13. Observation on 9/28/2017 10:22 a.m. R#121 ambulating with a wheelchair that had buildup on spokes of wheels. 14. Observation on 9/28/17 11:43 a.m.R#71 sitting in a wheelchair by the nurse station on Wing 1 with a build up of dirt on the wheelchair. 15. Observation on 9/28/17 at 12:09 pm R#51 observed in dependent dining room with dirt build up observed on the wheel chair. 16. Observation on 9/28/17 at 12:10 pm R#120 - foot and leg rest observed to have dirt build up. There was also black stripping on the floor separating independent from dependent dining rooms that was cracked and curled. 17. Observation on 9/28/17 at 12:12 pm R#1 observed sitting in wheelchair in dining room with buildup observed on the spokes of the residents wheelchair. Environmental tour began with the Maintenance Director on 9/28/17 at 11:09 a.m. until 12:10 p.m. Maintenance Director confirmed the staining of floor tiles in rooms and bathrooms and reported that there is a current plan for the facility to update the flooring throughout Unit 1 and tile has been ordered. It was further reported that this project is anticipated to be completed by January 2018. It was reported that ceiling tiles that were water stained were old and denied any leaks. It was further reported that there was a plan to replace sinks in the facility as well. Maintenance Director reported that housekeeping staff are responsible for the cleaning of wheelchairs but this is only done on an as needed basis. It was further reported that wheelchairs can be washed this week but will be dirty again next week. He further denied being aware of the black stripping being cracked and curled on the floor in the dining room until surveyor identified it. Review of supplies revealed two and a half boxes of tile and four sinks.

Based on observation, record review, and staff interview, the facility failed to code the Dental section of the Minimum Data Set (MDS) accurately for two residents (R) (#15 and #72) who were edentulous (without teeth) with no dentures. The sample size was 35 residents. Findings include: 1. Review of R #15's Significant Change MDS dated [DATE] revealed that he had no dental issues, and Dental Care did not trigger as an area of concern on the Care Area Assessment Summary (CAAS). Review of his potential for weight loss care plan revealed that the weight loss potential was related to a therapeutic diet, disease process, and use of dentures. Review of Nursing Monthly Assessment Forms dated 12/5/16, 1/5/17, 7/5/17, and 8/24/17 revealed that he was assessed as having no natural teeth or tooth fragments. During observations on 9/25/17 at 4:59 p.m., 9/27/17 at 1:05 p.m., and 9/28/17 at 8:32 a.m., R #15 was observed to be edentulous, with no dentures in his mouth. During interview with Registered Nurse (RN) MDS Coordinator AA on 9/28/17 at 8:41 a.m., she stated that she usually looked at the dental section of the nursing assessment to code the dental section of the MDS. She further stated that as long as a resident had dentures and they fit well, that she would not code the resident as edentulous. During interview with Certified Nursing Assistant (CNA) BB on 9/28/17 at 8:32 a.m., she stated that R #15 used to have dentures, but that she had not seen them for a while. During observation at this time, she was not able to find any dentures for R #15 in his room. During interview with Licensed Practical Nurse (LPN) CC on 9/28/17 at 8:36 p.m., she stated that R #15's dentures were lost over a year ago, and he has had none since then. During interview with RN MDS Coordinator AA on 9/28/17 at 8:41 a.m., she stated that the look-back period for coding the Dental section of the MDS was seven days from the Assessment Reference Date (ARD). 2. Review of R #72's Significant Change MDS dated [DATE] revealed that he had no dental issues, and Dental Care did not trigger as an area of concern on the Care Area Assessment Summary (CAAS). Review of his aspiration care plan revealed that R #72 is edentulous. Review of Nursing Monthly Assessment Form dated 5/24/17 revealed that R #72 was assessed as having no natural teeth or tooth fragments. Oral assessment form dated 5/24/17 indicated no teeth remaining. Observation of R #72 on 9/26/17 at 5:06 p.m., 9/27/17 at 8:30 a.m., 09/27/17 1:44 p.m., and 9/28/17 at 7:31 a.m. revealed R #72 edentulous and not wearing dentures. Interview on 9/28/17 at 9:14 a.m. with Registered Nurse MDS Coordinator AA who reported that the coding on MDS done through review of nursing assessment and observation of resident. If there are any questions the Certified Nursing Assistants (CNAs) or staff working with the resident is consulted. It is reported that annual assessment dated [DATE] for R #72 was coded as being edentulous but confirmed that the annual assessment dated [DATE] was not coded correctly. It was reported that this information would be corrected and resubmitted.

Based on observation and interview the facility failed to assure that cold food was being held at a temperature below forty-one (41) degrees until the completion of the food service with the potential to effect sixteen (16) residents who receive milk and twelve (12) who receive ice cream out of a total of ninety eight (98) residents served meals. Findings include: Observation of food temperatures on 08/21/2013 at 12:45 p.m., with the Dietary Manager, during food service revealed there was one (1) tray containing two (2) cartons of milk and another tray containing three (3) ice cream cups that were not sitting in ice or cold water. A checked the temperature of one (1) milk which was at sixty-two (62) degrees Fahrenheit and attempted to check one (1) ice cream, which was in a liquid state and spilled, therefore it was not possible to measured the ice cream temperature. An interview with the Dietary Manager on 08/22/2013 at 8:30 a.m. revealed that the milk temperatures were not checked prior to the meal service on 08/21/2013. He further reported that the milk temperatures may not always be checked depending on who was working. He also stated that the cold foods did start out packed in ice but due to the time it took to prepare the large number of trays resulted in the ice melting prior to the end of the service. Information was provided at this time revealing that sixteen (16) residents were receiving milk and twelve (12) residents were receiving ice cream. A review of the Food Temperatures Policy and Procedure revealed: 2. All potentially hazardous cold foods must be held at forty (40) degrees or less 3. Food temperatures will be taken before and after serving, temperatures will be logged directly on the extended menus. 11. Potentially hazardous cold food should be held on the line in an ice bath. Temperature Maintenance Tips: 1. Take food temperatures 15 minutes prior to service. 4. Cold foods should not be set up on trays longer than 15 minutes prior to meal service