Every finding on record at Renaissance at the Terraces

Based on observation, interview, review of facility policy and staff interviews the facility failed to ensure the safe storage of medications for 3 (Resident #14, #37 and #38) of 41 residents' rooms observed.The findings included:Review of facility provided 5.3 Storage and Expiration Dating of Medications and Biologicals with an effective date of 12/1/07, and latest revision date of 6/30/25 documented, Applicability: Policy 5.3 sets forth the procedures relating to the storage . of medications . Procedure: . Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.Resident #14:On 7/7/26 at 9:23 a.m., observation of Resident #14's room revealed a container of triamcinolone acetate 0.1% cream on Resident #14's overbed table. In an interview, Resident #14 said she brought the medication from home and applies the cream every morning and night for psoriasis. uses the cream for psoriasis.On 7/8/26 at 9:11 a.m., observation of Resident #14's room revealed the container of triamcinolone acetate 0/1% cream remained on Resident #14's overbed table. Photographic evidence obtained.Resident #37:On 7/7/26 at 9:45 a.m., observation of Resident #37's room revealed a tube of Voltaren gel on the resident's overbed table. In an interview, Resident #37 said he applies the gel to his right shoulder as needed for pain.On 7/8/26 at 8:12 a.m., observation of Resident #37's room revealed 2 tubes of Voltaren gel and a container of Metamucil 3-in-1-daily fiber were stored unsecured on the resident's bedside table. Photographic evidence obtained.Resident #38:On 7/7/26 at 9:57 a.m., observation of Resident #38's room revealed a bag of Cough and Throat Relief Drops on Resident #38's overbed table. In an interview, Resident #38 said she takes them for a dry throat.On 7/8/26 at 9:17 a.m., observation of Resident #38's room revealed a bag of Cough and Throat Relief Drops on Resident #38's overbed table. Photographic evidence obtained.On 7/8/26 at 10:51 a.m., in an interview, Registered Nurse (RN) Staff A said she did not know the medications were in the residents' rooms. Registered Nurse, Staff A verified the unsafe and unsecured storage of medications at Resident #14, #37 and #38's bedside.On 7/8/26 at 11:06 a.m., in an interview, the Director of Nursing (DON) said in order for residents to self-administer medications a physician order and evaluation is required. The DON said that all medications including treatment items should be locked at all times.

Based on observation and interview, the facility failed to properly store raw meat to prevent cross contamination of ready to eat food in the walk-in refrigerator of the facility.The findings included:On 2/2/26 at 10:30 a.m., during a tour of the kitchen, Life Safety Code observation of the walk-in refrigerator revealed a pan containing raw beef tenderloin stored over cooked meat and raw mushrooms. The Director of dining verified that the raw meat was stored over ready to eat food.On 2/2/26 at 10:54 a.m., in an interview the Director of dining said the walk-in cooler went out a few nights prior. They moved all the food to the walk-in refrigerator. He said it had been challenging to get everything in the refrigerator and they missed the raw meat stored over the cooked meat and mushrooms. He said normally they kept meat on one side and dairy on the other. The Director of dining verified that raw meat should not be stored over ready to eat food, including vegetables. He said they were working on getting a quote on getting the walk-in cooler fixed. He said the Executive Chef was in charge of making sure food items are stored properly but ultimately it was his responsibility since he oversaw the dietary department.

Based on observation, review of facility policy and procedure and staff interviews, the facility failed to prepare, and store food in a sanitary manner by failing to cover and date food in 1 walk-in dairy refrigerator and 1 refrigerator and failed to clean surfaces on food preparation equipment including ovens and ice machine to prevent potential contamination. Additionally, the facility did not ensure staff wear hair restraints during preparation of food. The lack of sanitation in the kitchen had the potential to affect all residents consuming an oral diet. The findings included: 1. On 7/1/24 at 9:09 a.m., during an initial observation of the kitchen in the presence of the Director of Food and Beverages, the following was observed: The outside of the ice machine had a layer of dust with debris on the top of the machine. There was a brown colored substance on the outside top of the machine. Observation of the ice machine lid was dusty and grimy with brown substance and debris. The inside of the ice machine where the lid closes had a layer of dust, debris and had a brown substance along the ridge where the door opens and closes. The air filter on the top of the ice machine had a thick layer of dust. There was a black substance on the inside upper part of the lid. The scoop for the ice machine was lying on top of the dusty machine. The filter for the ice machine was dated 3/31/23. Photographic evidence obtained. Dietary [NAME] Staff B was observed cleaning peeling raw shrimps over an uncovered trashcan and was placing the raw shrimp in a strainer. The metal strainer was positioned over the trash with the handles resting on the rim of the trashcan to keep it from falling into the can. Staff B said, I do it to keep the water from the shrimp going on the floor. On 7/1/24 at 9:15 a.m., Dietary Staff A was observed chopping vegetables. Dietary Staff C and D were observed preparing food for the lunch meal. Dietary Staff A, C, and D did not wear a hair net. The Executive Chef verified the observation and provided a hair net to the staff. The findings of the ice machine were confirmed by the Director of Food and Beverages and the Registered Dietitian. The Director of food and beverages said the ice machine filter should be changed at least yearly and confirmed the filter was dated 3/31/23. Review of the Preventive Maintenance Contract effective September 1, 2022 through August 31, 2023 for the ice machine specified the company would Replace ice machine filters two times per year. The facility policy personal hygiene documented, All dietary employees shall practice optimal personal hygiene to minimize cross contamination and foodborne illnesses. Eating, drinking, chewing gum or using any form of tobacco shall be prohibited in the Dietary Department. Effective hair restraints shall be worn at all times. Dietary employee personal items, drink cups and bottled water were observed on clean shelves and racks in the kitchen. Photographic evidence obtained. In a plastic bin containing uncooked rice there was a scoop on top of the rice. Photographic evidence obtained. Review of the facility policy Cross Contamination Overview specified clean and sanitize work surfaces and food contact equipment between uses. Observation of drying rack for the clean pots, pans and other items. The shelves were dusty and had a brown substance on the metal. On the bottom shelf the lid to a red trash can was noted on top of a clean serving tray. Photographic evidence obtained. On the top shelf of the drying rack were wet stacked pans, stacks of drip trays from the juice and coffee machines that were wet nesting (wet dishes are stacked, preventing them from drying, creating conditions for microorganisms to grow). Several of the drip trays were noted to have a white food substance in the cervices. Photographic evidence obtained. On a clean storage rack next to the walk-in freezer were clean pots, lids and other items. A blue jacket was observed hanging from the rack and in was contact with the clean items. The Director of Food and Beverages said it was the jacket staff use to keep warm when going into the walk-in freezer. Photographic evidence obtained. Review of the facility policy Refrigerated Storage specified refrigerated items shall bear a label indicating product name and date product was received used or first opened. a) Observation of the serving refrigerator contained a pitcher of iced tea dated 6/27/24. The part of the sticker for the use by date was blank. Photographic evidence obtained. b) There was an uncovered tin serving dish with grated cheese that was hard and dry. Photographic evidence obtained. c) There was a covered serving tin of a white cream substance without a description of the food and with no date. Photographic evidence obtained. d) A plastic container of Micro Fiesta Blend with no date on it. Photographic evidence obtained. The findings in the serving refrigerator were verified with the Executive Chef. The facility policy Cross Contamination specified All raw meat shall be stored separately and in drip proof containers to avoid cross contamination of other food in the refrigerator. In the walk-in dairy cooler there was a rolling rack with sheet pans of undated and uncovered shrimp, grouper and [NAME]. On the bottom of the rack was a sheet pan with thawing, raw turkey sitting in red tinged liquid. Photographic evidence obtained. There was another rolling rack with three sheet pans of uncovered and undated raw meat. The Director of Food and Beverage [NAME] said the meat was meatloaf for the nights dinner. No meatloaf was listed on the menu for the week. The meat appeared to be brisket on the menu for the next night's dinner. Photographic evidence obtained. The findings in the walk-in dairy refrigerator were verified by the Director of Food and Beverage. Observation of the cooking area, where the ovens were noted to have a thick layer of grime and debris on the handle and temperature knobs. There was a thick brown, dried substance that had dripped down the front of the oven doors. Photographic evidence obtained. 2. On 7/2/24 at 11:51 a.m., during an observation with the Registered Dietitian (RD) of the ice machine in the main kitchen, the machine had grime on the front door and on the inner ledge of the door. There was a black substance lining the entire upper inner frame of the ice machine. The RD said the ice machine was cleaned every quarter. The RD confirmed the observation of the ice machine. 3. On 7/3/24 at 10:51 a.m., during a tour of the kitchen the Executive Chef was without a beard covering for his facial hair. A female staff member with long hair walking in the kitchen without a hair net on. The cook had on a baseball cap but no hair net. The Director of Food and Beverage was present in the kitchen and did not provide instruction to the staff regarding required hair coverings. There were no hair nets available outside of the kitchen door or on the inside of the kitchen.

