Every finding on record at Red Boiling Springs TN Opco LLC

Based on facility policy review, State Operations Manual (SOM) review, Internet website LocalConditions.com review, medical record review, observations, and interviews, the facility failed to recognize a resident's individuality and ensure treatment with respect and dignity in a manner and an environment that promoted maintenance or enhancement of quality of life, for 1 of 7 residents (Resident #1) reviewed for Resident Rights. The failure to recognize a resident's individuality and ensure treatment with respect and dignity resulted in the facility's failure to protect and promote the rights of the resident. The findings included: Review of the facility's policy titled, Resident Rights, reviewed 3/22/2022 revealed, .The resident has the right to a dignified existence, self-determination .to be supported by the facility in the exercise of his or her rights .The resident has a right to be treated with respect and dignity . Review of the State Operations Manual (SOM) revealed, .483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 F [Fahrenheit] . Review of the Internet website LocalConditions.com revealed the outside temperature on 7/21/2023 at 3:00 PM was 89 degrees F. On 8/14/2023 at 2:00 PM the temperature was 86 degrees F in the facility's local area. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lymphedema, Major Depressive Disorder, and Chronic Pain Syndrome. Review of the care plan for Resident #1 dated 6/16/2023 revealed, .Behavioral Symptoms .[Resident #1] is trying to keep her room temperature on 90 degrees .For her safety it should only be on 85 due to state guidelines [state guidelines indicate comfortable and safe temperatures 71 to 81 degrees Fahrenheit (F)] .goal .To maintain temp [temperature] in her room at an acceptable range .7/21/2023 .Her heater has a lock on it .reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Observations on 8/14/2023 at 2:11 PM, revealed Resident #1 in her room sitting in a chair next to the PTAC (Packaged Terminal Air Conditioner) Unit with a blanket around her upper body. The PTAC Unit control was padlocked. Resident #1 stated she was cold as usual and was not allowed to turn the heat up any higher. During an interview on 8/14/2023 at 2:11 PM, Resident #1 stated she didn't know what the temperature in the room was because the control panel was locked. Resident #1 stated she felt like her rights were violated by the facility when the PTAC Unit control pad was locked and she complained often about not being able to adjust the room temperature. Resident #1 stated the facility did not consider her rights or wishes when they placed the lock on the control panel. Resident #1 stated the Director of Nursing (DON) had told her the lock was being placed to prevent the roommate (Resident #7) from being too hot. Resident #1 stated she and Resident #7 both like the room extra warm. During an interview on 8/15/2023 at 9:55 AM, Licensed Practical Nurse (LPN) #1 stated the resident's PTAC unit control had a padlock on it to prevent Resident #1 from setting the heat on 90 degrees. LPN #1 stated, She has a roommate and state regulations say the temperature cannot be more than 85 degrees. LPN #1 confirmed Resident #7 (roommate) had not ever complained about the heat to her [LPN #1], rather the family had complained when they visited a few days ago. When asked what the temperature in the room was when the family complained, LPN #1 replied, I don't know really if it was checked. LPN #1 confirmed she was unable to tell this surveyor what temperature the unit was set on because the digital setting was not viewable with the controls padlocked. LPN #1 stated, Residents have the right to control the temperature in their room unless it makes it unsafe for them and their roommate. [Named Residents #1 and #7] always liked the room hot even though Resident #7 wore multiple layers of clothes. [Name Residents #1 and #7] had not shown any symptoms of elevated body temperatures like fever or dehydration that I have seen charted. During an interview on 8/15/2023 at 10:00 AM, the DON stated Resident #1's PTAC Unit control panel was locked to prevent her from setting the control to 90 degrees. The DON stated Resident #1 had been asked not to turn the setting over 85 degrees due to state regulations and Resident #1 had been non-compliant with the request. The DON stated Resident #7's (roommate) had not complained about the heat because she liked it warm in the room. The DON stated Resident #7's family members had complained about the heat during recent visits and Resident #7 had to be moved to another room. The DON confirmed the padlock was placed on the controls on 7/21/2023 and the family complained after 7/21/2023 about the heat. When asked what the temperature was set on at this time, the DON replied, I believe around 85 degrees, the Maintenance Director monitors the temperature. The DON stated, Residents have a right to control room temperatures within state guidelines[she was unable to quote the state guidelines]. The DON confirmed Resident #1 could not control the temperature of her room due to the control panel being locked. Observations on 8/15/2023 at 10:15 AM revealed, the Maintenance Director measured Resident #1's room temperature at 75 degrees with the PTAC Unit controls set to 83 degrees. During an interview on 8/15/2023 at 10:15 AM, The Maintenance Director stated, The setting on the unit is just a setting, the temperature will not reach 90 degrees when set at 90 degrees, just like the temperature today did not reach 83 degrees. I was told by the Administrator to place a lock on the PTAC Unit in Resident #1's room to prevent the resident from turning the heat up to 90 degrees. The day the lock was placed the room temperature measured 79 degrees [LocalConditions.com revealed the outside temperature on 7/21/2023 at 3:00 PM was 89 degrees F]. I had not been asked to measure the room temperature prior to that day and I have not measured the temperature since placing the lock on the unit. The Maintenance Director confirmed the temperature on the day the padlock was placed on the unit and the temperature today (8/15/2023) did not exceed state regulations. During an interview on 8/15/2023 at 10:26 AM the former Social Services Director (SSD) stated staff reported Resident #1 frequently set the heating unit in her room to 90 degrees. The former SSD stated, I intentionally put [Resident #1 and Resident #7] in the same room because both of them like warmer room temperatures and that made them perfect roommates. The former SSD stated the Administrator ordered the padlock to be placed on the temperature controls in Resident #1's room because 90 degree temperature was too hot and violated state regulations. The former SSD stated she was not aware of any temperature readings taken prior to placing the padlock on the unit. She stated the Administrator ordered the padlock and she did not question the order. During an interview on 8/15/2023 at 1:18 PM, LPN #2 stated Resident #1 frequently complained about being cold and often stated her rights were being violated because she wasn't able to control the temperature of her room. LPN #2 stated she had made the DON aware of Resident #1's complaint related to comfort and her rights being violated. LPN #2 stated Resident #7 never complained of the room being hot because she was comfortable with the temperature (LPN #2 had inquired about her comfort due to warm temps in the room). LPN #2 stated the room temperature was not an issue until Resident #7's health declined and staff had to provide incontinence care more often and staff complained about the temperature of the room being hot during care (staff inconvenience). LPN #2 stated residents have the right to live in an environment that was comfortable to them and staff should not regulate the temperature to suit their comfort level.

Based on facility policy review, medical record review, and interview, the facility failed to develop a care plan for 2 of 34 sampled residents (Resident #5 and Resident #37). The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 8/30/2022, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. Resident #5 required extensive assistance with bed mobility with two staff. Resident #5 had impairment on one side of his upper and lower extremities. Review of Resident #5's care plan dated 4/8/2021 and 4/9/2021 revealed .has frequent pain 5/10 .he took more pain meds at home .[named Resident #5] is at risk for changes in mood state and psychosocial well-being related to Covid-19 Virus and restricted visitation and community activities . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes dated 4/17/2021 revealed .Staff reported that resident was trying to get them to give him medication out of nightstand. Medication confiscated, which was labeled [MEDICATION(S)], and locked up in narc [narcotic] box on cart 1. Explained to resident that he was not allowed to have medication brought in from outside the facility. States understanding . Review of the Social Service Note dated 5/14/2021 revealed .Today 1 orange colored round pill ([MEDICATION(S)]) [a medication to assist with cravings and opioid withdrawls] was given to me. This was found in [named Resident #5's] belongings. He has had items brought in by his son on 5/12/2021. This is the second time for this . During an interview on 9/27/2022 at 9:55 AM, the Social Service Director (SSD) stated the staff had found pills in his room on two different occasions. A continued interview with the SSD confirmed she had not implemented a behavioral care plan regarding the family and Resident #5 bringing non-prescribed medications into the facility. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Paxlovid 300/100 mg twice a day for 5 days for COVID started on 9/23/2022. [MEDICATION(S)] 1 gram intravenously daily for 5 days for infection started on 9/22/2022. Review of Resident #37's current care plan revealed no implementation or interventions for Covid, Pneumonia or antibiotic use. During an interview on 9/27/2022 the Director of Nursing confirmed Resident #37 did not have a care plan implemented or interventions for Covid, Pneumonia or antibiotic use.

