Every finding on record at Queens Boulevard Extended Care Facility

Based on observation, interview, and record review conducted during the Recertification Survey from 06/13/2024 to 06/21/2024, the facility did not ensure that food was served at an appetizing temperature during meal service. This was evident for 2 (5th and 6th floor) of 2 units observed during dining observation. Specifically, food served during lunch meal service were not maintained at palatable and appetizing temperatures. The findings are: The facility's policy titled Communal Dining with a revision date of 04/10/2024 documented the purpose of the policy was to enhance the quality of life through the provision of nourishing, palatable, attractive meals that meet the residents' daily nutritional needs in a communal dining experience. The policy documented that the dietary department would bring meals to the floors via food trucks as quickly as possible to maintain temperatures, where nursing staff will be ready to receive and distribute meals. Temperatures for hot meals must be maintained at 140 degree Fahrenheit or above. Temperature for cold meals must be maintained at 35 degrees or below. The Meal Service Schedule documented that lunch meal service for 5th floor starts at 12:15 PM and 6th floor starts at 12:30 PM. 1.) Resident #38 was admitted to the facility with diagnoses of Hyperlipidemia, Hypertension and Heart Failure. The Minimum Data Set assessment dated [DATE] documented that Resident had intact cognition and required supervision for eating. During an interview on 06/13/2024 at 12:56 PM, Resident #38 stated meals were served lukewarm most of the time and not hot enough. 2.) Resident #124 was admitted to the facility with diagnoses of Anxiety Disorder, Mood Disorder, Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented that Resident had severely impaired cognition and required set-up or clean-up assistance with eating. During an interview on 06/14/2024 at 11:05 AM, Resident #124 stated that meals were always lukewarm and sometimes cold. Resident #124 stated they often like their food to be hotter. 3.) Resident #227 was admitted to the facility with diagnoses of Hypertension, End Stage Renal Disease, and Hyperlipidemia. The Minimum Data Set assessment dated [DATE] documented that Resident had intact cognition and required set-up or clean-up assistance with eating. During an interview on 06/13/2024 at 11:23 AM, Resident #227 stated they always ask staff to heat up their food in the microwave. On 06/18/2024 at 12:15 PM, the meal carts arrived, and distribution of meal trays continued until 1:01 PM on 5th floor. On 06/18/2024 at 12:30 PM, the meal carts arrived, and distribution of meal tray continued until 1:08 PM on the 6th floor. On 06/18/2024 at 1:01 PM, the food temperature on the test trays on the 5th floor were checked and revealed the following: chicken cacciatore at 124.8 degrees Fahrenheit, rice at 118.9 degrees Fahrenheit, broccoli at 119.3 degrees Fahrenheit, juice at 63.5 degrees Fahrenheit, milk at 63 degrees Fahrenheit, chopped chicken at 133.5 degrees Fahrenheit, chopped rice at 128 degrees Fahrenheit, chopped broccoli at 129.1 degrees Fahrenheit, and vegetable soup at 122.3 degrees Fahrenheit. On 06/18/2024 at 1:08 PM, the food temperature on the test trays on the 6th floor were checked and revealed the following: chicken cacciatore at 134.2 degrees Fahrenheit, broccoli at 123.5 degrees Fahrenheit, milk at 59.6 degrees Fahrenheit, rice at 127.9 degrees Fahrenheit, vegetable soup at 123.8 degrees Fahrenheit, chopped broccoli at 126.5 degrees Fahrenheit, and chopped chicken 126.7 degrees Fahrenheit. On 06/21/2024 at 10:07 AM, Certified Nurse Aide #4 was interviewed and stated there were a few residents on the 6th floor who request their meal to be heated up in the microwave daily because they want their food hot. On 06/21/2024 at 11:12 AM, the Food Service Director was interviewed and stated the food temperature was not hot enough when temperature checks were done on 06/18/2024. They stated that hot food should be higher than 140 degrees Fahrenheit and a little higher for the soups, and that meals should not be heated in the microwave daily to make it hot. They stated that the meal delivery on the 5th and 6th floor took longer than expected and that they will review their meal service process to correct the temperature issues. 10 NYCRR 415.14(d)(1)(2)

Based on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00340566) from 06/13/2024 to 06/21/2024, the facility did not ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #164) of 2 residents reviewed for abuse out of 38 total sampled residents. Specifically, there was no documented evidence that an investigation was conducted for Resident #164, who complained of being roughly handled by a Certified Nursing Assistant during care. The findings are: The facility's policy and procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with a last reviewed date of 10/31/2023 documented that residents will be protected from abuse, neglect, and harm while residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. It is the policy of the facility that reports of abuse are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. Resident # 164 was admitted to the facility with diagnoses of Anxiety Disorder and Rheumatoid Arthritis. The Minimum Data Set assessment dated [DATE] documented that Resident #164 had intact cognition. Resident #164 was dependent on toileting, shower/bathing, dressing, and personal hygiene; required supervision for eating; and required substantial / maximal assistance for oral hygiene and lower body dressing. On 06/18/2024 at 10:44 AM, Resident #164 was interviewed and stated they had a horrible experience with a Certified Nursing Assistant from the evening shift. The Resident stated they left a message for the social service director and the Resident told the director on what occurred. During a follow-up interview with Resident #164 on 06/20/2024 at 10:12 AM, the Resident stated that 2 months ago they reported to the Social Worker that a Certified Nursing Assistant was rough towards them during care. They stated the Social Worker did not do anything about it. Resident #164 stated every time they report something, the facility will tell them they will investigate but does not get back to them. The interdisciplinary progress notes dated 04/19/2024 to 04/30/2024 had no documentation of Resident #164's allegation that a Certified Nursing Assistant was rough during care. There was no documented evidence that Resident #164's allegation, that a Certified Nursing Assistant was rough during care, was investigated. On 06/18/2024 at 10:35 AM, the Director of Social Services was interviewed and stated that Resident #164 told them they wanted a Certified Nursing Assistant to be changed because they were uncomfortable. The Director of Social Services did not elaborate on why Resident #164 was uncomfortable with the Certified Nursing Assistant. On 06/18/2024 at 12:27 PM, the Assistant Director of Nursing was interviewed and stated that they received a complaint from Resident #164 that a Certified Nursing Assistant roughly handled them during care, that the way they were being cleaned was too rough for them. The Assistant Director of Nursing stated they assessed Resident #164's skin and found no bruises, scratches, or wound. During a follow-up interview with the Assistant Director of Nursing on 06/18/2024 at 3:02 PM, they stated they usually investigate abuse allegations involving scratches or bruises. They stated they did not investigate Resident #164's allegation because they had no scratch or bruise. On 06/18/2024 at 3:50 PM, the Director of Nursing was interviewed and stated they were unaware of Resident #164's allegation that they were roughly handled by a Certified Nursing Assistant and that they were only made aware of it on 06/18/2024. They stated they were told by the Assistant Director of Nursing that the allegation did not rise to the level of an investigation because Resident #164 had no scratches or bruises. The Director of Nursing stated that an allegation of abuse must be investigated soon as they become aware of it. 10 NYCRR 415.4(b)(3)