Based on observation, staff and resident interviews, record review, and review of facility policy and procedure, the facility failed to ensure 2 (Residents #22 and #30) of 19 residents with bed rails were assessed for alternative interventions prior to the use of the bed rails. The findings included: The facility policy Proper Use of Bed Rails, effective 10/20/22 documented, It is the policy of the Renaissance two utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. Alternatives include but are not limited to: Roll guards, foam bumpers, lowering the bed, and concave mattresses. Alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered. If no appropriate alternatives are identified the medical record should include evidence of the following purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful. 1. Review of the clinical record revealed Resident #22 had an admitted [DATE] with diagnoses including falls, dementia and syncope. On 7/2/24 at 8:35 a.m., Resident #22 was observed in bed with 1/4 bed rails in the raised position on both sides of the bed. Review of the Side Rail assessment dated [DATE] failed to document the alternate interventions that were attempted prior to the use of the bed rail. 2. Review of the clinical record revealed Resident #30 had an admitted [DATE] with diagnoses including Parkinson's disease, anxiety, and major depressive disorder. On 7/1/24 at 11:37 a.m., Resident #30 was observed in bed with 1/4 bed rails on both sides of the bed in the raised position. Review of the Side Rail assessment dated [DATE] documented 1/4 rails bilaterally were used. The assessment failed to document the alternate interventions that were attempted prior to the use of the bed rail. On 7/2/24 at 1:36 p.m., in an interview the Director of Nursing confirmed no alternate interventions were attempted for Resident #22 and #30 prior to the use of the bed rails.

Based on observation, interview, and record review, the facility failed to show effective coordination to ensure 1 resident (#94) of 2 residents reviewed received podiatry services to maintain good foot health for identified foot concerns. The findings included: Review of the facility policy on Foot Care effective 10/17/22: It is the policy (of the facility) to ensure residents receive care and treatment to maintain good foot health. 1b. If necessary, the facility will assist the resident in making appointments with a qualified person, arranging for transportation to and from such appointments. 2b. A comprehensive assessment process is used for identifying conditions that increase the risk for impaired skin integrity of the foot. 2c. The comprehensive assessment will include an assessment of the feet for disorders which may require treatment including but not limited to corns, neuromas, calluses, bunions, hammertoes, heel spurs, and nail disorders. 3aiii. Referrals to podiatrists will be made when appropriate. Review of the clinical record for Resident #94 revealed an admitted [DATE]. Review of the Interdisciplinary Note dated 5/11/23 at 5:38 p.m. revealed Resident 94's heels and toes were dry, flaky, red, and blanchable. Resident may need to see the podiatrist. Review of the Skin Evaluation for Resident #94 dated 5/11/23 at 5:39 p.m. revealed the term Inapplicable for Foot problems, Infections of the foot, Open Lesions of the Foot, and Nails/Calluses Trimmed Last 90 days. The nurse documented, She may need to be seen by the podiatrist . Assistant Director of Nursing (ADON) was present during skin assessment. Review of the second Skin Evaluation for Resident #94 dated 5/11/23 at 6:56 p.m. revealed the term Inapplicable for Foot problems, Infections of the foot, Open Lesions of the Foot, and Nails/Calluses Trimmed Last 90 days. Review of the Baseline care plan dated 5/12/23 did not include interventions for foot care or podiatry. On 5/15/23 at 3:02 p.m., observed Resident 94 in her room sitting in recliner. Resident #94 said her toes were pretty bad and would like the toenails to be cut because she was not able reach them. The resident said they had not been done in a while. The resident was wearing sandals and her toes were visible. The toes on each foot overlapped. The toenails on both feet were thick and extending approximately half an inch from the nail bed. The nail of the 5th toe on each foot were curled over the toes. Resident #94's feet had an unpleasant smell. Review of the Interdisciplinary Note dated 5/12/23 at 10:17 a.m. by the Social Services Coordinator (SSC) did not include mention of podiatry care. Review of Interdisciplinary Notes dated 5/15/23 and 5/16/23 for Resident #94 revealed no new skin concerns. Review of the Physician's Orders and Care Plans for Resident #94 revealed no instructions or interventions for foot or podiatry care. On 5/17/23 at 3:54 p.m., the SSC said she was responsible for arranging podiatry services. The SSC said the nurses complete a Skin Evaluation and let her know who needs podiatry care. The podiatrist comes to the facility every nine weeks and whenever necessary when there is an identified concern. The SSC said the podiatrist sees all residents; the last visit was on 5/12/23. She said the staff was not allowed to cut the residents' toenails due to the risk of injury. On 5/17/23 at 4:36 p.m., the ADON said the admitting nurse completes a thorough head to toe skin evaluation when residents are admitted and within 24 hours a second skin evaluation is done to make sure nothing is missed. She confirmed staff do not cut toenails. The ADON said she remembers observing Resident #94's feet, including the long toenails, and overlapping toes. The ADON said she did not tell the SSC to add Resident #94 to the podiatry list when she identified the problem. The ADON said she did not arrange for podiatry care for #94. The ADON went into Resident #94's room, removed Resident #94's socks, exposing overlapping toes with long, thick toenails. Resident #94 remarked, they are really bad. Resident #94 said she could not cut her own toenails. The ADON asked Resident #94 if she wanted podiatry care and Resident #94 said yes. On 5/18/23 at 8:34 a.m., the SSC said she was not aware Resident #94 needed podiatry care until this morning. The SSC said the next podiatry visit was scheduled for 6/9/23 and provided the list of residents to be seen, including Resident #94. On 5/18/23 at 9:22 a.m., the SSC said if she had known Resident #94 needed podiatry care, she could have arranged it to be done on 5/12/23, preventing delay. On 5/18/23 at 10:27 a.m., Registered Nurse (RN) Staff A said she wrote the Interdisciplinary Note on 5/11/23 which noted Resident #94 may need podiatry. Staff A said she did not notify the SSC Resident #94 needed podiatry care. She said she dropped the ball and took responsibility.