Based on medical record review and interview, the facility Administrator failed to respond to an identified concern of unauthorized narcotics found on two separate occasions for 1 of 34 residents (Resident #5). The findings include: Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #5 required extensive assistance with bed mobility with two staff. Resident #5 had impairment on one side of his upper and lower extremities. Review of the Progress Notes dated 4/17/2021 revealed .Staff reported that resident was trying to get them to give him medication out of nightstand. Medication confiscated, which was labeled [MEDICATION(S)], and locked up in narc [narcotic] box on cart 1. Explained to resident that he was not allowed to have medication brought in from outside the facility. States understanding . Review of the Social Service Note dated 4/19/2021 revealed .I spoke with the pt. [patient], due to the report of the nurses finding the [MEDICATION(S)] [treats opioid use disorder and relieves cravings to use and withdrawal symptoms] in his room talked to him about the risks etc. with taking medications that are not being given to him by the staff here. Review of the Social Service Note dated 5/14/2021 revealed .Today 1 orange colored round pill ([MEDICATION(S)]) was given to me. This was found in [named Resident #5's] belongings. He has had items brought in by his son on 5/12/2021. This is the second time for this. I did speak with the Administrator [named Administrator #1] in regard to this. During an interview on 9/27/2022 at 9:55 AM, the SSD stated they had known Resident #5 for a long time, and he was part of the community. The staff had found pills in his room on 2 different occasions. The SSD stated the son had brought Resident #5 two pills and thought Resident #5 had already taken one when the other one was found in the bed on 5/14/2022. The nursing staff realized Resident #5 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD then gave the one [MEDICATION(S)] pill to an unknown nurse to be wasted. During a telephone interview on 9/27/2022 at 3:36 PM, Former Administrator #2 confirmed he and the staff suspected either friend or family were bringing Resident #5 narcotics. Former Administrator #2 confirmed he did not conduct a QAPI (Quality Assurance and Performance Improvement) meeting or developed a PIP (Performance Improvement Plan) for the concern. During a telephone interview on 9/27/2022 at 4:57 PM, Former Administrator #1 confirmed he was not aware of the incidents on 4/17/2022 and 5/14/2022. Continued telephone interview on 9/27/2022 at 4:57 PM, Former Administrator #1 confirmed he was not made aware of and he did not investigate the incidents involving Resident #5. During an interview on 9/27/2022 at 6:35 PM, the current Administrator confirmed there was no documentation of an AdHoc QAPI meeting conducted related to the medication ([MEDICATION(S)]) found in Resident #5's room on April 17, 2021. Continued interview she confirmed there was no evidence an investigation had been conducted into the two instances where Subloxone was found in the possession of Resident #5.

Based on medical record review and interview the facility QAPI program failed to identify a problem with a resident having access to unauthorized medication and failed to develop an action plan to correct the problem for 1 of 34 residents (Resident #5). The findings include: Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #5 required extensive assistance with bed mobility with two staff. Resident #5 had impairment on one side of his upper and lower extremities. Review of the Progress Notes dated 4/17/2021 revealed .Staff reported that resident was trying to get them to give him medication out of nightstand. Medication confiscated, which was labeled [MEDICATION(S)], and locked up in narc [narcotic] box on cart 1. Explained to resident that he was not allowed to have medication brought in from outside the facility. States understanding . Review of the Social Service Note dated 4/19/2021 revealed .I spoke with the pt. [patient], due to the report of the nurses finding the [MEDICATION(S)] [treats opioid use disorder and relieves cravings to use and withdrawal symptoms] in his room talked to him about the risks etc. with taking medications that are not being given to him by the staff here. Review of the Social Service Note dated 5/14/2021 revealed .Today 1 orange colored round pill ([MEDICATION(S)]) was given to me. This was found in [named Resident #5's] belongings. He has had items brought in by his son on 5/12/2021. This is the second time for this. I did speak with the Administrator [named Administrator #1] in regard to this. During an interview on 9/27/2022 at 9:55 AM, the SSD stated they had known Resident #5 for a long time, and he was part of the community. The staff had found pills in his room on 2 diffrent occassions. The SSD stated the son had brought Resident #5 two pills and thought Resident #5 had already taken one when the other one was found in the bed on 5/14/2022. The nursing staff realized Resident #5 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD then gave the one [MEDICATION(S)] pill to an unknown nurse to be wasted. The SSD had reported her findings to the Former DON and Administrator. During a telephone interview on 9/27/2022 at 3:36 PM, Former Administrator #2 confirmed he and the staff suspected either friend or family were bringing Resident #5 narcotics. Former Administrator #2 confirmed he did not conduct a QAPI (Quality Assurance and Performance Improvement) meeting or developed a PIP (Performance Improvement Plan) for the concern. During a telephone interview on 9/27/2022 at 4:57 PM, Former Administrator #1 confirmed he was not aware of the incidents on 4/17/2022 and 5/14/2022 During an interview on 9/27/2022 at 6:35 PM, the current Administrator confirmed there was no documentation of an AdHoc QAPI meeting conducted related to the medication ([MEDICATION(S)]) found in Resident 5#'s room on April 17, 2021. Continued interview she confirmed there was no QAPI meeting conducted until June 2021 concerning the medication [[MEDICATION(S)]] found in the resident's room May 14, 2021 and the incident was only mentioned but no definite plan was put into place to ensure it would not recur in the future. Review of QAPI mintes from meetings held in 2021 revealed no discussion of the incident nor was there evidence any action plan was put in place to correct the problem and ensure it woud not occur again.

Based on facility policy review, medical record review, and interview, the facility failed to adequately monitor 10 of 10 sampled residents (Resident #5, #7, #15, #19, #25, #29, #37, #41, #42, #100) reviewed for anticoagulant therapy. The findings include: Review of the facility's policy titled, High Risk Medications-Anticoagulants, dated 1/1/2022, revealed, .This facility recognizes anticoagulants are associated with greater risks of adverse consequences than other medications .The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage . Review of the facility's policy titled, Unnecessary Drugs-Without Adequate Indication for Use, revised 8/30/2022, revealed, .It is the facility's policy that each resident's drug regiment is managed and monitored . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #5 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Medical Administration Record (MAR) dated September 2022 revealed the resident received [MEDICATION(S)] 5mg two times a day. Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment for Resident #7 dated 7/15/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #7 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change In Status MDS assessment for Resident #15 dated 7/22/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #15 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS for Resident #19 dated 8/3/2022 revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #19 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment for Resident #25 dated 6/17/2022 revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #25 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment for Resident #29 dated 8/23/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #29 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment for Resident #37 dated 9/5/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #37 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment for Resident #41 dated 9/12/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #41 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS for Resident #42 dated 9/14/2022 revealed the resident received anticoagulant medication 6 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #42 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . continued reviuew revealed there was no monitoring for side effects of [MEDICATION(S)]. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change In Status MDS assessment for Resident #100 dated 7/25/2022, revealed the resident received anticoagulant medication 7 of 7 days of the look back period. Review of the current Physician Orders revealed Resident #100 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #100's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed there was no monitoring for side effects of [MEDICATION(S)]. During an interview on 9/28/2022 at 10:03 AM, the Director of Nursing (DON) confirmed there was no physician's order to monitor side effect of anticoagulants for Residents #5, #7, #15, #19, #25, #29, #37, #41, #42, #100. She stated, We haven't done that since I've been here. During an interview on 9/28/2022 at 11:47 AM, Licensed Practical Nurse (LPN) #4, who had been employed at the facility for [AGE] years, stated, If a resident is on an anticoagulant, we monitor for side effects such as bleeding and bruising and it's documented on the resident's MAR. She reviewed Resident #41 and Resident #7's MAR, and stated, They are on [MEDICATION(S)], we don't do monitoring for that. I have never seen monitoring for side effects of [MEDICATION(S)]. Continued interview LPN #4 stated, The care plan may say to monitor, but there's no way to check off that you monitored if it's not on the MAR. I don't look at care plans every day; I only look at them if I have been off a few days. During an interview on 9/28/2022 at 11:59 AM LPN #5, who had been employed at the facility for 7 years, stated, if a resident is on an anticoagulant, then you would monitor for bleeding. She reviewed Resident #37's physician orders and stated, She's on [MEDICATION(S)] and I don't see anywhere to document monitoring of side effects of it. She reviewed the resident's care plan and stated, there's monitoring for side effects on there but I don't look at the care plans unless I am updating them, I don't look at them every day. During a telephone interview on 9/28/2022 at 1:14 PM, the Consultant Pharmacist stated, if a resident is taking [MEDICATION(S)], I would recommend monitoring for side effects.