Based on record review and staff interview conducted during the Recertification Survey from 06/13/2024 to 06/21/2024, the facility did not ensure that a resident was assessed using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every 3 months. This was evident for 1 (Resident #107) of 2 residents reviewed for Resident Assessment out of 38 total sampled residents. Specifically, Resident #107's quarterly assessment was not completed. The findings are: The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 documented that the Federal requirement mandates facilities to encode and electronically transmit Minimum Data Set 3.0 data. The Manual also stated that Assessment Completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete. The undated facility policy titled Minimum Data Set 3.0 documented the Minimum Data Set assessments and reviews are maintained electronically by the facility's Electronic Medical Record software company. The policy documented that the Minimum Data Set Coordinator shall determine the type of assessment needed and the assessment reference date, completion date, and comprehensive care plan meeting date following the Centers for Medicare and Medicaid Services guidelines. The schedule will be given to all disciplines to start and complete in a timely manner. The Minimum Data Set Coordinator will sign for completion and ready for transmission following the Federal and State regulations. Resident #107's Minimum Data Set Admission Assessment was completed on 12/22/2023 and submitted on 01/09/2024. There was no documented evidence of quarterly assessment completed after 12/22/2023. On 06/18/2024 at 9:48 AM, the Director of Minimum Data Set was interviewed and stated they were responsible for ensuring all Minimum Data Sets were completed and submitted on time. They stated that they completed and submitted Resident #107's Admission and 5-day scheduled assessment on 01/09/2024. They stated that they created a Discharge Assessment for Resident #107 because they had a planned discharge in February 2024, but the discharge did not happen. The Director of Minimum Data Set stated they deleted the discharge assessment and did not realize that the system in their electronic medical record had stopped generating the subsequent assessments. They stated that they completed Resident #107's quarterly assessment on 06/17/2024. On 06/21/2024 at 1:25 PM, the Director of Nursing was interviewed and stated they were not aware that Resident #107's quarterly assessment had not been completed and submitted. On 06/21/2024 at 4:22 PM, the Administrator was interviewed and stated that Resident #107 was supposed to be discharged from the facility. They created a Discharge Assessment, but the Resident did not leave, and the Minimum Data Set assessment schedule sequence was altered. The Administrator stated that the quarterly assessment was not completed because of a computer glitch. 10 NYCRR 415.11(a)(4)

Based on observation, record review, and interviews conducted during the Recertification Survey from 06/13/2024 to 06/21/2024, the facility did not ensure that services provided or arranged by the facility met professional standards of quality. This was evident for 2 (Resident #85 and #20) of 38 total sampled residents. Specifically, 1.) Resident #85 was observed with oxygen via nasal cannula with no physician's order. 2.) Resident #20 had physician's order to notify the physician when Resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 70 milligrams per deciliter or more than 400 milligrams per deciliter. The licensed nurse failed to notify the physician when Resident #20's finger stick blood sugar was higher than 400 milligrams per deciliter on 7 occasions from 06/09/2024 through 06/18/2024. In addition, Resident #20 was administered 7 units of Novolin R insulin (a short acting insulin that lowers blood sugar) on 5 occasions, when Resident #20's finger stick blood sugar results were above 400 milligrams per deciliter, without a physician's order. The findings are: 1.) The facility's policy titled Oxygen Therapy - Oxygen Tanks dated 02/2022 documented that oxygen therapy must be ordered by a physician. However, in an emergency, a Registered Nurse may start oxygen therapy without a physician's order and then obtain the order. Resident #85 was admitted to the facility with diagnoses of Renal Insufficiency and Pneumonia. The Minimum Data Set assessment dated [DATE] documented Resident #85's had intact cognition. On 06/14/2024 at 9:56 AM, Resident #85 was observed in bed with oxygen via nasal cannula at 2 liters per minute. On 06/18/2024 at 9:43 AM, Resident #85 was observed in a wheelchair inside their room with oxygen via nasal cannula at 2 liters per minute. An oxygen tank was noted attached to the wheelchair. On 06/20/2024 at 12:12 PM, Resident #85 was observed in bed with oxygen via nasal cannula at 2 liters per minute. A review of Resident #85's physician's orders from 06/11/2024 to 06/18/2024 showed no orders for oxygen therapy. A review of the nurses' and medical progress notes from 06/01/2024 through 06/20/2024 showed no documentation of oxygen use. During an interview on 06/18/2024 at 2:50 PM, Resident #85 stated they had been using oxygen for about a week and they even take it to dialysis and physical therapy. During an interview on 06/20/2024 at 2:32 PM, Certified Nursing Assistant #1 stated that Resident #85 started using oxygen about a week ago. During an interview on 06/20/2024 at 2:40 PM, Licensed Practical Nurse #1 stated that Resident #85 was being administered oxygen, but they had not seen the physician's order for it. During an interview on 06/20/2024 at 2:56 PM, Registered Nurse #1, who was the nursing supervisor, stated that Resident #85 was being administered oxygen as needed at 2 liters per minute depending on the oxygen saturation (the measure of how much oxygen is traveling through a person's body in their red blood cells). They stated they do not know why Resident #85 had no physician's order for oxygen use. During an interview on 06/20/2024 at 3:34 PM, Registered Nurse #2 stated that Resident #85 sometimes had difficulty breathing and that oxygen was being administered when the Resident's oxygen saturation was low. They stated that Resident #85 was administered oxygen on and off after dialysis. Registered Nurse #2 stated that the order to administer oxygen must be obtained from the physician. During an interview on 06/20/2024 at 3:04 PM, Attending Physician #1 stated Resident #85 had been transferred to their service 3 days ago. They stated licensed nurses may administer oxygen to the resident but have to obtain a physician's order. During an interview on 06/21/2024 at 1:16 PM, the Director of Nursing stated that a nurse can administer oxygen and then call the doctor to get an order. The nurse who initiated the oxygen should have called the doctor for an order, and oxygen administration must be documented. 44842 2.) The facility's policy titled Change in a Resident's Condition or Status with a reviewed date of 01/2011 documented the Nurse Supervisor / Charge Nurse will notify the resident's attending physician or on-call physician when there has been a change in resident's physical condition. Resident #20 had diagnoses of Schizophrenia, Bipolar Disorder, and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented that Resident #20 was severely cognitively impaired. A Comprehensive Care Plan for Diabetes was initiated on 02/20/2023. The facility interventions include to observe for signs and symptoms of hypoglycemia (a condition when the blood sugar level was lower than normal) and hyperglycemia (a condition when the blood sugar was higher than normal), finger stick as ordered, and to refer to physician accordingly. A physician's order dated 06/19/2024 documented Basaglar KwikPen 100 units per milliliter (3 milliliters) subcutaneous, inject 5 units subcutaneously once daily at bedtime. Monitor blood sugar and notify the physician if finger stick blood sugar result is less than 70 milligrams per deciliter or more than 400 milligrams per deciliter. A physician's order dated 06/19/2024 documented Novolin R Regular 100 units per milliliter injection solution, inject subcutaneously every day at 11:00 AM and 5:00 PM when finger stick blood sugar reading are as follows: Between 0 and 180 no insulin, between 181 and 260 give 3 units, between 261 and 340 give 5 units, between 341 and 400 give 7 units. Above 400 or below 70, call the physician. The electronic Medication Administration Record for 06/2024 documented the following finger stick blood sugar results: On 06/06/2024 at 9:00 PM, 406 milligrams per deciliter. On 06/09/2024 at 5:00 PM, HI (high reading on a glucometer, blood glucose level is very high exceeding the maximum range that the device can measure). On 06/15/2024 at 5:00 PM, HI. On 06/16/2024 at 5:00 PM, HI. On 06/17/2024 at 5:00 PM, HI. On 06/17/2024 at 9:00 PM, 425 milligrams per deciliter. On 06/18/2024 at 5:00 PM, 427 milligrams per deciliter. A further review of Resident #20's electronic Medication Administration Record showed that 7 units of Novolin R were administered to Resident #20 at 5:00 PM when Resident #20's finger stick blood sugar results were above 400 milligrams per deciliter on 06/09/2024, 06/15/2024, 06/16/2024, 06/17/2024, and 06/18/2024 without a physician's order. A review of the nurses' and medical progress notes from 06/06/2024 through 06/19/2024 showed no documentation that the physician was notified when Resident #20's finger stick blood sugar results were above 400 milligrams per deciliter. During an interview on 06/20/2024 at 3:33 PM, Licensed Practical Nurse #2, who was the evening shift nurse on duty on 06/06/2024, 06/09/2024, and 06/15/2024 through 06/18/2024, stated they did not notify the physician when Resident #20's blood sugar was above 400 because Resident #20 was a known sensitive diabetic. They stated that they administered the insulin without notifying the physician of the blood sugar results exceeding 400 because Resident #20 had a history of life threatening hypoglycemia and that Resident's blood sugar will drop if they were given additional insulin coverage. During an interview on 06/21/2024 at 5:39 PM, Attending Physician #1 was interviewed and stated that even though Resident #20 had history of life threatening hypoglycemia, the licensed nurse should have notified them of finger stick blood sugar result above 400 so an infection can be ruled out. During an interview on 06/21/2024 at 10:36 AM, the Director of Nursing stated that the standard of practice dictates that Licensed Practical Nurse #2 should have followed the physician's order to notify the physician when Resident #20's blood sugar was above 400 milligrams per deciliter. 10 NYCRR 415.11(c)(3)(i)