Based on observations, interviews, and record review, the facility failed to ensure proper cleaning of the CPAP (Continuous Positive Airway Pressure) machine to prevent respiratory infections for 1 (Resident #93) of 1 resident requiring the use of the CPAP machine. The findings included: The facility's policy for CPAP machine with an effective date of 5/18/23 noted, It is the policy of the facility to clean CPAP equipment in accordance with current Centers for Disease Control guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection . Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections . Empty the (water) chamber completely after each use and wipe dry . Clean mask and tubing daily after use, dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. Review of the clinical record for Resident #93 revealed an admitted [DATE]. Diagnoses included unspecified sleep apnea (sleep disorder in which breathing repeatedly stops and starts). The Respiratory Care Plan started on 5/11/23 revealed Resident #93 utilizes CPAP for sleep apnea. The interventions included monitoring for proper functioning of the device and making sure it was clean. The care plan, the Medication Administration Record and the Treatment Administration Record for May 2023 did not include instructions to properly care for the CPAP machine, including a schedule for emptying, the water chamber, and cleaning the face mask, water chamber and tubing. Review of the Physician Orders of 5/18/23 revealed no instructions for the use of the CPAP machine. Review of the Progress Notes for Resident #93 from 5/10/23 through 5/18/23 revealed no interventions, instructions, monitoring, or cleaning of the CPAP machine. On 5/16/23 at 4:33 p.m., a CPAP machine was observed stored on the nightstand next to Resident #93's bed. Resident #93 said she uses the machine every night, but no one has helped her clean the machine since her admission to the facility on [DATE]. On 5/17/23 at 9:25 a.m., Resident #93 said the CPAP machine has been on the nightstand since her admission and was last cleaned on 5/8/23. The resident said no one at the facility has asked her about cleaning the machine. The resident said every night she uses the bottle of water the hospital gave to her for the water chamber. A bottle of water dated 5/9/23 was observed on the nightstand next to the machine. On 5/18/23 at 9:06 a.m., Licensed Practical Nurse (LPN) Staff B said she has cared for Resident #93 the past several days this week and did not clean the CPAP machine. The Assistant Director of Nursing who was present during the interview said she did not add orders for the care of the CPAP machine. She said she dropped the ball on it.

Based on observation, record review, review of facility policies and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain grooming and hygiene for 2 (Resident #3 and Resident #180) of 3 dependent residents reviewed for assistance with activities of daily living. This has the potential to cause psychological harm to the resident. The findings included: A review of the facility policy Activities of Daily Living (ADLs), Supporting (revised 11/28/16), specified, Residents who are unable to carry out ADLs independently, will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming and oral care). 1. A review of Resident #3' s clinical record revealed a care plan specifying Resident #3 required extensive to total assistance with ADLs including nail care, secondary to stroke and bilateral hand contractures (permanent tightening of joint). The care plan instructed staff to perform oral care daily and as needed and nail care as needed. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record showed Resident #3 was on Hospice services. On 9/20/21 at 12:36 p.m., Resident #3's fingernails were observed extending over 1/2 inch from the fingertips with a large amount of brown substance under the nail beds. Resident #3's hands were contracted, curled inward in a fist with several fingers pressed into the palm of the hands. Resident #3 was observed to have greasy, uncombed hair. The same observation was made on 9/21/21 at 11:08 a.m. Resident #3's had caked food between the teeth. Resident #3's mouth and lips were dry. Resident #3 asked for something to eat several times and said, I'm hungry. On 9/21/21 at 11:11 a.m., Licensed Practical Nurse (LPN) Staff I was notified of Resident #3's request for something to eat. Staff I replied Resident #3 was demented, confused, and had eaten breakfast. On 9/21/21 at 11:30 a.m., LPN Staff I had not offered Resident #3 food or fluids. On 9/22/21 at 11:05 a.m., during an observation Registered Nurse (RN) Staff K and LPN Staff I were at Resident #3's bedside and confirmed the resident's fingernails were long and had a brown substance under nail beds. In an interview on 9/22/21 at 11:10 a.m., RN Staff K said she did not know who was responsible to trim the resident's fingernails. On 9/22/21 at 11:11 a.m., in an interview LPN Staff I said the Hospice aide was responsible to clean and cut Resident #3's fingernails but did not know when the Hospice aide would visit the resident. LPN Staff I said Resident #3 was bedbound and received bed baths from facility staff. LPN Staff I said she did not know when Resident #3 received bed baths or nail care. On 9/22/21 at 12:21 p.m., in an interview, Certified Nursing Assistant (CNA) Staff J said CNAs were not permitted to cut fingernails and the podiatrist would do it. The CNA said she could clean and file the residents' nails but not cut them. On 9/22/21 at 12:30 p.m., in a telephone interview, the Hospice aide said she visited Resident #3 on Mondays and Thursdays and would provide a bed bath and nail care. The aide said she would cut Resident #3's nails because she was worried, they would grow into the skin because of the hand contractures. The Hospice aide said she had not visited Resident #3 in three weeks. A review of the daily charting from 9/1/21 through 9/22/21 noted documentation the CNAs provided oral care. On 9/22/21 at 4:00 p.m., in an interview the Director of Nursing (DON) said the staff were responsible for nail care, but the Hospice aide would usually cut Resident #3 nails. The DON said staff were to observe resident for needs during care and if nails were long, they should take care of it. The DON said, the expectation was the staff provide ADL care to the residents each shift. 2. On 9/20/21 at 12:10 p.m., Resident #180, was observed in his bed, his fingernails were long, extending approximately 1/2 inch past the fingertips, with a large accumulation of brown and black substance under the nailbeds. Resident # 80 was unshaven, approximately two days growth, and unkempt. Crumbs of food were on his shirt and on the bed linen. Resident #180 said he had not received a shower or bath in several days and did not like for his nails to be so long. Resident # 180 said no one had cut or cleaned his nails. On 9/21/21 at 10:43 a.m., in an interview, Resident #180 said he had told the nurse he would like to have his nails cut. 9/22/21 at 12:35 p.m., in an interview CNA Staff J said CNAs followed the shower schedule, and it did not change. The CNA said the showers were assigned by room assignments and by shift, so it was always the same. The CNA said Resident #180 was scheduled to receive a shower on the 2:00 p.m. to 10:00 p.m., shift on Sundays, Tuesdays, and Thursdays. A review of the clinical record showed Resident #180 was admitted on [DATE]. The care plan documented the resident had a deficit in ability to self-perform ADLs. The clinical record lacked documentation Resident #180 received a shower on Sunday 9/19/21.