Based on medical record review and interview, the facility failed to have a Quarterly Care Plan conference meeting with resident/resident representative for 1 of 34 sampled residents (Resident #41) reviewed for care plan conference meeting. The facility also failed to revise a care plan for 1 of 34 sampled residents (Resident #31) reviewed. The findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a Quarterly Minimum Data Set (MDS) assessment was completed for Resident #41 on 9/12/2022. Review of the medical record for Resident #41 revealed there was no care conference meeting conducted with the resident or resident representative for the assessment on 9/12/2022. During an interview on 9/27/2022 at 11:00 AM, the Social Service Director confirmed she had not completed a care conference meeting with Resident #41 or her representative. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment for Resident #31 dated 8/29/2022 revealed Resident #31 was at risk for developing pressure ulcers/injury with no actual pressure ulcer injury at the time of the MDS assessment dated [DATE]. Review of Resident #31's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Apply to anal area topically every shift related to PRESSURE ULCER OF OTHER SITE, STAGE 3 .9/13/2022 . Review of Resident #31's care plan revealed there was no care plan revision to reflect the actual Pressure Ulcer which was diagnosed on [DATE]. During an interview on 9/27/2022 at 7:02 PM the MDS Coordinator confirmed Resident #31's care plan was not revised related to the wound [pressure ulcer] near his rectum until today [9/27/2022]. She stated, it [care plan revision] should have been completed last Tuesday [9/20/2022].

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure 1 of 34 sampled residents (Resident #19) had clean and groomed fingernails. The findings include: Review of the facility policy titled, Care of Fingernails/Toenails, with revision date 10/2010 revealed, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care included daily cleaning and regular trimming . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed a Brief Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Continued review of the MDS revealed Resident #19 required total assist of two staff for personal hygiene and bathing. Review of the current Visual/Bedside Kardex Report for Resident #19 revealed .BATHING/SHOWERING .req [require] ext [extensive] to total assist .Shower 2 x week, bed bath daily .PERSONAL HYGIENE/ORAL CARE .assist her w/ [with] all her hygiene . Observation in Resident #19's room on 9/26/2022 at 10:46 AM, revealed Resident #19's fingernails were not groomed and had dried brown debris under her nails. Continued observation in Resident #19's room on 9/26/2022 at 12:27 PM and 1:30 PM, her fingernails continued to be ungroomed with dried brown debris under her fingernails. During an observation and interview in Resident #19's room on 9/26/2022 at 1:55 PM, the Director of Nursing (DON) confirmed Resident #19's fingernails were ungroomed with dried debris under her fingernails and stated her nails needed to be cleaned and trimmed.

Based on facility policy review, observation, and interview, the facility failed to post appropriate signage that clearly describes the type of precautions needed and required Personal Protective Equipment (PPE) on a Transmission Based Precautions (TBP) room. The findings include: Review of the facility policy titled, Novel Coronavirus Prevention and Response, revised on 2/6/2022, revealed, .Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE . Observations outside of room [ROOM NUMBER] on 9/26/2022 at 11:15 AM and 5:00 PM, revealed a red square sign with black lettering STOP Isolation Precautions was posted on the door with no specific isolation precautions or what type of PPE was required to enter the room. During an interview on 9/26/2022 at 10:08 AM, the Director of Nursing (DON) confirmed the resident in room [ROOM NUMBER] was on TBP. Observation and interview outside of room [ROOM NUMBER] on 9/26/2022 at 6:47 PM, the Administrator confirmed signage on the door did not state specific isolation precautions or PPE required. She stated The policy is for the sign on the door to state the type of isolation precautions and PPE required.