Based on interviews and record review conducted during the Recertification survey from 05/18/22 to 05/25/22, the facility did not ensure a resident was provided information to formulate advanced directives (AD). This was evident for 1 (Resident #417) of 1 resident reviewed for ADs out of a sample of 37 resident reviewed. Specifically, there was no documented evidence Resident #417 received education and formulated ADs. The findings are: The facility policy titled Advance Directives dated October 21, 2008, documented the Social Worker (SW) will discuss and distribute to all new resident and/or Designated Representatives, information about Advance directives; and document that information was given. Resident #417 was admitted to the facility 05/17/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/23/22 at 12:27 PM, Resident #417 was interviewed and stated they were admitted to the facility approximately one week ago and no one has educated them regarding ADs. On 05/23/22 at 12:56 PM, the Registered Nurse (RN) # 1 was interviewed and stated Social Workers (SW) is responsible for immediately educating alert and oriented residents re: ADs when the resident is newly admitted to the facility. SW contacts the resident's family and discusses AD wishes when the resident is unable to make decisions. On 05/23/22 at 02:13 PM, SW was interviewed and stated they are responsible for educating newly admitted , alert and oriented residents re: ADs within 24-48 hours of admission to the facility. The resident's representative (RR) is contacted to discuss ADs when a resident is unable to make decisions. Then an AD care plan is initiated. There was a delay in providing Resident #417 with AD education because the facility has a lot of new admissions, and the SW is unable to meet with all of them. On 05/24/22 at 08:10 AM, The Director of Social Service was interviewed and stated the SW educates the resident or RR as soon as possible upon admission but no later than 72 hours. 415.3(e)(1)(ii)

Based on observation, record review, and interview conducted during the Recertification Survey from 5/18/22 to 5/25/22, the facility did not ensure the Minimum Data Set 3.0 (MDS) assessment accurately reflected the resident's status. This was evident for 1 (Resident #65) of 5 residents reviewed for Unnecessary Medications. Specifically, the MDS did not document Resident #65's evaluation for Gradual Dose Reduction (GDR) of [CONDITION(S)] drugs. The findings are: The facility undated policy titled MDS 3.0 documented the facility will ensure MDS Coordinators work with floor Nurses to ensure accurate documentation. Resident #65 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] and 02/09/2022 documented Resident #65 was severely cognitively impaired, received antipsychotic and antidepressant medication within 7 days prior to the MDS date, and a GDR had not been attempted or documented physician (MD) as clinically contraindicated. Psychiatric Evaluation Progress note dated 12/03/2021 documented Resident #65 was examined, and GDR was not attempted because the resident's symptoms were not resolved, the resident was at risk for psychiatric decompensation, and at risk for impaired functioning or increased dysphoria if the resident received a lower dose. MD Order dated 5/12/2022 documented Resident #65 received [MEDICATION(S)] 50 mg tablet twice daily for [CONDITION(S)] and [MEDICATION(S)] 100 mg tablet once daily at bedtime for major depressive disorder. On 5/23/22 at 11:33 AM, the MDS Coordinator (MDSC) was interviewed and stated Resident #65 resident is frequently seen by the Psychiatrist for medication review. The Psychiatrist documented on 12/3/2021 that GDR for Resident #65 was contraindicated, and this was wrongly coded on the MDS. 415.11(b)

Based on observations, interviews, and record review conducted during the Recertification Survey from 05/18/2022 to 05/25/2022, the facility did not ensure the development of a comprehensive, person-centered care plan (CCP) consistent with the resident's medical, nursing and mental and psychosocial needs. This was evident in 1 (Resident #264) of 1 resident reviewed for constipation. Specifically, Resident #264 was receiving [CONDITION(S)] and constipation medication, and related CCPs were not developed. The findings are: The undated facility policy titled Care Planning - Interdisciplinary documented the comprehensive care plan will facilitate the inclusion of the resident and/or RR and will include an assessment of the resident's strengths and needs. Resident #264 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS) dated [DATE] documented Resident #264 was cognitively intact. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also ordered [MEDICATION(S)] sodium 100 mg daily, [MEDICATION(S)] 10 gm/15 ml twice daily, [MEDICATION(S)] 17 gm once daily, senna 86 mg 2 tabs at bedtime, and disposable enemas as needed for constipation. A CCP related [CONDITION(S)] drugs was initiated on 04/22/2022 and a CCP related to constipation was initiated on 04/23/2022 for Resident #264. There were no documented interventions on the CCPs related to [CONDITION(S)] drugs and constipation. On 05/23/2022 at 2:28 PM, Registered Nurse #5 was interviewed and stated they are responsible for filling out the CCPs for Resident #264 and they were unaware the CCPs related to [CONDITION(S)] drug use and constipation were not completed and had no interventions listed. This was an oversight. 415.11(c)(1)

Based on interviews and record reviews conducted during a Recertification and Complaint (NY 185) Survey from 05/18/2022 to 05/25/2022, the facility did not ensure that a resident's representative (RR) was involved in revision of a resident's person-centered plan of care (CCP) with the interdisciplinary team (IDT). This was evident in 1 (Resident #48) of 35 residents reviewed. Specifically, the facility did not involve Resident #48's RR in revision of the resident's CCP to address Resident #48's ongoing refusal to be transferred out of bed and to receive showers. The findings are: The undated facility policy titled Care Planning - Interdisciplinary documented the comprehensive care plan will facilitate the inclusion of the resident and/or RR and will include an assessment of the resident's strengths and needs. Resident #48 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented the Resident #48 was severely cognitively impaired, was totally dependent on two people for assistance with bed mobility, transfers and toileting, and required extensive assistance of one person for personal hygiene. On 04/13/2022, the Aspen Complaint Tracking System documented a complaint Resident #48 was not being taken out of bed or showered. The CCP related to Activities of Daily Living (ADL) initiated 10/15/2019 and revised 12/01/2021 documented Resident #48 received showers twice weekly or as preferred. A CCP related to noncompliance initiated 10/21/2019 and revised 03/12/2022 documented Resident #48 refused to get out of bed. Documented interventions included to checking resident's unmet needs, encouraging family to visit, encouraging participation in ADLs, monitoring behavior, notifying the physician for the resident to be assessed medically for signs of inappropriate behavior, orienting to daily routines, providing reorientation through verbal cues and calendars, and redirecting negative behaviors and use a calm approach. There was no documented evidence the IDT involved Resident #48's RR to review and revise Resident #48's CCP related to refusals to be transferred out of bed or shower. On 05/23/2022 at 9:30 AM, Registered Nurse (RN) #2 was interviewed and stated Resident #48 is encouraged to come out of bed but the resident fears the mechanical lifter and geri-chair. Resident #48's RR was informed of the resident's refusal to come out of bed and have showers. RN #2 could not recall the last time they spoke with Resident #48's RR and was unable to provide documented evidence RN #2 included the resident's RR in the CCP process relating to Resident #48's refusals to get out of bed and shower. On 05/23/2022 at 9:56 AM, Certified Nursing Assistant (CNA) #2 was interviewed and stated Resident #48 has not gotten out of bed for several months, has not been weighed, and has not left the bed to have the linens changed. This is the resident's choice. CNA #2 has not spoken with Resident #48's RR. On 05/24/2022 at 8:49 AM, CNA #3 was interviewed and stated the Resident #48 was never given a shower but was always bathed in bed due to daily refusals to come out of bed. On 05/24/2022 at 9:00 AM, RN #3 was interviewed and stated they have never seen Resident #48 taken out of bed and Resident #48 received bed baths instead of showers. RN #3 is primarily the medication nurse and spoke with the Resident #48's RR once. If there are any concerns, the charge nurse is responsible for addressing them with the RR. On 05/24/2022 at 9:11 AM, the Social Worker (SW) was interviewed and stated they have been assigned to Resident #48 for approximately 2 months and spoke with Resident #48's RR twice. The SW did not discuss Resident #48's refusal to get out of bed or shower with the RR because the SW was unaware Resident #48 was displaying this behavior. Resident #48's refusal to get out of bed could be addressed by revising CCP interventions to include scheduling showers on days the RR visits; however, the IDT did not meet and discuss interventions for Resident #48's behavior. On 05/25/2022 at 10:06 AM, the Director of Nursing (DON) was interviewed and stated if a resident's refusals become a pattern the family must be involved in the care planning process. The IDT spoke with Resident #48's RR on numerous occasions. The DON was unable to provide documented evidence Resident #48's RR was involved in the revision of the resident's CCP related to refusal to get out of bed and shower. 415.11(c)(2)(i-iii)