Based on observation, record review, review of policies and procedures, resident and staff interview, the facility failed to provide reasonable interventions and adequate monitoring to meet the needs of 1 (Resident #180) of 1 sampled resident requiring continuous use of oxygen. The findings included: The facility policy Oxygen Administration (revised 10/2010) documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (blue tone to the skin and mucous membranes). 2. Signs or symptoms of [CONDITION(S)] (rapid breathing, rapid pulse, restlessness, confusion). 3. Signs or symptoms of oxygen toxicity (difficulty breathing, slow or shallow rate of breathing). Review of the clinical record showed Resident #180 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed a care plan dated 9/20/21 specifying Resident #180 was at risk for respiratory complications due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions listed on the care plan included to administer oxygen per order and monitor the resident for signs and symptoms of hypoxemia (low concentration of oxygen in the blood) such as restlessness, forgetfulness, anxiety, cyanosis (bluish discoloration of the skin from inadequate oxygenation), and lethargy. The staff was to assess the resident's respiratory status as needed and notify the physician of any abnormalities. On 9/20/21 at 12:14 p.m., Resident #180 was observed in bed, moving about in bed, restless and breathing fast. Resident #180 said he was short of breath and wanted a nebulizer (a machine that turns liquid medication into a mist inhaled into the lungs) treatment. Resident #180 said the nurse gave him an inhaler and said she would have to contact the physician to order the nebulizer. Resident #180 said, I keep telling her I can't breathe. The oxygen concentrator was observed plugged to the wall outlet, turned on and set at three liters. The oxygen tubing prongs were correctly placed in the resident's nostrils. The other end of the tubing was on the floor and not connected to the oxygen concentrator. Resident #180 was not receiving any oxygen. *Photographic Evidence Obtained* Registered Nurse (RN) Staff H was notified of Resident #180's complaint of difficulty breathing and request for assistance. RN Staff H walked in the room, checked the concentrator, said it was functioning properly. Upon further conversation with RN Staff H she noted the oxygen tubing was not connected to the concentrator. RN Staff H replaced the oxygen tubing, connected it to the concentrator and Resident #180. RN Staff H did not complete a respiratory assessment to determine the need for further intervention. On 9/21/21 at 5:10 p.m., a review of the clinical record showed no documentation RN Staff H completed a respiratory assessment for Resident #180 on 9/20/21. On 9/22/21 at 5:05 p.m., in an interview the Director of Nursing, said it was the nurse's responsibility to ensure a resident's oxygen was set on the physician ordered flow rate and functioning properly.

Based on observation, staff interview, and policy review, the facility failed to ensure all medications were locked and secured when not in sight and failed to date opened medications to prevent expired medications from being administered to residents in 1 (3rd floor medication cart) of 2 medication carts. This had the potential for unsecured and expired medications to create hazardous health consequences for residents in the facility. The findings included: The facility policy Storage of Medications (revised 4/2007) specified, The facility shall store all drugs biologicals in a safe, secure and orderly manner . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Compartments (including carts, drawers, and boxes) containing drugs and biologicals shall be locked when not in use. 1. On 9/20/21 at 9:35 a.m., during observation the 3rd floor medication cart with Registered Nurse (RN) Staff H the following was found: A Budes/Formot AER 80-4.5 inhaler (medication inhaled to treat respiratory symptoms) for Resident #180 with directions to discard the inhaler after 90 days from the date opened. The inhaler was open and there was no date on the label to identify when the inhaler was opened. Registered Nurse (RN) Staff H said when she used the inhaler today it was already opened. RN Staff H confirmed without the open date it was impossible to know when the inhaler would expire. *Photographic Evidence Obtained* An opened bottle of Refresh Tears 0.5%, without a date to indicate when the medication was first opened. The Manufacturer instructions specified to discard the medication 90 days after opening. RN Staff H confirmed without a date, it was impossible to know when the medication would expire. *Photographic Evidence Obtained* 2. On 9/20/21 at 4:44 p.m., during a medication observation, RN Staff H poured Milk of Magnesia (MOM) liquid into a medication cup for Resident #181. RN Staff H left the medication uncapped on top of the cart and did not lock the cart. RN Staff H walked down the hall to the resident's room, leaving the cart and medication unsecured, and out of her sight. Two Certified Nursing Assistants were observed standing next to the unsecured medication cart. RN Staff H returned to the cart and confirmed she had left the medication open on top of the cart and did not lock the medication cart when the cart was not in her sight.