Based on facility policy review, record review, and interviews, the facility failed to ensure medications and treatments were administered per physician's orders and accurately documented, for 3 of 3 residents (Residents #1, #2, and #3) reviewed with ordered treatments and medications. The findings include: Review of the facility's policy titled, Medication Administration, revised 11/2017, revealed, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Policy Explanation and Compliance Guidelines: 17. Sign MAR [Medication Administration Record] after administered. For those medications requiring vital signs, record the vital signs onto the MAR .20. If medication is unavailable notify MD [Medical Doctor] and document MD notification . Review of the facility's policy titled, Wound Treatment Management, revised 3/24/2022, revealed, .Policy: To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .3. Dressing changes may be provided outside the frequency parameters in certain situations: c. The dressing is soiled otherwise, or is wet .4. Dressings will be applied in accordance with manufacturers recommendations and/or physicians order .5. Treatment decisions will be based on: a. Etiology of wound .b. Characteristics of the wound .c. Location of the wound .d. Goals and preferences of the resident/representative .6. The facility will follow specific physician orders for providing wound care .7. Treatments will be documented on the Treatment Administration Record .8. The effectiveness of treatments will be monitored through ongoing assessments of the wound. Considerations for needed modifications include: a. Lack of progression towards healing .b. Changes in the characteristics of the wound .c. Changes in the resident's goals and preferences, such as end-of-life or in accordance with his/her rights . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease, Polyneuropathy, Dementia, Peripheral Vascular Disease, Depressive Disorder, [CONDITION(S)], and [CONDITION(S)] Heart Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 7 on the BIMS (Brief Interview for Mental Status) assessment, which indicated severely impaired cognition. Continued review revealed Resident #1 required total dependence of two persons physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing, during the 7-day look-back period. Review of the Comprehensive Care plan revealed Resident #1 was care planned for health-related complications due to Behaviors such as Impaired Cognition, Refuses to have ADL (Activities of Daily Living) Care Completed at Times, Requires Set-Up with Meals to Total Care with other ADL's, Bowel and Bladder Incontinence, Risk for Falls due to Decreased Self Mobility, Little to No Safety Awareness, Severe [CONDITION(S)] with Contractures, Risk for Skin Breakdown, Risk for Alteration in Nutrition, [CONDITION(S)], Alteration in Comfort, Risk for Changes in Moods, Frequently Refuses her Meds, and other care areas, with appropriate goals, interventions, and updates, with no concern. Review of the facility's, Order Summary Report, dated 6/30/2022, revealed Resident #1 had orders which included, .[MEDICATION(S)] Suspension 0.3-0.1% ([MEDICATION(S)]-[MEDICATION(S)]) Instill 1 drop in both eyes two a day .[MEDICATION(S)] Tablet 10 mg (milligrams) ([MEDICATION(S)] HCl [[MEDICATION(S)]]) Give 1 tablet by mouth at bedtime .[MEDICATION(S)]-Acetaminophen Tablet 7.5 mg-325 mg Give 1 tablet by mouth three times a day .[MEDICATION(S)] 300 mg ([MEDICATION(S)]) Give 1 capsule by mouth 3 times a day . Review of the MAR (Medication Administration Record), dated 6/1/2022-6/30/2022, for Resident #1, revealed no documentation of administration of [MEDICATION(S)] Suspension 0.3-0.1% ([MEDICATION(S)]-[MEDICATION(S)]) Instill 1 drop in both eyes two times a day on 6/25/2022 at 1800 (6:00 PM), and no supporting progress notes for missed administration explanation. Continued review revealed no documentation for [MEDICATION(S)] Tablet 10 mg (milligrams) ([MEDICATION(S)] HCl [[MEDICATION(S)]]) Give 1 tablet by mouth at bedtime on 6/19/2022 at 1800 (6:00 PM) and 6/25/2022 at 1800, and no supporting progress notes for missed administration explanation. Continued review revealed no documentation for [MEDICATION(S)]-Acetaminophen Tablet 7.5 mg-325 mg Give 1 tablet by mouth three times a day on 6/19/2022 at 1800 (6:00 PM) and 6/25/2022 at 1800, and no supporting progress notes for missed administration explanation. Continued review revealed no documentation for [MEDICATION(S)] 300 mg ([MEDICATION(S)]) Give 1 capsule by mouth 3 times a day on 6/19/2022 at 1800 (6:00 PM) and 6/25/2022 at 1800, and no supporting progress notes for missed administration explanation. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses which included Urinary Tract Infection, Unstageable Pressure Ulcer of Sacral Region, Dementia with Behavioral Disturbance, Type 2 Diabetes Mellitus, Neuromuscular Dysfunction, Hypertension, Stage 3 Chronic Kidney Disease, [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), and Depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored 10 on the BIMS (Brief Interview for Mental Status) assessment, which indicated moderately impaired cognition. Continued review revealed Resident #2 required total dependence of two persons physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Continued review revealed Resident #2 had an indwelling catheter and was always incontinent of bowel. Continued review revealed that Resident #2 was assessed as being at an increased risk for developing pressure ulcers and had 1 unstageable pressure ulcer present on admission to the facility. Continued review revealed Resident #2 was assessed as having a pressure reducing device for his bed, received nutrition or hydration interventions to manage skin problems, and received pressure ulcer/injury care during the 7-day look-back period. Review of the Comprehensive Care plan revealed Resident #2 was care planned for health-related complications due to Depression, [CONDITION(S)] (Urinary Tract Infection), Unstageable Pressure Ulcer to Sacrum, Risk for Non-Healing, Chronic F/C (Foley Catheter) associated with [CONDITION(S)], Cardiac Concerns, Diabetes, Risk for Skin Breakdown, and other care areas, with appropriate goals, interventions, and updates, with no concern. Review of the facility's, Order Recap Report, dated 6/1/2022-6/30/2022, revealed Resident #2 had orders which included, .[MEDICATION(S)] Capsule 500 MG (milligrams) Give 1 capsule by mouth three times a day for bacterial infection for 7 days . started 6/7/2022 and ended 6/15/2022. Continued reviewed revealed orders for Dakin's (full strength) Solution 0.5 % (percent) (Sodium Hypochlorite) Apply to R. (Right) gluteal fold topically every shift .Clean coccyx with normal saline do dakins wet to dry dressing and cover with foam dressing . started 6/8/2022 and ended 6/15/2022. Continued review revealed orders, which included, .[MEDICATION(S)] Capsule 0.4 mg (Tamsulosin HCL [[MEDICATION(S)]] Give 1 capsule by mouth at bedtime .[MEDICATION(S)] 5 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day .[MEDICATION(S)] XL Tablet Extended Release 24 Hour 10 mg ([MEDICATION(S)] ER [Extended Release] Give 1 tablet by mouth one time a day .[MEDICATION(S)] Tablet 5 mg ([MEDICATION(S)] HCL) Give 1 tablet by mouth in the morning .[MEDICATION(S)] Capsule 300 mg Give 1 capsule by mouth three times a day .[MEDICATION(S)] Capsule 300 mg Give 1 capsule by mouth every 8 hours .[MEDICATION(S)] Sodium Tablet 40 mg Give 1 tablet by mouth at bedtime .[MEDICATION(S)] Tablet Delayed Release 20 mg ([MEDICATION(S)] Sodium) Give 1 tablet by mouth one time a day .[MEDICATION(S)] Tablet 500 MG ([MEDICATION(S)] HCL) Give 1 tablet by mouth two times a day .[MEDICATION(S)] Tablet 6.25 MG Give 1 tablet by mouth two times a day .[MEDICATION(S)] HCL Tablet 500 mg Give 1 tablet by mouth two times a day .[MEDICATION(S)] Tablet 25 mg ([MEDICATION(S)]) Give 1 tablet by mouth two times a day .Indwelling Urinary (Foley) Catheter Care: Cleanse with soap and water every shift .[MEDICATION(S)] Capsule 150 mg ([MEDICATION(S)]) Give 1 capsule by mouth two times a day .Protein Liquid three times a day for wound healing mix 30 ml (milliliters) with 120 ml liquid, can mix with Juven .[MEDICATION(S)] Tablet 50 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day . Review of the TAR (Treatment Administration Record), dated 6/1/2022-6/30/2022, for Resident #2, revealed no documentation of completion for, .Dakin's (full strength) Solution 0.5 % (percent) (Sodium Hypochlorite) Apply to R. (Right) gluteal fold topically every shift .Clean coccyx with normal saline do dakins wet to dry dressing and cover with foam dressing . on 6/8/2022, 6/9/2022, 6/10/2022, 6/11/2022, and 6/12/2022 and no supporting progress notes for missed administration explanation. Continued review revealed no documentation for completion for, Indwelling Urinary (Foley) Catheter Care: Cleanse with soap and water every shift, for 6/10/2022 on nightshift, 6/11/2022 on dayshift, and 6/12/2022 on dayshift and no supporting progress notes for missed administration explanation. Review of the MAR (Medication Administration Record), dated 6/1/2022-6/30/2022, for Resident #2, revealed no documentation of administration of Protein Liquid three times a day for wound healing mix 30 ml (milliliters) with 120 ml liquid, can mix with Juven on 6/18/2022 at 1800 (6:00 PM) and 6/19/2022 at 1800 and no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Capsule 150 mg ([MEDICATION(S)]) Give 1 capsule by mouth two times a day on 6/16/2022 at 0600 (6:00 AM), 6/18/2022 at 1800, and 6/19/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 25 mg ([MEDICATION(S)]) Give 1 tablet by mouth two times a day on 6/8/2022 at 1800, 6/16/2022 at 0600, 6/18/2022 at 1800, and 6/19/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] HCL Tablet 500 mg Give 1 tablet by mouth two times a day on 6/8/2022 at 1800, 6/16/2022 at 0600, 6/18/2022 at 1800, and 6/19/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 6.25 MG Give 1 tablet by mouth two times a day on 6/8/2022 at 1800, 6/16/2022 at 0600, 6/18/2022 at 1800, and 6/19/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 500 MG ([MEDICATION(S)] HCL) Give 1 tablet by mouth two times a day on 6/8/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Sodium Tablet 40 mg Give 1 tablet by mouth at bedtime on 6/18/2022 at 1800, and 6/19/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet Delayed Release 20 mg ([MEDICATION(S)] Sodium) Give 1 tablet by mouth one time a day on 6/16/2022 at 0600, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] 5 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day on 6/16/2022 at 0600, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 5 mg ([MEDICATION(S)] HCL) Give 1 tablet by mouth in the morning on 6/16/2022 at 0600, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Capsule 300 mg Give 1 capsule by mouth three times a day on 6/8/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Capsule 300 mg Give 1 capsule by mouth every 8 hours on 6/16/2022 at 0600, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] XL Tablet Extended Release 24 Hour 10 mg ([MEDICATION(S)] ER [Extended Release] Give 1 tablet by mouth one time a day on 6/16/2022 at 0600, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 50 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day on 6/16/2022 at 0600, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Capsule 0.4 mg (Tamsulosin HCL [[MEDICATION(S)]] Give 1 capsule by mouth at bedtime on 6/18/2022 at 1800 and 6/19/2022 at 1800, with no supporting progress notes for missed administration explanation. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with readmission on 7/2/2022, with diagnoses which included [CONDITION(S)], Unstageable Pressure Ulcer of Sacral Region, Chronic Ulcer of the Left Foot, Peripheral Vascular Disease, Hypertension, Depression, Dementia, Anxiety, [CONDITION(S)], and Gastrostomy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 15 on the BIMS (Brief Interview for Mental Status) assessment, which indicated intact cognition. Continued review revealed she required total assistance with most ADLs. Continued review revealed that Resident #3 was assessed as being at an increased risk for developing pressure ulcers and had 1 unstageable pressure ulcer and 1 Stage 3 pressure ulcer present on admission/entry or reentry, to the facility. Continued review revealed Resident #3 was assessed as having a pressure reducing device for his bed, received pressure ulcer/injury care, received applications of ointments/medications other than to feet, and received application of nonsurgical dressings (with or without topical medications) other than to feet, during the 7-day look-back period. Review of the Comprehensive Care plan revealed Resident #3 was care planned for health-related complications due to Short-Term Memory Deficit, Pressure Areas with at risk for Further Skin Breakdown, Hypertension, Peripheral Vascular Disease, Gastrostomy Care, Risk for Falls, Pain, DVT ([CONDITION(S)]) requiring Anticoagulation Therapy, Decreased Mobility, Gastrostomy Tube Placed, All nourishment, hydration, and meds per G (Gastrostomy) Tube; can still have pleasure foods on request, and other care areas, with appropriate goals, interventions, and updates, with no concern. Review of the facility's, Order Recap Report, dated 6/1/2022-6/30/2022, revealed Resident #3 had orders which included, .Protein Liquid Give 2 times a day for Wound healing .Sodium [MEDICATION(S)] Tablet 650 mg Give 1 tablet via G-Tube (Gastrostomy Tube) two times a day .