Based on observation, interviews, and record review conducted during the Recertification survey from 5/18/22 to 5/25/22, the facility did not ensure a residents environment remained free of hazards. This was evident for 1 (#516) of 4 residents reviewed for respiratory care. Specifically, a large Oxygen Cylinder (OC) at Resident #516's bedside was not properly secured. The finding includes: The facility policy titled Oxygen Administration/Therapy dated 07/20/2021 documented when using oxygen cylinders, secure oxygen cylinders at the bedside by using a tank holder/chain. Tighten around the cylinder's base or placing the cylinder carrier vertically, making sure the cylinder is strapped or chained to the carrier and the wheels on a carrier are folded flat against the cylinder. On 05/18/2022 at 11:59 AM, 05/19/2022 at 10:10 AM, and 05/20/2022 at 9:58 AM, a large OC was observed on the right side of Resident #516's bed. The large OC was not secured in a carrier or chained to the wall. Resident # 516 was admitted on [DATE] and had diagnoses asthma and acute embolism/thrombus. On 05/2020/22 at 2:23 PM, the Director of Maintenance (DOM) was interviewed and stated the large OC is secured with a chain at bedside. The large OC at Resident # 516's bedside is not secured, and it should have been secured. Whenever Maintenance brings a large OC to the floor, it is supposed to be secured with a chain for safety. On 05/20/2022 at 2:37 PM, the Registered Nurse Supervisor (RNS) was interviewed and stated the central supply office and Maintenance department are responsible for checking and ensuring that the OC is secured. The large OC comes in a stand or is chained to the wall for safety. The RNS stated they did not notice the large OC at Resident # 516's bedside was not secured and did not inform maintenance. On 05/24/2022 at 4:30 PM, the Administrator was interviewed and stated the central supply office ensures that large OCs are placed it in a holder and secured to the wall with a chain for safety. The nursing staff should have immediately notified Maintenance when the unsecured OC was left at the bedside. 415.12(h)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 05/18/2022 to 05/25/2022, the facility did not ensure residents with respiratory care were provided such care consistent with professional standards of practice. This was evident for 1 (Resident #516) of 4 residents reviewed for respiratory care. Specifically, Resident #516 was observed several times being administered oxygen therapy via nasal cannula (NC) without a Medical Doctor Order (MDO). The findings are: The facility policy titled Care of Oxygen Equipment dated 07/15/2020 documented the licensed nurse implements oxygen delivery orders per MDO and according to the plan of care. Resident # 516 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/18/2022 at 11:59 AM, 05/20/2022 at 9:58 AM, and 05/20/2022 at 9:58 AM, Resident # 516 was observed with oxygen 2 liters per minute (lpm) via NC running from a concentrator to the resident's nose. On 05/20/2022 at 1:55 PM, Resident # 516 was interviewed and stated their inhaler was not available upon admission and the nurse gave Resident #516 oxygen therapy. There was no documented evidence Resident #516 was ordered to have oxygen therapy. On 05/20/2022 at 1:50 PM, Registered Nurse # 2 (RN) was interviewed and stated Resident # 516 receives oxygen 2 lpm via NC. RN #2 was unable to provide documented evidence Resident #516 had an MDO to receive oxygen therapy. On 05/20/2022 at 2:37 PM and 05/24/2022 at 10:52 AM, the Registered Nurse Supervisor (RNS) was interviewed and stated the nurse assesses residents with difficulty breathing, initiates oxygen 2 lpm via NC and calls the Medical Doctor (MD) to obtain an MDO. Oxygen is administered according to MDO, and Resident #516 does not have a MDO for oxygen therapy. The RNS called the MD and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Any nurse working with Resident #516 would have seen the resident being administered oxygen and should have checked to ensure there was an MDO. On 05/25/2022 at 1:11 PM, the MD was interviewed and stated the nurse initiates oxygen based on their assessment of the resident and then calls the MD for an MDO. The nurse called the MD but forgot to transcribe the MDO. On 05/25/22 at 1:38 PM, the Director of Nursing (DON) was interviewed and stated RNs must promptly obtain an MDO for oxygen therapy and document the MDO in the resident's medical record. All nurses thereafter ensure the resident receives oxygen therapy according to MDO. 415.12(k)(6)

Based on observation, record review, and interviews conducted during the Recertification Survey from 5/18/2022 to 5/25/2022, the facility did not ensure a resident was adequately equipped to call for assistance through a communication system. This was evident for 1 (Resident #29) of 35 residents reviewed. Specifically, there were multiple observations of Resident #29 without an operating Call Bell (CB) next to their bed. The findings are: The facility's policy titled Call Lights/Bells dated 9/2005 documented the CB system is the primary means of communication between residents and nursing staff. CBs will be operable, accessible, and within resident's reach. Resident #29 had diagnoses of heart failure, [CONDITION(S)] of the right eye, and hearing loss. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #29 had mild cognitive impairment, required extensive assistance of one person for bed mobility, transfers and personal hygiene, and required limited assistance of one person for dressing and toilet use. On 05/18/22 at 10:13 AM, Resident #29 was interviewed and stated their CB was disconnected from the wall and not functioning. Resident #29 reported the disconnected CB to a staff member the previous evening and was told someone would come repair it. During the interview the CB was observed dislodged from the wall and hanging on a chair next to the resident's bed. On 05/19/22 at 09:40 AM and 05/20/22 at 09:29 AM, Resident #29 was observed in bed and their CB was disconnected from the wall. There was no documented evidence a request to fix Resident #29's CB was written in the Maintenance work order book prior to 05/20/22. On 05/20/22 at 09:38 AM, Certified Nursing Assistant (CNA) #6 was interviewed and stated CNA #6 was assigned to Resident #29 and was unaware the CB next to Resident #29's bed was disconnected and not functioning. Resident #29 is alert and rings the CB for assistance, uses their walker to ambulate to the bathroom unassisted, and used the CB in the bathroom to call CNA #6 yesterday. Maintenance is responsible for checking CBs are functional. On 05/20/22 at 02:13 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated Maintenance checks the CBs periodically. LPN #2 was unaware Resident #29's CB was not functioning and did not know if Resident #29 informed staff. There is no way for staff to know the CB is not functioning unless Resident #29 alerts staff. On 05/23/22 at 02:51 PM, Maintenance Worker (MW) #13 was interviewed and stated there is a work order book where staff alert MWs to CBs in need of repair and staff can immediately contact MWs by paging them on the overhead system. 415.29