Based on observation, policy review, and interview, the facility failed to store, label, food products in walk in refrigerator and freezer in a safe and sanitary manner to prevent potential cross contamination. The facility failed to discard expired food items in the walk-in refrigerator. The findings included: The Santa Fe Senior living Food Storage and Handling Policies and Procedures created [DATE] read, Policy It is the policy of the Dining services team (managers and associates) to cover, label, date, and store all foods in a safe storage area: refrigerator, freezer, or dry storage. Purpose The purpose is to prevent food borne illness(es). Procedures All cooked, pre-packaged open container, protein-based salads, desserts, and canned fruits are labeled, dated, and accurately covered. Dating System for Opened Foods Always securely cover the food item(s). Using a label, complete the following information using the referenced guide. Clearly write the item mane/contents, made on date, use by date, and initials of the person who prepared the label. On [DATE] at 9:20 a.m., during observation of the initial kitchen tour with the Consultant Dietitian in the walk-in freezer, there was an unwrapped, frozen pizza not covered or labeled. In the walk-in refrigerator there was: Salisbury steaks uncovered and unlabeled Crab mix with an expiration date of [DATE], not discarded. Pea soup uncovered and unlabeled. Cooked Asparagus uncovered and unlabeled. Raw pork uncovered and unlabeled. Raw fish uncovered and unlabeled. Raw chicken marinating unlabeled. *Photographic Evidence Obtained* On [DATE] at approximately 9:30 a.m., in an interview the Consultant Dietician verified the crab mix was expired and should have been discarded. She also verified all food items stored in the freezer and refrigerator should be covered and labeled.

Based on observation, record review, and staff interview the facility failed to administer medication according to physician's orders for 1 (Resident #16) of 5 residents observed for medication administration. Three licensed nurses on 2 different shifts with 29 opportunities were observed. Six medication errors were observed resulting in a 20.7% error rate. The findings included: During the survey, medication administration by 3 licensed nurses on 2 different shifts with 29 opportunities was observed. On 11/14/19 at 9:10 a.m., observations included Licensed Practical Nurse (LPN) Staff B discontinued the tube feeding. He prepared to administer 6 different medications to Resident #16 via a percutaneous endoscopic gastrostomy (PEG) tube (a flexible feeding tube placed through the abdominal wall into the stomach). To begin the administration, LPN Staff B filled a graduated container with water then placed a 60 milliliter (ml) syringe into the end of the PEG tube. Staff B then poured an undetermined amount of water into the syringe and watched it drain into the tube. Next each medication was poured into the syringe followed by a small amount of fluid poured in behind it. This was done until the quantity of water that the nurse had placed in the graduate container was gone. In an interview on 11/14/19 at 9:22 a.m., LPN Staff B said that he put 300 ml of water in the graduated container prior to starting the procedure. He said he dissolved each of the pills he had crushed with 5 ml of water in separate medication cups. Staff B said he administered each cup of medication followed with 5 ml of water. LPN Staff B said he also gave 300 ml of free water at the time. He said this was the order on the resident's record which was on the computer in front of him. On review, the physician orders directed to flush with 150 ml water before and after tube feeding every 12 hours. The physician orders directed Resident #16 was to have a water flush of 50 ml before the start of a medication pass, flush with 50 ml of water between each medication, and 50 ml flush with water at the end of each medication pass each day. In an interview on 11/15/19 at 1:10 p.m., the Director of Nursing (DON) acknowledged that, according to physician order, the nurse should have flushed the peg tube with 150 ml of water after discontinuing the peg tube feeding. The DON said Staff B should have flushed with 50 ml of water between each medication given via the PEG tube and Staff B should have flushed with 50 ml of water after the last medication was given. Resident #16's Plan of Care instructed to administer tube feeding and water flushes as ordered. The 6 medication errors equated to a 20.7% error rate.

Based on observation, review of policies and procedures, and staff interview the facility failed ensure multi-resident use glucometer (device to check blood sugar) was properly disinfected for 1 (Resident #29) of 1 resident observed to have a blood sugar check. The findings included: Review of the facility's police and procedure Obtaining a Fingerstick Glucose Level (revised (MONTH) 2011) revealed instruction to: Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of the glucometer manufacturer's cleaning and disinfecting guidelines indicated Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe . With all the recommended meter cleaning and disinfecting methods, it was critical the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. The facility used Super Sani-Cloth germicidal disposable wipes as their disinfecting agent. Review of the manufacturer's directions for the use of the wipe revealed to clean, disinfect non-food contact surfaces: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. On 11/13/19 at 11:54 a.m., Licensed Practical Nurse (LPN) Staff B, was observed obtaining a blood sample for Resident #29 with a glucometer. After the procedure, LPN Staff B took a germicidal wipe and wiped the glucometer all over with the wipe for about 10 seconds. The nurse then put the glucometer in the top drawer of the medication cart and closed the drawer. The nurse did nor ensure the glucometer remained wet for 2 minutes. In an interview on 11/13/19 at 2:48 p.m., the Director of Nursing (DON) said that the facility used the Super Sani-Cloth germicidal wipes to clean the glucometer and the meter was supposed to be kept wet for two minutes. She confirmed the nurse did not follow proper disinfection procedures for the glucometers.