[MEDICATION(S)] Sulfate [MEDICATION(S)] 220 (Fe [Iron] Give 7.5 milliliter via G-tube three times a day .Flush G-Tube with 240 ML H2O (Water) every 6 hours .[MEDICATION(S)] Patch 72-hour 75 MCG (Micrograms)/HR (Hour) Apply 1 patch transdermally every 72 hours for pain .[MEDICATION(S)] HCl Tablet 5 mg Give 10 mg via G-Tube two times a day .[MEDICATION(S)] HCl Tablet 10 mg Give 1 tablet via G-Tube two times a day .[MEDICATION(S)] Tablet 5 mg ([MEDICATION(S)]) Give 1 Tablet via G-Tube two times a day .[MEDICATION(S)] Tablet 5 mg Give 5 mg via G-Tube . Review of the MAR (Medication Administration Record), dated 6/1/2022-6/30/2022, for Resident #3, revealed no documentation of administration of Protein Liquid Give 2 times a day for Wound healing on 6/19/2022 at 1800 (6:00 PM) and 6/25/2022 at 1800 and no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for Sodium [MEDICATION(S)] Tablet 650 mg Give 1 tablet via G-Tube (Gastrostomy Tube) two times a day on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Sulfate [MEDICATION(S)] 220 (Fe [Iron] Give 7.5 milliliter via G-tube three times a day on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for Flush G-Tube with 240 ML H2O (Water) every 6 hours on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Patch 72-hour 75 MCG (Micrograms)/HR (Hour) Apply 1 patch transdermally every 72 hours for pain on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] HCl Tablet 5 mg Give 10 mg via G-Tube two times a day on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] HCl Tablet 10 mg Give 1 tablet via G-Tube two times a day on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 5 mg ([MEDICATION(S)]) Give 1 Tablet via G-Tube two times a day on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. Continued review revealed no documentation of administration for [MEDICATION(S)] Tablet 5 mg Give 5 mg via G-Tube at bedtime on 6/19/2022 and 6/25/2022 at 1800, with no supporting progress notes for missed administration explanation. During an interview on 8/9/2022 at 5:20 PM, the Treatment Nurse stated that he performed wound care on Resident #2 while he was a resident at the facility. The Treatment Nurse stated, he came to us with the wound. He stated that the NP (Nurse Practitioner) at the facility does the residents' wound measurements once a week. When asked about the wound treatments not being signed off on the TAR (Treatment Administration Record) for Resident #2, the Treatment Nurse stated, I know I did them but forgot to sign them off. During an interview on 8/9/2022 at 7:30 PM, the Administrator reviewed the MAR and TAR for Residents #1, #2, and #3. She confirmed there were multiple documentation errors on the MAR and TAR for each resident reviewed. She stated, We are going to have QAPI (Quality Assurance and Performance Improvement) which includes daily checks and have already started in-services today on documentation on MARs and TARs.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to follow infection control measures by failing to disallow non-essential COVID-19 positive staff to work, failing to complete COVID-19 assessments twice daily on 2 of 4 sampled residents, failing to maintain an active screening process, failing to don proper PPE (personal protective equipment) prior to entering a COVID-19 isolation room, and failing to ensure staff wore a face shield or goggles as a facility practice. The findings include: Review of an untitled and undated facility policy showed, .The same screening performed for visitors should be performed for facility staff Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work . Review of the facility policy, Identification of Possible COVID-19 Protocol, dated 3/5/2020, showed .Covid-19 screening tool - to be completed BID (twice daily) . Review of documentation used as facility policy, COVID-19 Prevention, Monitoring, and Management for Long-Term Care Facilities, dated 8/28/2020, showed .HCP should be screened daily for fever or symptoms of illness before beginning work .HCP .may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test .Implement universal use of personal protective equipment .wear eye protection in addition to their facemask . Review of COVID-19 Manifest (the point of care COVID-19 test log) documentation, dated 12/24/2020, showed .Legal Name .(Business Office Manager) .Test Date .12/24/2020 .[DIAGNOSES REDACTED]-COV-2 (COVID-19) .Positive . Review of the Business Office Manager's time punches showed she worked on 12/28/2020 for 8.83 hours, 12/29/2020 for 7.9 hours, 12/30/2020 for 8.32 hours, 12/31/2020 for 6.25 hours, and on 1/1/2021 for 6.42 hours. Review of the Maintenance Director's POC (point of care) Test Result Reporting documentation showed Date 12/28/2020 .[DIAGNOSES REDACTED]-COV-2 (COVID-19) .test result .(positive) . Review of the Maintenance Director's time punches showed he worked on 12/30/2020 for 8.73 hours, 12/31/2020 for 8.85 hours, 1/1/2021 for 6.53 hours, 1/4/2021 for 7.92 hours, and on 1/5/2021 had clocked in at 6:58 AM. Review of the Occupational Therapy Assistant #1's POC Test Result Reporting documentation showed .Test Date .12/30/2020 .[DIAGNOSES REDACTED]-COV-2 (COVID-19) .Positive . Review of the Occupational Therapy Assistant #1's Clock In & Clock Out Variance Report showed he worked on 12/31/2020 from 9:26 AM until 4:26 PM, 1/1/2021 from 9:26 AM until 5:21 PM, 1/4/2021 from 9:23 AM until 2:17 PM, and on 1/5/2021 from 9:01 AM until 11:56 AM. Review of the facility Sign In Form For Employees And Visitors documentation showed the Business Office Manager was not screened prior to her shifts on 12/28/2020, 12/29/2020, nor 12/30/2020. On 1/1/2021, the Business Office Manager indicated yes to New/Old signs or sympt(oms) and checked a y to the follow symptoms: throat, cough, runny nose, SOA (shortness of air), and diarrhea . The Maintenance Director was not screened prior to his shifts on 12/30/2020, 1/1/2021, 1/4/2021, and 1/5/2021. Occupational Therapy Assistant #1 was not screened prior to his shifts on 1/1/2021, 1/4/2021, nor 1/5/2021. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's COVID-19 Screening Tool documentation revealed the facility failed to complete the twice daily COVID-19 screenings on 12/20/2020, 12/21/2020, and 12/23/2020. On these dates, the resident was screened only once for signs and symptoms of COVID-19. Medical record review of the POC Result Reporting documentation revealed Resident #3 tested positive for COVID-19 on 12/28/2020. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's COVID-19 Screening Tool documentation revealed the facility failed to complete the twice daily COVID-19 screenings on 12/3/2020, 12/21/2020. On these dates, the resident was screened only once for signs and symptoms of COVID-19. Medical record review of the POC (point of care) Result Reporting documentation revealed Resident #4 tested positive for COVID-19 on 12/23/2020. Observation inside the facility on 1/05/2021 over the course of the day, showed facility staff do routinely not wear a face shield or goggles. During an interview on 1/5/2021 at 12:06 PM, the DON (Director of Nursing) confirmed the Maintenance Director tested positive for COVID-19 on 12/28/2020 and was inside his office doing paperwork at the moment. On-going interview confirmed he doesn't go on the white (non-COVID-19) hall and had no direct contact with residents. During an observation of the Maintenance Director at 12:25 PM on 1/5/2020, he was seated in his office working at his desk and wearing an N95 facemask around his neck and no face shield or goggles, and the office door was wide open. When the Maintenance Director saw the DON and this surveyor approaching, he quickly pulled up his N95 facemask so it was on properly. Interview confirmed he had tested positive for COVID-19 on 12/28/2020, did not have a fever, was currently having symptoms including sinus drainage, a runny nose, and was frequently blowing his nose. Over the course of the interview, the Maintenance Director frequently touched his N95 facemask without completing hand hygiene afterwards. During continued interview, via phone, on 1/5/2020 at 1:25 PM, the Maintenance Director confirmed he returned to work on 12/30/2020 and worked 12/31/2020, 1/1/2021, and 1/4/2021. He confirmed he'd been screening himself at the front door when he comes into work. He confirmed there is a receptionist that screens some people, but .for the people who know what they're doing, we do it our self . During an interview on 1/5/2021 at 4:45 PM, the Social Worker was observed not wearing a face shield or goggles and wearing an N95 face mask with the top strap around the back of her head and the bottom strap dangling under her chin. The Social Worker stated she wore it that way .because it chokes me to death . and .no one has said anything to me about it . During an interview on on 1/5/2021 at 5:06 PM, the ADON (Assistant Director of Nursing) confirmed facility staff don't wear a face shield or goggles as a facility practice. During an interview on 1/5/2021 at 6:53 PM, the DON and the Administrator confirmed the observation of the dangling N95 facemask chin strap was not proper use of PPE. On-going interview confirmed facility staff wear a face shield or goggles inside of isolation rooms, but not in the hallways or at the nurse's station because it gets so hot. The DON and the Administrator indicted staff wearing a face shield or goggles had been a routine facility practice during the COVID-19 outbreak, but as most residents and staff were off isolation, this practice had fallen off. During an observation on 1/5/2021 at 7:04 PM, Resident #4 was in bed in his room being fed by a CNA who had no face shield or goggles and wearing a surgical mask. The resident's door was wide open, and an isolation cart was stationed outside the door. During an interview on 1/5/2021 at 7:05 PM, CNA (Certified Nursing Assistant) #1 was not wearing a face shield or goggles, and confirmed she was feeding Resident #4 without proper PPE inside of an isolation room. During an interview on 1/5/2021 at 7:37 PM, the DON confirmed the nursing staff failed to complete the twice daily COVID-19 screenings on 12/20/2020, 12/21/2020, and 12/23/2020 for Resident #3, and failed to complete them on 12/3/2020 and 12/21/2020 for Resident #4. The DON confirmed CNA #1 should have been in full PPE, including an N95 face mask, a face shield or goggles, a gown, and gloves, and this was a breach in infection control. During an interivew on 1/5/2021 at 7:44 PM, the Infection Preventionist confirmed the facility does not have a full-time screener nor a consistent active screening process. Around the time of the outbreak, the screening process devolved to where now staff screen themselves. During a phone interview on 1/6/2021 at 9:10 AM, the ADON confirmed the facility does not have a consistently active screening process. At one time, there had been a consistent designated screener, but .now everybody knows the routine . and staff screen themselves. On-going interview confirmed the facility's understanding that COVID-19 positive staff wouldn't need to complete the screening process because they were already positive. Further interview confirmed the Business Office Manager also worked while positive for COVID-19. During a phone interview on 1/6/2021 at 10:11 AM, the Business Office Manager confirmed she tested positive for COVID-19 on 12/24/2020 and was given permission to work in her office on 12/28/2020, 12/29/2020, 12/30/2020, 12/31/2020, and on 1/1/2021 while positive. She confirmed she was not screened on 12/28/2020, 12/29/2020, 12/30/2020, nor 12/31/2020 to avoid lingering in the facility's foyer. During a phone interview on 1/6/2021 at 10:20 AM, Occupational Therapy Assistant #1 confirmed he tested positive for COVID-19 on 12/30/2020, and worked on 12/31/2020, 1/1/2021, 1/4/2021, and 1/5/2021. Occupational Therapy Assistant #1 confirmed he had been working with COVID-19 positive residents inside their rooms and understood this (continuing to work while positive for COVID-19) was facility protocol.