Based on observation, record review, and staff interviews during the re-certification survey, the facility did not ensure a resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing of ulcers. Specifically, pressure relieving devices were not put in place for a resident with bilateral heel wounds. This was evident for one (1) of four (4) residents investigated for Pressure Ulcer Care Area (Resident #344) out of a final sample of 35 residents. The finding is: The facility's policy and procedure titled, Pressure Relief Assistive Devices, (Dated 10/17), documented, If problems are identified that warrant pressure relief, appropriate pressure relief interventions are initiated. Examples of pressure relief interventions include but are not limited to the following: Lower extremity devices such as multipodus boots, heel lifts and heel pads, off loading shoes, abductor rolls. Resident #344 was initially admitted on [DATE] with [DIAGNOSES REDACTED]. On 08/05/19 at 09:43 AM, resident #344 was observed lying on his bed watching television in his room. Resident's legs were extended and flat and had blue non-skid socks on his feet. His feet and heels were resting on a flat pillow. The Registered Nurse (RN) #1 was observed performing the wound care treatment to both feet. The right heel was observed with a large area of black necrotic tissue. The skin underneath the toes was noted with black necrotic tissue. After RN #1 completed the wound care, his feet were left resting on the same thin pillow. No pressure relieving device were observed in place. On 08/08/19 at 09:39 AM, the resident was observed in bed awake wearing a pair of blue non-skid socks to both feet. RN #2 was in the room performing wound care to both feet. The same necrotic tissue to heel and underneath toes were observed. After completing the wound care treatment, RN #2 placed the non-skid socks back on feet and placed both feet on a thin flat pillow. No heel protectors were observed in placed. The admission Minimum Data Set (MDS) assessment dated [DATE] documented resident with intact cognition including clear speech. Resident documented as at risk for pressure ulcers/injuries with a stage 2 pressure ulcer upon admission. Other ulcers, wounds, and skin problem [MEDICAL CONDITION](second or third degree). Skin and ulcer/injury treatments included pressure reducing device for bed and pressure ulcer/injury care. Review of the Comprehensive Care Plan (CCP) for, Pressure Ulcer, (Dated 07/2019) documented, left heel lift when in bed and a right heel pad when out of bed to facilitate decubitus ulcer healing and prevention. Review of the physician's orders [REDACTED]. Review of the Certified Nursing Assistant (CNA) accountability record for (MONTH) 2019 was found with no documented evidence for the application of the use of heel protectors while in bed. The CNA record does document use of multipodus boots when out of bed. The admission nurse progress note dated 07/19/19 documented, .Right foot - healing [MEDICAL CONDITION] the toes and under the toes; dry black scab on the right heel. Left foot stage 2, measures: 10 centimeters (cm) by 17 cm. On 08/08/19 at 09:47 AM, the CNA #1 was interviewed and stated she has been caring for the resident more than once this month. She stated she has not put on heel pad or devices while resident is in bed. However, she does place multipodus boots when he is out of bed. She stated that she was not aware that devices have to be placed on resident's feet while in bed during the day. On 08/08/19 at 10:13 AM, resident #344 observed in bed with right heel pad and left heel protector to feet. The resident stated he has diabetes and has no sensation to his feet as a result of his medical condition. He stated he burnt both feet at home while in the tub with scalding water. The resident stated he does not have heel devices or pads placed on him while he is in bed. He further stated he actually feels much better and less pressure to his feet now with the heel pad on his feet. He stated he prefers to have these devices on his feet and feels that this is an improvement compared to the pillow. On 08/08/19 at 10:17 AM, RN #1 was interviewed and stated she should have been proactive in providing heel devices for the resident while in bed during the day. She stated she thought the order was for time of sleep. RN #1 makes rounds of her staff to ensure residents needs are being met as well as have morning meeting reports to discusses and provide updates to her staff. On 08/08/19 at 10:20 AM, the Physical Therapist (PT) was interviewed and stated these assistive devices relieves pressure and prevents further skin damage to feet. These devices were recommended and ordered because of the residents leg and feet discomfort. On 08/08/19 at 10:37 AM, RN #2 stated she is floater and did not know the resident should have had these devices placed on his feet after the wound care treatment. She further stated she could've asked if the resident required any adaptive heel devices. On 08/08/19 at 10:45 AM, the Unit RN Supervisor was interviewed and stated the nurse who picks up the physician's orders [REDACTED]. She stated all of the CCP's are interdisciplinary and can be viewed by all departments. The staff should have questioned the devices and brought it to her attention for further review and clarification. The RN Supervisor makes rounds and follow up on areas of concerns and complaints. She further stated the nursing staff should have known a resident with a heel injury most likely require an adaptive devices. 415.12(c)(1)

Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure that food was stored, prepared, and served under sanitary conditions to prevent food-borne illness. Specifically, (1) Prepared tuna fish was stored in the refrigerator with no label and date (2) Raw Italian sausage meat was left uncovered on a tray in a rack stored inside the refrigerator (3) Tuna fish sandwich, applesauce, and raw ground turkey meat did not maintain temperatures of 41 degrees Fahrenheit and below. This was evident during the Kitchen and Food Service Observation task. The findings are: The facility policy and procedure titled, Food Protection/Food Handling/Food Leftovers, Food Temperature, Food Handling Infection Control General, and Food Storage dated 10/2/17 were reviewed and documented the following. .Potentially hazardous foods will be maintained at temperatures of 41 degrees Fahrenheit below .; .All refrigerated foods will be covered and dated .; .Bulk foods being held for any length of time will be kept below 41 degrees Fahrenheit and if stored under refrigeration must be dated, covered, and identified to restrict growth of bacteria .; .All food items must be stored at proper temperature until ready for service .; .Items left in refrigerator or freezer must be covered and labeled .; .food storage in refrigerators is properly wrapped and dated . On 10/10/17 at 10:45 AM during the initial kitchen tour, prepared tuna fish was observed stored in a hotel pan in the bottom of refrigerator #3 left undated and unlabeled. Raw Italian sausage was also observed on a silver tray stored in a rack inside refrigerator #3 uncovered. On 10/12/17 at 11:55 AM during the lunch tray line temperature observation, the following cold food item temperatures were observed. Tuna fish sandwich temperature was 43.5 degrees Fahrenheit and Apple sauce was 42.5 degrees Fahrenheit. An additional temperature reading was conducted from where cold food items were stored. Raw ground turkey meat was tested and the temperature was 60 degrees Fahrenheit. On 10/13/17 at 10:30 AM, the Assistant Food Service Director (AFSD) was interviewed and stated the process for preparing and storing raw meat and tuna fish should be the following. Raw meat are to be broken up into small batches and refrigerated at a temperature of 41 degrees Fahrenheit and below during storage. Raw meat will then be stored in the refrigerator, covered and dated. When raw meat does not maintain a temperature of 41 degrees Fahrenheit or below, he is instructed to bring the temperature back down as soon as possible by placing it back in the refrigerator or discard the food item. Tuna fish is prepared by mixing the ingredients together in a bowl and then place it in another bowl filled with ice. The tuna is then covered and dated and stored inside the refrigerator. He stated tuna fish should be maintained at a temperature of 41 degrees Fahrenheit and below. The AFSD stated if the tuna is not maintaining temperature he is instructed to discard it. On 10/13/17 at 11:00 AM, the Food Service Director (FSD) was interviewed and stated the following. When preparing and storing raw meat, the food service workers are instructed to break meat into small batches and keep it out of refrigeration in as little time as possible so they can prepare it as they cook it. She stated raw meat and tuna fish should be below 42 degrees Fahrenheit. Staff are instructed to discard food items if it is not maintaining temperatures. The FSD also stated all cooked and uncooked food items should be covered and dated. 415.14(h)