Based on record review and staff, resident and family interview, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary assistance with toileting and/or transferring to the bathroom for 4 (Residents #1, #2, #3, and #4) of 4 residents reviewed requiring assistance. The findings included: 1. On 2/28/19 at 7:22 a.m., Licensed Practical Nurse (LPN) Staff A said Resident #1 was admitted to the facility approximately 2:00 p.m., on the afternoon of 1/3/19. Staff A said she arrived to the facility at 6:00 p.m. Staff A said she didn't get much of a report just that he was a new resident. LPN Staff A said Resident #1 was seated on the recliner and when she asked if he wanted to get in bed, he said no. Staff A said around 7:00 p.m., she saw a Certified Nursing Assistant (CNA) answer his call light. Staff A said she didn't see him again until 5:00 a.m., the next morning when she went in to give him a medication. Staff A said at that time, Resident #1 was still seated in the recliner. Staff A said she asked him if he was ok and he responded that he was. Staff A said the CNA filled out the bowel & bladder paperwork and said they did rounds on him. Staff A said rounds were done at 12:00 a.m., and 4:00 a.m., but she herself didn't do rounds as she had to get paperwork done. Staff A said it turned out he had been left in the recliner all night long and wet. Staff A said the resident transferred out of the facility the next day. 2. On 2/28/19 at 7:15 a.m., Resident #2's sister said her sister is incontinent and she has witnessed waits of an hour for a response. Resident #2's sister said they don't come in and tell you why, you just sit there and wait. 3. On 2/28/19 at 7:30 a.m., Resident #3 said sometimes with the call bell, they didn't put it where he could reach it, other times he pushed it and could wait for hours for someone to answer it. Resident #3 said they didn't come in and tell him why the wait was so long. Resident #3 said he guessed they've been trying to work on it by hiring more staff, but it had caused him problems with being incontinent at times. 4. Resident #4 filed a grievance on 1/28/19 about call bell response time being 1 hour. Resolution to the grievance was listed as administration team was working on hiring and training staff. On 2/28/19 at 8:51 a.m., Resident #4 said she thought it was understaffed at night and if you didn't have a good bladder by the time they got there you had a problem. Resident #4 said it did cause her to be incontinent and she was annoyed, so that was when she complained. On 2/28/19 at 6:40 a.m., the Director of Nursing (DON) said she had only been employed with the facility for 3 weeks. Said she was aware of the incident with Resident #1. The DON said they planned on doing education for all the licensed staff and go over what expectations were for oversight of CNA's but this had not been done yet. The DON said she had spent some one on one time with some of the staff, but nothing formal or documented. The DON said she hadn't been there long enough to get anything formal together where they came in with a sign in sheet. The DON said since she had been there, she had received complaints from residents regarding call light response time and incontinence. On 2/28/19 at 6:45 a.m., the Assistant Director of Nursing (ADON) said she was an employee at the time of the incident with Resident #1. The ADON said Resident #1 was admitted on [DATE] from the hospital. They sat him in his recliner, and over the course of the night, no one put him to bed. When day shift arrived they found him in the recliner completely saturated with urine. The ADON said it turned out the night CNA's never changed him, he had sat in a urine soaked hospital brief until the next morning. The wife came in and was very upset and requested transfer to another facility and they arranged transport to another facility that day. The ADON said she and the Social Worker called into Department of Children and Families (DCF) to report it. DCF came that afternoon and the CNA's involved were identified and both of them were terminated. The remaining CNA's were informally educated about call lights, but agreed there had been no formal education on call lights or incontinence care. The ADON said she had basically been trying to catch up on staffing as the previous DON left and the Administrator resigned, so there had been some other issues that put training on the back burner. On 2/28/19 at 7:18 a.m., the Administrator said she was aware of the situation that occurred with Resident #1. The Administrator explained she was not employed by the facility at the time and had only been in the position for the past 3 weeks. She said she was aware some of the staff involved were either let go or if they were agency, were no longer being used by the facility. She said they had not yet done any in-services or retraining for the staff but were working on getting a training package together. There were also no current audits being conducted for this.

Based on Administrative staff interview, and a review of the agency's Infection Control Surveillance Program, the facility failed to implement an effective program to address the risk of Legionella disease. The facility failed to establish an infection prevention program to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infections. The DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Medicare & Medicaid Services describes Legionella disease (LD) as a severe sometimes fatal pneumonia, can occur in persons who inhale aerosolized droplets of water contaminated with the bacterium Legionella. The findings included: On 12/13/17 at 1:54 p.m., a review of the agency's infection control program was conducted with the Interim Director of Nursing. The facility failed to provide evidence of performing a facility risk assessment, and water monitoring for the bacterium Legionella. There was no documentation of a Legionella surveillance program. On 12/13/17 at 2:05 p.m., the Maintenance Director said, We have not had a vender in to do an assessment of the facility or perform the water testing. On 12/13/17 at 3:00 p.m., the Administrator confirmed the facility did not implement a water management program. The facility failed to provide a facility risk assessment, of possible areas for potential growth and spread for bacteria growth.

Based on resident, family, and styaff interviews and record review, the facility failed to ensure resident rights were honored in regards to visitation for 1 (Resident #2) of 3 residents sampled. The findings included: Record review on 5/31/16 showed Resident #2 was admitted to the facility on [DATE]. A physician order [REDACTED]. In an interview on 5/31/16 at 11:00 a.m., Resident #2 stated he was happy his daughter was coming soon. During several conversations with Resident #2 throughout the day, he was able to speak about his hobbies and verbally express his feelings and make his needs known. On 5/31/16 at 1:38 p.m., Resident #2's daughter confirmed she is coming in a couple of days. She said that she would normally come down for one week every month to visit with her father. She said last month she was informed by the facility she would not be able to visit her father and she knows that his two friends who live in the area were turned away from seeing him. On 5/31/16 at 4:00 p.m., one of Resident #2's friends said he attempted to visit on 4/6/16 and was turned away at the gate and not given a reason. He would just sit and talk to the resident about their crafting. He has not tried to visit since he was turned away at the beginning of April. On 5/31/16 at 4:10 p.m., the Director of Nursing confirmed this order was carried out by the facility saying the physician wrote the order because the daughters were arguing in front of the resident. The facility felt this caused his medical issues. On 6/2/16 at 5:06 p.m., the ordering physician said he wrote the order with no intention of limiting certain visitors but more of an advisement to limit stress. He said the facility was not the resident's home, it was a nursing environment and in a nursing facility it translated into an order just as if he would write an order for [REDACTED]. The facility's visitation policy stated if a resident chooses to withdraw consent for visitation for a particular individual, the name of that person and the date of withdrawn consent shall be documented in the resident's medical record. There was no documentation in the resident's record. The resident care plan identified visitor restriction information. Review of residents record and care plan found no consent to withdraw visitation or documentation the resident or his legal representative requested restricting visitation.