Based on facility policy review, observation and interview the facility failed to clean 1 of 3 portable water cooler spouts. The findings include: Facility policy review, Cleaning and Sanitizing Equipment, dated 2005 revealed .All equipment is cleaned and sanitized .a. After every use . Observation on 7/22/19 at 10:24 AM on the 200 Hall revealed the portable water cooler #3 had black debris in the spout. Observation on 7/22/19 at 1:44 PM in the dining room revealed the portable water cooler #3 still had black debris in the spout. Interview with Certified Nurse Aide #3 on 7/22/19 10:36 AM on the 200 Hall revealed she had passed water to all the residents on the 100 Hall. Interview and observation with the Dietary Manager present on 7/22/19 at 1:49 PM in the kitchen revealed dietary staff cleaned the water coolers daily. Continued interview when shown the spout confirmed .Nope that is just nasty; I expect them to clean it everyday .

Based on facility policy review, medical record review and interview the facility failed to update/revise care plans for 3 (#4, #8 and #58) of 22 residents reviewed. The findings include: Facility policy, Comprehensive Care Planning Process, undated, revealed .care plans are updated as resident condition changes; resident events occur; or resident's plan of treatment is revised .including monitoring each resident condition and responding with appropriate interventions .Updates are completed by the Department Heads and Unit Managers/Staff Nurse .Staff Nurses are expected to update when Unit Managers are not available . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the progress note dated 7/4/19 revealed .ALERT SBAR (situation, background, assessment, recomendation) -Fall Note RESIDENT UP TO BATHROOM. UPON EXITING BATHROOM RESIDENT SLIPPED AND fell LANDING ON RIGHT SIDE FACING BED. Action: ASSESSED FOR INJURY. SKIN TEAR NOTED TO LEFT LOWER OUTER LEG BELOW THE KNEE. ASSISTED BACK TO BED. SKIN TEAR CLEANED WITH Normal Saline (NS), EDGES APPROXIMATED, AND STERI-STRIPS APPLIED . Record review of the facility risk log dated 7/4/19 revealed Resident #4 had a fall. Continued review revealed .Therapy evaluate for balance . Medical record review of Resident #4's care plan revised 5/6/19 revealed no interventions for the 7/4/19 fall. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitvely intact. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #8's Nursing Smoking Screen dated 2/6/19 revealed .Resident need for adaptive equipment .supervision . Medical record review of Resident #8's Nursing Smoking Screen dated 5/2/19 revealed .Resident need for adaptive equipment .smoking apron .supervision . Medical record review of Resident #8's Smoking Safety Evaluation dated 7/15/19 revealed .note: supervision will be required for all residents during designated smoking times .This evaluation will be utilized for the resident's smoking care plan on admission and as indicated .apply smoking apron . Medical record review of Resident #8's Smoking Safety Evaluation dated 7/22/19 revealed .note: supervision will be required for all residents during designated smoking times .This evaluation will be utilized for the resident's smoking care plan on admission and as indicated . Medical record review of Resident #8's care plan revised 5/7/19 revealed no care plan addressing supervision when smoking or the use of a smoking apron. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of Resident #58's Significant Change in Status MDS dated [DATE] revealed Resident #58 had a fall with major injury. Continued review revealed Resident #58 required 2 person total assist with transfers. Medical Record review of Resident #58's care plan dated 10/16/18 revealed no fall interventions for Resident #58's fall on 6/25/19. Interview with Resident #4 on 7/22/19 at 1:36 PM in Resident #4's bedroom revealed the resident had fallen recently while walking from the bathroom to the bed. Interview with Licensed Practical Nurse (LPN) #3 on 7/22/19 at 4:12 PM in the dining room when asked to review Resident #8's Smoking Screen dated 5/2/19 and care plan dated 5/7/19 confirmed I did (Resident #8's) smoking screen but I did not update the care plan; I'm not sure who is supposed to update the care plans. Interview with the Director of Nursing (DON) on 7/22/19 at 4:17 PM in her office confirmed nurses can update care plans as needed and the nurses were responsible to notify the social services or any interdisciplinary team (IDT) member when there's a change in a resident's condition requiring a care plan update; we have IDT meetings each morning and review resident changes and care plan recommendations and update the care plans then; there's a miscommunication; the nurse who did (Resident #8's) smoking assessment failed to notify anyone of the need for (Resident #8) care plan to be updated so the care plan did not get updated. Telephone interview with LPN #1 on 7/23/19 at 2:35 PM revealed the immediate interventions put in place for Resident #58's fall on 6/25/19 were diversional activities. Telephone interview with LPN #5 on 7/23/19 at 2:59 PM when asked concerning updating Resident #4's care plan related to the fall revealed .I notified the family, and faxed the doctor; I updated the care plan on the computer . Interview with the DON on 7/24/19 at 3:00 PM in the conference room confirmed, care plans were to be updated timely with appropriate interventions after the daily IDT meeting and (Resident #58) care plan was not updated. Interview with the DON on 7/24/19 at 3:16 PM in the conference room revealed the staff had to manually update the care plan in the computer. Continued interview when asked to review Resident #4's care plan confirmed anybody can update the care plans. I would think the care plan coordinator would do it, and it wasn't updated. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 had a fall with major injury. Medical Record review of Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 requires a two person assist. Interview with the Director of Nursing (DON) on 7/24/19 at in the conference room confirmed, care plans are to be updated timely with appropriate interventions after daily Interdisciplinary (IDT)meeting.