Based on observations, record review, and interviews during the re-certification survey the facility did not promote care for residents in a manner that enhances the residents' dignity. Specifically, two residents foley catheter drainage tube were visible to other residents in the common area. This was evident for 2 of 2 residents reviewed for dignity (Resident #584 and #383) out of a total sample of 28 residents reviewed in Stage 2. The findings are: The facility policy and procedure titled, Daily Care for Indwelling Catheter, dated 10/2/17 documented the following. .the tubing should be placed over the leg (as opposed to under the leg) and must be concealed and not touching the floor . 1) Resident #584 was admitted on [DATE] with [DIAGNOSES REDACTED]., and Urinary tract infection. The Admission Minimum Data Set (MDS) 3.0 dated 8/2/17 documented the resident had severely impaired cognition. The MDS further documented the resident required extensive assist with toileting and had an indwelling catheter. Multiple observations were conducted from 10/10/17 at 12:29 PM to 10/13/17 at 12:39 PM. On 10/10/17 from 12:29 PM to 12:57 PM and at 2:50 PM, the resident was observed seated in his wheelchair in the dining room waiting for lunch with a portion of the foley catheter drainage tube extending from the bottom of his left pant leg containing urine in full view of other residents in the room. The resident was later observed seated in his wheelchair in the lobby area listening to recreational music with a portion of the foley catheter drainage tube extending from the bottom of his left pant leg containing urine in full view of other residents again. On 10/11/17 from 10:14 AM to 10:24 AM, the resident was observed seated in his wheelchair in the dining room listening to recreational music where a portion of his foley catheter drainage tube was extending from the bottom of his left pant leg visible to other residents which contained urine inside the tube. On 10/12/17 at 11:27 AM and 12:30 PM, the resident was observed seated in his wheelchair in the dining room passively participating in recreational activity and was observed later again waiting for lunch. During both observations, a portion of his foley catheter drainage tube was extended out from the bottom of his left pant leg containing urine and was visible to other residents. On 10/13/2017 at 12:39 PM, the resident was observed seated in his wheelchair in the dining room waiting for lunch where a portion of the foley catheter drainage tube was extended from the bottom of his left pant leg visible to other residents. On 10/16/17 at 9:14 AM, the Certified Nursing Assistant (CNA #1) was interviewed and stated when she transfers the resident from the bed to his wheelchair, she makes sure the foley catheter drainage tube is not exposed. On 10/16/17 at 9:22 AM, the Registered Nurse (RN #1) was interviewed and stated that she hasn't noticed residents foley catheter drainage tube sticking out and that it should be covered when he is wearing his pants. She further stated the last time she was in-serviced foley catheter care was last year. 2) Resident #383 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS 3.0 dated 9/1/17 documented the resident had intact cognition. The MDS further documented the resident required extensive assist with toileting and had an indwelling catheter. Multiple observations were conducted from 10/10/17 at 2:15 PM to 10/13/17 at 12:07 PM. On 10/10/17 from 2:15 PM to 2:30 PM, the surveyor observed the resident's foley catheter drainage tube dragging and touching the floor when resident was wheeling himself in the hallway into his room. The tubing was extended from the bottom of his right pant leg and was visible to other residents. The drainage tube contained urine. On 10/11/17 from 9:46 AM to 10:10 AM, the resident was seated in his wheelchair in the hallway facing the nurses station. A portion of the resident's foley catheter drainage tube was extended from the bottom of his right pant leg visible to other residents. The drainage tube contained urine. On 10/12/17 at 12:34 PM, the resident was seated in his wheelchair in the dining room waiting for lunch. A portion of his foley catheter drainage tube was visibly extended from the bottom of his right pant leg and touching the floor. Other residents were present in the dining room. The drainage tube contained urine. On 10/13/17 at 8:51 AM and 10:50 AM, the resident was observed wheeling himself in his wheelchair pass the nurses station. His foley catheter drainage tube was extended from the bottom of his right pant leg touching and dragging on the floor, and visible to other residents. The drainage tube contained urine. On 10/13/17 at 11:17 AM, CNA#2 was interviewed and stated her responsibility is to make sure the foley catheter bag and drainage tube is in place. She stated she will fix the residents drainage tube if it is touching the floor. She further stated the tubing is not supposed to touch the floor due to infection control. CNA#2 stated she was last in-serviced regarding foley catheter care about 3 months ago. On 10/13/17 at 11:27 AM, RN#2 was interviewed and stated that foley catheter drainage tubes should not be touching the floor because of infection control. She further stated she does not remember the last time she was in-serviced on foley catheter care. On 10/16/17 at 10:55 AM, the Director of Nursing (DNS) was interviewed and stated that staff are instructed to make sure the foley catheter drainage tube is not exposed and is not touching the floor due to dignity and infection control concerns. She further stated staff are in-serviced on foley catheter care when a resident is admitted with it and episodically. Staff are in-services on infection control upon hire, weekly, and episodically. 415.5(a)

Based on observation, record review, and interview, during the re-certification survey,the facility did not ensure that a comprehensive assessment of a resident's dental status was completed. This was evident for 1 of 3 residents reviewed for Dental Status and Services out of a total Stage 2 Sample of 28 residents (Resident #78). The finding is: Resident #78 is a resident re-admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident had no dental concerns. On 10/10/17 at 2:46 PM, the resident was observed during a resident interview. The resident was not wearing dentures and was edentulous. The resident stated that he never had dentures and did not want them. He stated that he eats fine without dentures. The Dental Consult dated 7/5/17 documented the resident was edentulous, and all oral tissues were within normal limits. On 10/16/17 at 11:10 AM, the MDS Director was interviewed and stated the coordinator should review the Dental consult, Dietary consult, Physician's Notes, and Nursing notes in the chart to assess the resident's dental status. She further stated the MDS Coordinator should also assess the resident. The Director reviewed the resident's chart and went to see the resident. Afterwards, she stated the resident's MDS assessment should have edentulous captured as a dental concern. She stated she would modify the MDS. 415.11(a)(2)

Based on observations, record review, and interviews during the re-certification survey, the facility did not ensure infection control practices were maintained. Specifically, (1) A staff member provided care to a resident who was on contact precautions without proper personal protective equipment (PPE) and (2) A resident's foley catheter drainage tube was observed dragging and touching the floor. This was evident for one random observation (8th floor) and 1 of 2 residents reviewed for Urinary Catheter Use (Resident # 383). The findings are: The facility policy and procedure for Guidelines for Isolation Precautions, Standard Precautions, and Transmission Based Precautions, dated 10/2/17 documented that a gown should be worn for direct resident contact due to unanticipated soiling of skin or clothing that may occur upon close physical contact with a resident or his or her environment. The policy further documented the procedure for entering a room for a resident on contact precautions includes donning a gown and gloves. 1) On 10/10/17 at 9:32 AM, during the initial tour on the 8th floor, the Registered Nurse (RN #2) was observed. She took gloves and red bag from a contact isolation cart and entered a resident's room with a STOP sign on door. She did not wear a gown when she entered the room. She exited the room with no bag. On 10/10/17 at 9:35 AM and 10/16/17 at 10:09 AM, the RN #2 was interviewed and stated that she went into the resident's room to disconnect the resident's tube feeding because it was completed. She further stated that the resident is on contact precautions for MRSE (Methicillin-resistant Staphylococcus Epidermidis) in the peg site. The nurse stated she used the red bag to dispose of her gloves and put them in the trash inside the room. She stated the protocol is to wear a gown and gloves to provide care to a resident on contact precautions. The RN stated if she does not think she will touch the resident with her clothes, she will use gloves and not a gown. She did not wear a gown when going to disconnect the feeding tube because she was just disconnecting the tube and not touching the dressing or insertion site. The RN stated that she makes sure she does not come in contact with the linens or anything else in the room. On 10/16/17 at 11:53 AM, the Infection Control Coordinator was interviewed and stated that staff should wear gloves and gowns at a minimum when providing care to residents on contact precautions. He further stated that if there is risk for splashing, a face guard can be used. He stated that even if the MRSE is localized to a location such as the Peg site, gowns and gloves must be worn when entering the room. This protocol should have been followed by the RN. The facility policy and procedure titled, Daily Care for Indwelling Catheter, dated 10/2/17 documented the following. .the tubing should be placed over the leg (as opposed to under the leg) and must be concealed and not touching the floor . 2) Resident #383 is an [AGE] year old who was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated 9/1/17 documented resident with intact cognition, extensive assist with toileting, and presence of an indwelling catheter. Multiple observations were conducted from 10/10/17 at 2:15 PM to 10/13/17 at 12:07 PM. On 10/10/17 from 2:15 PM to 2:30 PM the State Surveyor (SA) observed residents foley catheter drainage tube dragging and touching the floor when resident was wheeling himself in the hallway into his room. The drainage tube contained urine. On 10/12/17 at 12:34 PM resident was seated in his wheelchair in the dining room waiting for lunch. A portion of his foley catheter drainage tube was visibly extended from the bottom of his right pant leg and touching the floor. The drainage tube contained urine. On 10/13/17 at 8:51 AM and 10:50 AM the resident was observed wheeling himself in his wheelchair pass the nurses station. His foley catheter drainage tube was extended from the bottom of his right pant leg touching and dragging on the floor. The drainage tube contained urine. On 10/13/17 at 11:17 AM, CNA#2 was interviewed. CNA#2 stated her responsibility is to make sure the foley catheter bag and drainage tube is in place. She stated she will fix the residents drainage tube if it is touching the floor. She further stated the tubing is not supposed to touch the floor due to infection control. CNA#2 stated she was last in-serviced regarding foley catheter care about 3 months ago. On 10/13/17 at 11:27 AM RN#2 was interviewed. RN#2 stated that foley catheter drainage tubes should not be touching the floor because of infection control. She further stated she does not remember the last time she was in-serviced on foley catheter care. On 10/16/17 at 11:53 AM the Infection Control Coordinator was interviewed and stated foley catheter tubing should be kept off the floor for infection control purposes, as a precaution to prevent infection. On 10/16/17 at 10:55 AM the Director of Nursing (DNS) was interviewed. DNS stated that staff are instructed to make sure the foley catheter drainage tube is not exposed and is not touching the floor due to dignity and infection control concerns. She further stated staff are in-serviced on foley catheter care when a resident is admitted with it and episodically. Staff are in-serviced on infection control upon hire, weekly, and episodically. 415.19(a)(1-3)