Based on observation, interview, and record review the facility failed to ensure food was stored, and prepared in a sanitary manner. The facility failed to ensure facial hair was restrained, and food was being served in a sanitary manner by staff members. This has the potential of spreading harmful microorganism, which can cause food borne illness to residents receiving an oral diet. The findings included: 1. On 9/15/14 at 9:22 a.m., observations in the kitchen with the Executive Chef (EC) included the ice machine had an accumulation of dust and dirt on the exterior vent slots. The walk-in interior freezer floor was dirty with an extensive amount of food debris. Observations in the main part of the kitchen included a shelf in a reach-in cooler that held a sleeve/tray of eggs. The eggs were not pasteurized; Chef Staff L confirmed the eggs were not pauperized. Staff L said we use them for poached, fried, and omelets for the long term care residents. The interior base of the reach-in cooler had food spillage and food debris. The hot food preparation area had 2 boning knives lodged between 2 counters. When examined, both knives were dirty. The EC retrieved the knives and took them to be washed. The exterior handles on the reach-in cooler adjacent to the hot food preparation area were dirty and grimy, with an accumulation of dirt in the crevices of the handle. On the shelf in the dish room there were 3 plastic cutting boards. All 3 boards had nicks and cuts in them and were significantly stained. The boards had rubber hand grips on each side of the cutting board. The groves on the grip handles had a buildup of a white substance. There was a stand-alone ice cream freezer. The exterior housing for the freezer's fan had a significant built up of dust, and dirt. The cold preparation area had cutting boards which were nicked, cutup, and stained. The boards were being used to prepare vegetables. There was a metal mixing bowl attached to a mixer. The interior of the metal bowl had a large area with a burn mark and dried on food particles. The EC immediately took the bowl out of service. 2. On 9/16/14 at 4:00 p.m. and 9/17/14 at 9:00 a.m., follow-up visits were made to the kitchen. The freezer floor was still dirty. There were no pasteurized eggs being utilized. The other areas of concerns identified on the initial visit were in the same condition as first observed. 3. On 9/17/14 at 11:20 a.m., tray line service was observed: Chef Staff M was taking the temperature of gravy in a sauce pan. After inserting the probe into the gravy, Staff M wiped the probe of the thermometer on a dirty rag that was located on the counter top. Staff M then took the dirty stained rag, cleaned the surface of a pieces of equipment, then wiped down a cutting board with the same dirty rag. Staff M then took the temperature of the gravy. He removed the thermometer probe from the gravy, again wiped the probe with the dirty stained rag, and returned the probe to the thermometer sleeve/case. Staff M was never observed washing/sanitizing hands after cleaning equipment or before returning to his food preparation duties. Staff M had facial hair that was not restrained. Staff R, S, U, and M also Chefs were preparing and serving food with facial hair that was not restrained. Staff T was preparing some food items. On his left wrist was a large wrist watch. The band of the watch was touching surfaces of food service equipment and utensils. 4. In a meeting on 9/18/14 at 9:15 a.m., issues and concerns observed in the kitchen throughout the survey were presented. The Registered Dietitian (RD), the EC, and the Director of Nursing (DON) were present. Issues included sanitary handling of food, facial hair not being restrained, and equipment in the kitchen not being cleaned appropriately. The importance of pasteurized eggs verses serving unpasteurized eggs to a venerable population was discussed. The facility staff confirmed there were issues in the kitchen that needed to be addressed and that pasteurized eggs would be utilized for long-term care residents. 5. Facility policies were reviewed. Facility approved policy for "Kitchen Safety and uniform" reads as follows: Under paragraph 2 sections titled "Proper Clothing": Article #2 "Jewelry will not be worn. Wedding rings and studs for pierced ears may be worn." This policy though does not demonstrate that hair restraints are required. The facility's approved policy titled "Dining Service Dress Code and Grooming Standards (effective date 7/1/13) under Bullet #9 addresses "Hair nets or hair restraints are to be worn as applicable." The facility's policy and procedure for the sanitary handling of food was requested but not provided. 6. Observations during tray line on 9/17/14 at 12:30 p.m. included Staff K plating food. Staff K left the tray line several times and opened the refrigerator door to obtain cold items. Staff K went back to the tray line and continued to plate food. During the observations, Staff K failed to remove gloves, wash hands, or re-glove between dirty and clean tasks. 7. Review of the RD report from the kitchen dated 3/10/14 documented: As "servers" are multi tasking (i.e. answering phone, etc. during tray line), any leaving from tray line requires hand washing prior to handling "clean food dishes." Review of the RD report dated 7/8/14 entitled AHCA Survey readiness documented under infection control: Staff will need in-service regarding hand sanitization for room trays and when serving after handling dirty dishes. Weekly 5 P's includes: Dirty to clean-sanitize!!! When diet aide leaves servicing line - must wash hands prior to serving again. Review of the RM/QI (risk management / quality improvement) Report Nutrition Services monthly audit tool revealed there is no section related to hand washing and infection control.

Based upon observation and interview the facility failed to ensure laundry staff are wearing appropriate personal protective equipment (PPE) while handling soiled and clean linens. The facility also failed to ensure Nursing, Dietary, and Laundry have an ongoing monitoring system in place for infection control. The facility also failed to have an updated hand washing policy in place. This places the residents and staff at risk for facility acquired infections and/or illness. The findings include: 1. Laundry During an interview with Staff S on 9/17/14 around 3:00 p.m., she confirmed the she uses latex gloves while sorting soiled linen. She said she wears a gown only when sorting infectious laundry in a yellow bag. Staff S was observed placing soiled linen into the washing machine on 9/18/14 around 8:00 a.m. The soiled linen was touching Staff R's uniform as she placed it into the washing machine. Staff R was wearing latex gloves. Staff Q was observed folding clean linen on 9/18/14 around 8:15 a.m. The clean linen was touching Staff Q's uniform. Staff Q was not wearing any PPE. The staff was observed folding the clean clothes and placing them on top of a barrel used to store clean mop heads. Follow-up visit to the laundry on 9/18/14 around 9:35 a.m., revealed the staff folding clean linen without any PPE and clean clothes were touching the uniforms. During an interview with the Director of Housekeeping and the Administrator on 9/18/14 around 8:30 a.m., they confirmed laundry staff should be wearing PPE when sorting soiled laundry. Review of the Nursing Services Policy and Procedure Manual, Departmental (Environmental Services) - Laundry (revised April 2012) documents: In the Laundry Item #1- Wear heavy-duty gloves when handling and sorting soiled linen. Items #2- Wear gown or apron when sorting soiled linen. Items #4- Wear mask to prevent inhalation of aerosolized contaminants when sorting soiled linen. During an interview with the Director of Nursing (DON) on 9/18/14 at 11:54 a.m., she said the monthly audits completed by the Director of Housekeeping document the staff utilizing PPE. She said the housekeeping director may think that just "gloves" are appropriate PPE. 2. Soiled utility room During a tour of the 3rd floor soiled utility room on 9/17/14 around 2:30 p.m., it was observed the cabinet contained 6 boxes of clean masks. During a tour of the 2nd floor soiled utility room with the Administrator on 9/18/14 around 8:15 a.m., packaged briefs were observed under the sink, clean sharps container and a drinking cup in the top cabinet. The trash barrels were overflowing and had spilled onto the floor. On 9/18/14 around 9:00 a.m., the Administrator confirmed the clean items should not be in the soiled utility and the trash barrels should not be overflowing. 3. Kitchen Staff K was observed during tray line on 9/17/14 at 12:30 p.m. She was plating food, leaving the tray line several times and opening the refrigerator door to obtain cold items. Staff K then went back to the tray line and continued to plate food. During this time Staff K failed to remove gloves, wash hands or re-glove between dirty and clean tasks. Review of the Registered Dietician (RD) report from the kitchen dated 3/10/14 documented: As "servers" are multi tasking (i.e. answering phone, etc.) during tray line, any leaving from tray line requires hand washing prior to handling "clean food dishes." Review of the RD report dated 7/8/14 entitled AHCA Survey readiness documented under infection control: Staff will need in-service regarding hand sanitization for room trays and when serving after handling dirty dishes. Weekly 5 P's includes: Dirty to clean-sanitize!!! When diet aide leaves servicing line-must wash hands prior to serving again. Review of the RM/QI (risk management / quality improvement) Report Nutrition Services monthly audit tool revealed there is no section related to hand washing and infection control. During an interview with the DON on 9/18/14 around noon she said the corporation views the kitchen as a food and beverage service instead of a healthcare facility kitchen. 4. During an interview with the DON on 9/18/14 at 11:54 a.m. she confirmed she does not have a grasp on the process for tracking and trending infections and ongoing monitoring. The infection control log for August and June was incomplete and the DON was unable to find the infections documentation for July. 5. During observation of medication pass on 9/17/14 at 8:15 a.m. and at 9:45 a.m., Staff P was observed carrying a plastic medication cup, cupped in his right hand. The medication cup's rim was touching Staff P's bare hand. Staff P gave the medication cups to Resident #115, who was observed to place the rim of the medication cups in her mouth in a drinking fashion. On 9/17/14 at approximately 9:50 a.m., Staff P acknowledged that carrying the medication cup, by cupping it in his hand/touching the rim of the cup, was an unacceptable infection control practice. 6. During observation of medication pass on 9/16/14 at 3:45 p.m., Staff V was observed washing her hands prior to the administration of eye drops to Resident #59. Staff V wet her hands under running water, applied soap and rubbed her hands together under the running water for 5 seconds. She then was observed drying her hands with a paper towel and using the same paper towel to turn off the running water. She then used the same paper towel to wipe off the wet sink counter, thus contaminating her right hand. Review of the facility policy entitled "Infection Control Guidelines for All Nursing Procedures", dated April 2012, states "Employees must wash their hands at least 15 seconds using antimicrobial or non-antimicrobial soap and water." The policy continues, "Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen seconds under a moderate stream of running water, at a comfortable temperature." Centers for Disease Control (CDC) guidelines (http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf page 32) instruct, "When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet."