Based on medical record review and interview, the facility failed to follow the care plan for 1 resident (#58) of 22 residents reviewed. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of Resident #58's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 had a fall with major injury. Continued review revealed the resident required 2 person assist with transfers. Medical Record review of Resident #58's care plan dated 10/16/18 revealed Resident #58 required a lift for all transfers. Interview with Certified Nursing Assistant (CNA) #2 on 7/23/19 at 7:38 AM in the conference room when asked concerning Resident #58's fall on 6/25/19 revealed she assisted Licensed Practical Nurse (LPN) #1 with putting Resident #58 back in the bed after finding the resident on the floor. When asked how the resident was returned to the bed, CNA #2 stated we lifted (Resident #58) up by the arms and returned (Resident #58) to bed. When asked what the care plan required for transferring Resident #58, CNA #2 stated she was not sure what the care plan required for transferring the resident. Telephone interview with LPN #1 on 7/23/19 at 2:35 PM when asked concerning Resident #58's fall on 6/25/19 revealed he assessed the resident for any injuries and lifted the resident back in bed with the assistance of CNA #2. Continued interview when asked how Resident #58 was transferred back to bed he stated we lifted the resident up with our arms and put the resident back to bed. Continued interview when asked what the care plan required for transferring the resident he stated I am not sure what the care plan required for transferring the resident because the resident never gets out of bed. Telephone interview with LPN #4 on 7/23/19 at 2:45 PM when asked concerning transferring Resident #58 after the fall on 6/25/19 confirmed she witnessed LPN #1 and CNA #2 return Resident #58 back to bed by scooping the resident up with their arms. Interview with the Director Of Nursing on 7/24/19 at 3:00 PM in her office confirmed the care plan for Resident #58 was not followed regarding the use of a lift while transferring Resident #58 from the floor back to bed after a fall.

Based on facility policy review, medical record review, observation, and interview, the facility failed to serve food in a safe and sanitary manner for 1 resident (#11) of 13 residents observed on the 200 hall. The findings include: Review of the undated facility policy Resident Tray Service and Delivery revealed .Bare hand contact with food is prohibited . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 required supervision with meal set up only. Observation of the noon meal on 10/29/18 at 12:33 PM on the 200 hallway revealed Certified Nurse Aide (CNA) #1 removed a sandwich on the meal tray from a plastic bag and cut the sandwich in half using a butter knife. Further observation revealed CNA #1 picked up the sandwich with her bare hand and handed it to the resident. Interview with CNA #1 on 10/29/18 at 12:37 PM in the 200 hallway confirmed gloves were to be worn when handling resident's food. Interview with the Director of Nursing on 10/31/18 at 7:31 AM in her office confirmed gloves were to be worn when handing residents food. She stated staff was not to handle resident's food with their bare hands.

Based on medical record review, observation, and interview, the facility failed to accurately assess bed rail use for 1 resident (#33); and failed to accurately assess the origin of the pressure ulcer for 1 resident (#62) of 34 residents reviewed. The findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed bed rails were used daily and assessed as a physical restraint. Observation on 10/29/18 at 11:40 AM revealed Resident #33 in his room lying on his right side in the bed with 2 half rails located at both sides of the bed by the head in the up position. Further observation revealed the resident used the rail to reposition himself. Interview with Licensed Practical Nurse #5 on 10/30/18 at 11:44 AM in the conference room revealed she was responsible for the MDS data for Resident #33. Further interview confirmed she had incorrectly identified the bed rails as restraints when in fact they were for mobility on the 9/14/18 MDS. Medical record review revealed Resident #62 was admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Skin Evaluation form dated 7/25/18, 7/31/18, 8/1/18, and 8/15/18 revealed redness in the perineal and buttocks areas with no open areas noted. Medical record review of the Nursing Admission/Readmission Data Collection form dated for the admission on 8/24/18 revealed .Skin - pinpoint open areas stage 2 (4 sites) on L (Left) buttock .Top - 1 cm (centimeter) x 0.5 cm x 0.1 cm, Middle - 0.6 cm x 0.6 cm x 0.1 cm, Bottom - 0.3 cm x 0.8 cm x 0.1 cm .stage 2 sheared area right buttock .4.5 cm x 3.0 cm . Medical record review of the Significant Change MDS dated [DATE] revealed the .Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry .0 (zero) . Interview with Registered Nurse #1 on 10/30/18 at 2:26 PM in conference room revealed she was the MDS Coordinator. Further interview confirmed the MDS dated [DATE] incorrectly identified the stage 2 pressure ulcers as facility acquired when in fact the resident was readmitted from the hospital with the pressure sites.