Based on observation and interview the facility did not ensure that the sanitary conditions were maintained in the kitchen to prevent food borne illness and cross contamination. This was evidenced by: (1) The freezer did not maintain the proper temperature, (2) hot and cold foods on the tray line were not held at the proper temperature and (3) the dish machine rinse temperature did not reach the temperature required for sanitization and the food service workers (FSW) not knowledgeable on the temperature guidelines. The findings are: 1) On 7/19/16 at 10:45 AM, the following was observed during the Kitchen tour: The freezer temperature registered + 20 Fahrenheit (F). The freezer was being used for lunch preparation. Pre-cooked meats (Hot dogs and chicken patties) and frozen vegetables were in the freezer. On 7/21/16 at 1:30 PM, a second observation was made of the freezer. The temperature was 30 F. The temperature of a chicken patty was taken and registered 22 F. The chicken patty was still firm and in a plastic bag. On 7/21/16 at 1:32 PM the Assistant Director of Food Service (ADFS) was interviewed and stated that he reads the centigrade (at the lower circle of thermometer) that reads close to zero degrees, and he was confused reading the zero degree centigrade verses Fahrenheit at 30 F. He further stated he assumed the Freezer was holding the correct temperature at 0 C. 2) On 7/21/16 at 11:45 AM the tray line was observed and food temperatures were taken. The following hot foods did not meet the temperature guidelines: Baked potato 131 F / Noodles 125 F and 130 F Pureed chicken 125 F / Ground chicken 118 F The steam table light was off at the center well, indicating the well of the steam table was not being heated. The well water temperature registered 140 F versus the functioning steam table well water temperature of over 200 F. The following cold foods did not meet the temperature guidelines: Chilled apricots 50 F, Cottage cheese 58 F, Strawberry milk shake 55 F All these food items were placed in a tray inside a rack near tray line. There was no mechanism in place to continuously keep it cold. On 7/21/16 at 11: 55 AM, the Food Service Worker (FSW), who was serving from the steam table, was interviewed on the hot foods and stated she just noticed the steam table light on the center well was off. She stated sometimes if the light is off the food stays hot. She further stated she was not aware the pureed chicken and ground chicken were not hot. On 7/21/16 at 12:00 noon, the ADFS, who took the food temperatures, was interviewed and stated that when he checked in the morning, the light was on, at the steam table. He stated if it is not lit, he resets the circuit breaker. He agreed that some foods did not meet the temperature standards. On 7/21/16 at 12:30 PM the Food Service Director (FSD) was interviewed and stated that she is responsible for the kitchen and over sees it. She did not walk through the kitchen or check the tray line today, since she was doing clinical work and charting. She stated she was not aware the steam table was not working or that food was not held at the proper temperature. She further stated the refrigerator that was used to hold cold foods during tray line was broken and needed parts, and they normally bring out cold food one batch at a time from the refrigerator. She stated she was aware that the cold food temperatures were not meeting the temperature standards sometimes. 3) On 7/21/16 at 12:40 PM a Dish machine operation observation was conducted, and the following was observed: The wash temperature registered 138 F and Rinse temperature at 161 F. When a load was run, the rinse gauge pointer did not move. The FSW (#1) was operating the machine. A third unlabeled gauge at the back of the machine, at the top, was registering 160 to 175 to 178 F at different times. The FSW (#2) and ADFS (Assistant Director of Food Service) were not able to read the gauge because it was positioned in a place that made it difficult to read. FSW #1 was tall enough to read the gauge and read the temperatures. The wash temperature should be between 150F and 165F, and the rinse cycle should be at least 180F for sanitization. On 7/21/16 at 12:45 PM, FSW (#1) was interviewed and stated that he is new to the job, and he does not know what the temperature gauges are for. He further stated that he does not know there required temperatures for the wash and rinse cycles. He stated that he was trained by another FSW (unsure of their name), and he only knows how to turn on the machine and run the dishes through. He stated that the Supervisor takes the machine temperatures. On 7/21/16 at 12:50 PM, the FSW (#2) who does the breakfast (BF) dishes, was interviewed and stated that she checks the wash and rinse cycle. She stated that when the machine is running, the wash cycle is 150 F, and the rinse cycle is 165 F. FSW (#2) then ran a load and the temperatures registered as: wash 142 F and Rinse 165 F. When asked about the third gauge at the back of machine, she stated that it is the water temperature, and she does not check that. On 7/21/16 at 12: 55 PM, the ADFS was interviewed and stated that the third unlabeled gauge at the back is the Final rinse gauge that has been newly installed and connected to the hot water booster. The ADFS stated that the temperature reaches over 180 F. On 7/21/16 at 1: 30 PM, the Food Service Director (FSD) was interviewed and stated that if the machine does not reach the correct rinse temperature, we switch to paper plates. She stated that she did not see the machine or check the temperatures today. The facility policy documents as follows: (a) The manufacturing guidelines for the thermometer used inside the freezer documents the acceptable temperature for freezer as: 0 F (-17 C) or lower. Based on Food and Drug administration (FDA) guidelines for safe temperatures for food storage, the freezer is set at 0 F (-18 C) and Refrigerator is set at 40 F (4 C) (b) The facility policy revised 1/5/12 for Food temperatures documents: Hot foods cooked to appropriate temperatures and served at a temperature of at least 135 F. All cold foods must be maintained and served at a temperature of 41 F or below. Temperatures should be taken periodically to ensure hot foods stay above 135 F and cold foods stay below 41 F during portioning, transporting and until received by recipient (resident). The Tray line taste temperature control record documents the goal as: Meat, regular, chop and pureed at 160 -170 F Vegetables, Starch, Puree at 160 F Cold foods, desert, milk, juices at 40 F (c) The facility policy revised 10/21/08 for Dish washing procedure documents on item # 13 as : Check the detergent feed indicator lights up and the wash temperature gauge reaches 140 to 160 F and final rinse reaches 180 F. 415.14 (h)