Based upon record review and interview the facility failed to administer the influenza (flu) vaccine to 2 (Resident #37 and Resident #116) of 5 records reviewed and failed to offer a pneumonia vaccine to 1 (Resident #117) of 5 resident records reviewed. The facility failed to follow the policy and procedure for administering vaccines. The findings included: Review of the Nursing Services Policy and Procedure Manual for Influenza Vaccine (revised December 2012) documented "residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of ... the resident's admission to the facility." Review of the Nursing Services Policy and Procedure Manual for Pneumococcal Vaccine (revised December 2012) documented "Prior to or upon admission, residents will be assessed for eligibility to receive the [MEDICATION NAME] (pneumococcal vaccine), and when indicated, will be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of the pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission." 1. Resident #37 was admitted to the facility on [DATE]. The resident signed an informed consent to receive both the flu and pneumonia vaccine on 1/14/14. The physician ordered the flu vaccine to be administered to the Resident on 1/26/14. During an interview with the Director of Nursing (DON) on 9/17/14 around 2 p.m., she confirmed the flu vaccine was not administered to Resident #37 as ordered by the physician. 2. Resident #117 was admitted to the facility on [DATE]. Review of the medical record documented the resident was never offered a pneumonia vaccine. Review of the TERRA Nursing Assessment documented the resident stated she had a flu vaccine on 9/1/13 but a declination on the informed consent was not completed. During an interview with the DON on 9/17/14 around 2 p.m., she confirmed Resident #117 had not signed the informed consent for the flu or pneumonia vaccine. 3. Resident #116 was admitted to the facility on [DATE]. Review of the medical record documented the resident signed the informed consent to receive the flu vaccine on 12/3/13. The resident did not sign an informed consent for the pneumonia vaccine. During an interview with the DON on 9/17/14 around 2 p.m., she confirmed the facility failed to administered the flu vaccine to Resident #116 and failed to complete an informed consent to accept or decline the pneumonia vaccine.

Based on observation and interview the facility failed serve food, with appropriate texture, in a appealing manner for 1 (Resident #92) a sample of 1 resident observed and interviewed regarding a pureed diet. The findings included: Resident #92 was observed in dining room on 9/16/14 during the noon meal. The resident was served a pureed diet. The food, on the main entree plate, appeared as 3 scoops of different colors of mushy, loose substance running into each other. The plate had no appeal and no garnish of any type. The type of food was indiscernible. Upon interview, at this time, Resident #92 said, "I don't have much of a choice here, so I'm eating it." Upon repeat interview on 9/16/14 at 9:45 a.m., the resident stated, "The food tasted okay, but my choice is limited, and the food did not look good." Review of the Registered Dietician(RD)'s "Weekly F(food) & B(beverage) Meeting" (with dietary staff), dated 7/23/14 showed "Puree concerns discussed. In-service as needed, use of molded items with disclaimer, piping." This same issue was documented as discussed in a 3/10/14 RD weekly "F&B meeting". In a "3/14/14 and 7/17/14 RD report related to "use of frozen reshaped puree food items, puree items needs to have smooth consistency, ground meat - size of cook ground hamburger."

Based on record review and interview, the facility failed to ensure the facility had 8 hours daily of Registered Nurse (RN) coverage when the Director of Nursing (DON) services was not present. The findings include: 1. A review of Registered Nurse (RN) coverage for when the Director of Nursing (DON) was out of the building at an in-service from 10/28/13 to 10/30/13. The RN who was present worked: 7 hours and 34 minutes from 7:43 a.m. to 3:07 p.m. on Monday 10/28/13; 7 hours and 32 minutes from 7:26 a.m. to 2:58 p.m. on Tuesday 10/29/13 and 8 hours and 37 minutes from 7:41 a.m. to 4:18 p.m. on Wednesday 10/30/13. Interview with the Administrator on 10/31/13 at 12:00 p.m., revealed the RN was supposed to be here 8 hours. That is what she (RN) was brought over for. I cannot lie, I won't lie, she was not here 8 hours those 2 days.