Based on facility policy review, medical record review, observation and interview, the facility failed to have emergency equipment (ambu bag-a hand held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) for 1 of 1 resident (#49) . The findings include: Record review of the facility policy revised 11/2017 [MEDICAL CONDITION] Care revealed no documentation addressing having emergency equipment needed readily assessable in the room of a resident. Medical record review revealed Resident #49 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders dated 10/19/18 revealed .Administer oxygen @ (at) 28 % (percent) [MEDICAL CONDITION] mask (collar) Q (every) shift . Medical record review of the care plan dated 9/13/18 revealed .Resident #49 has ineffective respiratory airway clearance associated with recurrent [MEDICAL CONDITION] require vent (ventilator). He has [MEDICAL CONDITION]. Observation on 10/29/18 at 9:44 AM and 3:31 PM and on 10/30/18 at 9:37 AM in Resident #49's room revealed no ambu bag. Observation on 10/29/18, 10/30/18, and 10/31/18 in the dining room revealed a crash cart with two ambu bags in plastic bags hanging on both sides of the crash cart. Observation and interview with Licensed Practical Nurse (LPN) #1 at 9:44 AM in Resident #49's room revealed no ambu bag in the room. Further interview revealed LPN #1 asked are we suppose to have it in his room? The surveyor replied yes, for emergencies. LPN #1 responded will order one from central supply. Interview with the Director of Nursing on 10/31/18 at 10:25 AM in her office revealed, We have a crash cart near by and it has everything on it, that is the closest one . I am not aware of an ambu bag in his room. We are going to have a ambu bag near him.

Based on medical record review, observation, and interview, the facility failed to maintain oxygen equipment in a sanitary manner for 1 resident (#46) of 9 residents receiving respiratory care. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Observation on 10/29/18 at 9:33 AM revealed Resident #46 was not in the room and an oxygen concentrator with a heavy accumulation of debris on the top of the concentrator, under the handle. Further observation revealed oxygen tubing stored in a bag dated 10/29/18 was hanging from the concentrator handle. Further observation at 12:12 PM revealed the oxygen concentrator remained with accumulation of debris. Observation on 10/30/18 at 7:40 AM revealed Resident #46 on the bed in his room with the oxygen concentrator on, and the nasal cannula on the floor. The oxygen concentrator remained with an accumulation of debris as the observations on 10/29/18. Further observation on 10/30/18 at 8:23 AM, with Licensed Practical Nurse (LPN) #3 present, revealed the oxygen concentrator was on, had an accumulation of debris present, and the nasal cannula was on the floor. Further observation at 8:30 AM revealed Registered Nurse (RN) #2 entered Resident #46's room and was asked by the surveyor to check the oxygen concentrator. Interview with RN #2 at 10/30/18 at 8:30 AM in Resident #46's room when asked if the oxygen concentrator was clean stated .not so much . Interview with the Director of Nursing on 10/31/18 at 1:40 PM in her office revealed her expectation was for the oxygen concentrators to be clean when in use by a resident.

Based on facility policy review, medical record review, facility investigation and interview the facility failed to report an allegation of abuse within the 2-hour time frame as required to the state agency for 2 residents of 5 sampled residents (Resident #1 and Resident #2) reviewed for abuse. Findings include: Review of the facility policy Abuse, Neglect, Exploitation & Misappropriation effective 11/30/14 and revised 11/28/17 revealed, .any employee .who witnesses or has knowledge of an act of abuse or an allegation of abuse .is obligated to report such information immediately, but not later than 2 hours after the allegation is made . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of the medical record revealed Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS dated [DATE] for Resident #2 revealed a BIMS score or 15 indicating no cognitive impairment. Review of a facility investigation revealed the allegation of resident to resident abuse occurred 1/29/18 at 11:00 PM. Continued review revealed the abuse protocol was initiated by Certified Nurse Aide #2 and Licensed Practical Nurse (LPN) #2. Further review revealed LPN #2 did not report the allegation of resident to resident abuse to the Director of Nursing (DON) until 1/30/18 when she arrived at work. Continued review revealed the DON reported the allegation of abuse to the state agency on 1/30/18 at 8:17 AM. Interview with the DON on 7/16/18 at 2:30 PM in the conference room confirmed LPN #2 failed to report the allegation of resident to resident abuse immediately according to facility policy.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary equipment was clean and stored in a sanitary manner. The findings included: Observation on 10/2/17 at 9:47 AM in the dietary department dry storage room, with the Dietary Manager (DM) present, revealed the standing mixer bowl was covered with plastic wrap. Further observation revealed white and yellow dried debris on the underside of the beater arm. Interview with the DM on 10/2/17 at 9:47 AM in the dietary department dry storage room revealed the plastic wrap covered mixer bowl meant the mixer was clean and ready for use. Further interview revealed the mixer had not been used since the holidays (November or December 2016). Further interview confirmed the facility failed to clean and store the standing mixer in a sanitary manner. Review of facility policy, undated, Thermometer Use, revealed .Thermometer must be sanitized following each use or measurement using .food sanitizer or thermometer wipes . Observation on 10/2/17 at 11:40 AM in the dining room of the resident lunch meal service, with the DM present, revealed the Dietary Services Worker wiped the thermometer with a paper napkin after each temperature was obtained. Further observation revealed the dietary service worker failed to sanitize the thermometer after each use. Interview with the DM on 10/2/17 at 11:50 AM in the dietary department revealed the thermometer was to be sanitized with a wipe after each use. The DM confirmed the facility failed to properly sanitize the thermometer after food temperatures were obtained.

Based on medical record review, observation, and interview, the facility failed to maintain a comfortable temperature range of 71 to 81 degrees Fahrenheit for 1 resident (#34) of 17 residents and 2 families interviewed of 35 residents reviewed in stage 1. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #34 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Continued review revealed the resident was independent with all activities of daily living (ADLs). Observation on 10/2/17 at 11:30 AM in the dining room revealed Resident #34 was wearing a jacket. Interview and observation on 10/3/17 at 9:45 AM with Resident #34 in the resident's room revealed the resident was cold-natured and currently felt cold. Observation revealed the resident was wearing socks, open toed shoes, long pants and a jacket. Interview with Certified Nurse Aide (CNA) #2 on 10/4/17 at 2:10 PM in the foyer of the 500 hall revealed the CNA was aware Resident #34 complained of being cold. Continued interview revealed the CNAs provided extra blankets or encouraged Resident #34 to wear a jacket when he complained of being cold. Interview with Licensed Practical Nurse (LPN) #2 on 10/4/17 at 2:15 PM at the 500 hall nursing station revealed the nurse was aware Resident #34 complained of being cold. Continued interview revealed the temperature on the 400 hall, where the resident resided, was difficult to control. Further interview revealed the CNAs provided extra blankets for the resident or encouraged the resident to wear a jacket. Observation on 10/4/17 at 5:00 PM in Resident #34's room revealed the resident was wearing a jacket. Interview with the Maintenance Director on 10/4/17 at 5:10 PM on the 400 hall revealed the heating unit on the 400 hall was centrally controlled and the temperature was difficult to regulate. Further interview revealed the problem could be solved for Resident #34 by moving him to a portion of the building that had an individual heating system and finding a roommate who preferred a warmer climate. Observation on 10/4/17 at 5:15 PM in Resident #34's room revealed the Maintenance Director obtained an air temperature of 70 degrees Fahrenheit in multiple sections of the room. The Maintenance Director confirmed the facility failed to ensure a comfortable temperature was maintained for Resident #34.