Based on observation, record review, and interview the facility did not ensure the resident's environment was free from accident hazards. Specifically, plastic bags were used to extend a cognitively impaired resident's light switch, creating a hazard. This was evident for 1 of 1 residents reviewed for Accidents (Resident #105). The finding is: Resident # 105 is a [AGE] year-old with medical [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident was usually able to understand, and the resident required extensive assistance with bed mobility, transfer, dressing toilet use and personal hygiene. During a medication observation on 7/21/16 at 9:50 AM, Resident #105 was observed in bed. The resident was alert and confused, and there was a large clear plastic garbage bag on the bed. There was a total of 5 plastic bags tied to each in a chain to create an extension for the resident's light switch cord. The metal cord, which extended directly from the light fixture, measured approximately 4 inches with plastic bags extending to the resident's shoulder. The opening of the last bag was noted resting on there resident's shoulder and chest. The resident was further observed using the end of the plastic bag to wipe her mouth. The resident was asked the purpose of the plastic bag and she stated I pull on it when I need someone to come in. An observation was made on 7/21/2016 at approximately 3:30pm, the resident was out of bed the bed was made and the plastic bag extension was observed on the bed, with the last open bag extending past the resident's pillow to approximately 1/3 the length of the bed. The Maintenance Work Order book was reviewed. There was no documented evidence that a work order request was pending for the resident's light switch. An interview was conducted with a Certified Nursing Assistant (CNA) on 7/22/16 at approximately 10:00 AM. The CNA stated that she worked with the resident the last 4 days, and she figured the plastic bags were used as an extension to the light cord and she did not report it. She further stated that looking back she sees how it can be a safety concern. An interview was conducted with the medication nurse Licensed Practical Nurse (LPN #1) on 7/22/16. She stated that she did not notice the plastic bags used as an extension for the light switch. An interview was conducted with the Unit Manager Registered Nurse (RN #1) on 7/21/16 at 3:14 PM. RN#1 stated that when resident equipment is broken or not working it is documented in the maintenance work order book, and maintenance checks the log daily. She further stated that she was not aware of anything broken in the resident's room. An interview was conducted with the Charge Nurse (RN #2) who regularly works 3-11 shift. She stated that she does not know how long the plastic bag extension was used, but she noticed it yesterday and meant to write it in the maintenance log but did not have the time. She further stated that if any type of equipment is broken, they report it to maintenance by writing it in the book and maintenance will check it in the morning. The nurse stated that she was aware the plastic bag was a safety risk, but she did not think the resident would choke or suffocate herself. The Administrator was called 7/21/16 at 4:27 pm and made aware of the concern, he stated that it should not be. He further stated the facility had plenty of extension cords in house and it will be taken care of immediately. 415.12(h)1

Based on observation, record review, and interview, the facility did not ensure that routine dental services were provided to meet the residents' needs. Specifically, two residents did not receive annual routine dental services since admission to facility over a year ago. This was evident for 2 of 3 residents reviewed for Dental Status and Services (Resident #411 and Resident #299). The findings are: 1) Resident #411 is an [AGE] year-old with [DIAGNOSES REDACTED]. Multiple observations of the resident's teeth were made from 7/19/16 to 7/22/16, from 11:49 AM to 8:57 AM. The resident had no lower teeth and some missing upper teeth. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and required extensive assistance of Resident requires extensive with one person assist for personal hygiene. The MDS further documented the resident received a mechanically altered consistency diet, and the resident had no dental concerns present. The Comprehensive Care Plan (CCP) titled Oral/Dental Care Alteration in Oral Cavity Has missing teeth dated 5/13/16 documented dental evaluation as needed as an intervention. There was no documented evidence that a physician order was placed for a dental consult since the admission date of [DATE]. The Nursing Annual Comprehensive Resident assessment dated [DATE] documented the resident had missing teeth. The Nutrition Annual Reassessment dated [DATE] documented the resident had a chewing problem due to missing teeth. The Speech Pathology Annual Screen dated 5/13/16 documented the resident had natural/partial dentition and was not a candidate for speech/language rehabilitation. On 7/21/16 at 2:59 PM, the Certified Nursing Assistant (CNA#1) was interviewed and stated the resident had no dentures and some natural teeth. She further stated she completes oral care in the morning and after meals by washing out the resident's mouth. The CNA stated she monitors for sores and broken teeth, and she reports any concerns to the Registered Nurse (RN). 2) Resident #299 is an [AGE] year-old with [DIAGNOSES REDACTED]. Multiple observations of the resident's mouth were made from 7/19/16 to 7/22/16, from 12:36 PM to 9:34 AM. The resident was edentulous. The Annual MDS 3.0 assessment dated [DATE] documented the resident had intact cognition and required total assist of one person for personal hygiene. The MDS further documented the resident received a mechanically altered diet and had no natural teeth or tooth fragments (edentulous). The CCP titled At risk for oral/gum infection r/t (related to) missing teeth dated 6/8/16 documented dental consult as needed as an intervention. There was no documented evidence that a physician order was placed for a dental consult since the admission date of [DATE]. The Nursing Comprehensive Resident assessment dated [DATE] and 6/11/16 documented the resident had no natural teeth or tooth fragment (edentulous). The Nutrition Annual Reassessment dated [DATE] documented the resident was edentulous and had difficulty chewing. The Speech Pathology Annual Screen dated 6/13/16 documented the resident had natural/partial dentition and was not a candidate for speech/language rehabilitation. On 7/21/16 at 12:15 PM, Resident #299 stated that she has no teeth and has not seen a dentist since she's been in the facility and would like to get dentures. She further stated that she eats soft food. On 7/22/16 at 9:25 AM, CNA #2 was interviewed and stated the resident does not have teeth and never had dentures since she's been in the facility. The CNA stated she provides oral care for the resident in the morning, and she looks for redness, swelling, and anything abnormal which she would report to the Registered Nurse (RN). She further stated the resident receives soft food, and the resident has not made any complaints to her. On 7/21/16 at 9:07 AM and 12:01 PM, the RN's for resident #411 and #299 both stated the following: There were no physician orders for a dental consult completed since both residents' initial admission on 3/19/15 (Resident #411) and 3/14/15 (Resident #299). Both RNs stated that dental consults are ordered by the physician as needed when residents have complaints of oral pain or difficulty, broken teeth, concerns reported by CNAs, or if triggered by the MDS. They both stated an annual dental consult should have been completed but it was overlooked. On 7/21/16 at 3:16 PM, the Physician for resident #411 and #299 stated he used to order annual dental consults, but now he only orders dental consults when it's needed and as requested. The facility policy and procedure titled Dental Services documented .The dentist will perform an oral assessment on all residents upon admission .Routine oral hygiene will be provided by the Facility's Dentist . 415.17(a-d)

Based on observation and interview, the facility did not ensure that sanitary conditions were maintained to help prevent the development and transmission of disease and infection during wound care. This was evident for 2 of 2 reviewed for Pressure Ulcer (Resident #565 and #299). The findings are: 1) Resident #565 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident had a Stage 2 and Stage 3 pressure ulcer. On 7/22/16 at 9:30 AM, a wound care observation was conducted with the Registered Nurse (RN). The nurse was observed removing the soiled dressing. Then, using a wet 4x4 she proceeded to clean the site, discarded the 4x4, and removed her gloves and discarded them. She then donned new gloves and applied the hydrogel to the wound bed followed by a clean 4x4 and an abdominal binder. The RN was immediately interviewed and stated that she is supposed to wash hands and don new gloves after removing the soiled dressing before cleansing the wound. She further stated that she is supposed to sanitize her hands or wash her hands prior to donning new gloves. She was unable to explain why she did not perform hand hygiene. 2) Resident # 299 is a [AGE] year old female with medical [DIAGNOSES REDACTED]. A quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition, and the resident required total assistance with bed mobility, transfer, toileting and personal hygiene. The MDS further documented the presence of an unhealed stage 4 pressure ulcer. A wound care observation was conducted on 7/21/16 at approximately 10:30 am. The resident was positioned to his right side. When the adult brief was opened, no dressing or barrier was observed between the wound and the adult brief. The wound was in direct contact with a clean adult brief. An interview was conducted with the RN immediately following the dressing change. The treatment nurse stated that incontinence care was provided to the resident after breakfast and the dressing was soiled, she further stated the Certified Nurses Assistance called her in and she removed the dressing. She stated that she did not redress the wound because she was awaiting the state agency observation. She further stated that she should have covered the wound with a clean 4x4 gauze if she was not able to do the dressing immediately to prevent direct exposure to the adult brief. She stated she was aware that there is an increased risk of contaminating the wound if left open, and she was unable to explain why the wound was not covered. The policy and procedure titled Medical Aseptic Dressing Technique documented: 3) Wash hands. (15-20 seconds) 4) remove soiled dressing with gloves and discard into a red plastic bag. Remove gloves, Wash hands 15-20 seconds and apply clean gloves. Clean wound with sterile normal saline (NS) solution or as specified by physician. Remove gloves, wash hands 15-20 seconds apply clean gloves . 415.19(a)(1-3)