Every finding on record at River Landing at Sandy Ridge

Based on observations, record reviews, and staff interviews, the facility performed perineal care by wiping from back to front and wiping back to front with the same area of the wipe for 1 of 2 residents reviewed for activities of daily living (Resident #4). The findings included: Resident #4 was readmitted on [DATE] with diagnoses including fractured left femur and Alzheimer's disease.The significant change in status Minimum Data Set (MDS) dated [DATE] showed Resident #4 was severely cognitively impaired. She required substantial to maximum assistance for toileting hygiene and set up/clean up assistance with personal hygiene. Resident #4's Care Plan dated 12/18/25 had a focus for Activities of Daily Living (ADL) self-care deficit with an intervention of assistance with toileting and dressing as needed. On 01/05/26 at 2:58 PM an observation revealed Nurse Aide (NA) #1 who was assigned to Resident #4, had assisted her up from the toilet after urination and having a bowel movement. Resident #4 stood in front of the toilet while leaning forward on her walker for support. NA #1 put on gloves, stood on Resident #4's side facing her back, and first wiped Resident #4's anal area with a disposable wipe in an upward motion toward her back. NA #1 then turned the wipe to a clean area and wiped Resident #4's anal area three times in an up-and-down motion from her anal area toward the lower back, down to the anal area then up toward the lower back without turning to a clean area of the disposable wipe after each wipe. NA#1 disposed of her soiled gloves, put on clean gloves and repositioned herself in front of the resident. NA #1 then wiped Resident #4's vaginal area and with a clean wipe, having reached between the Resident #4's legs and wiped beginning in back near the anal area toward the front near the vaginal area. With a clean area if the same wipe, NA #1 then wiped again from the anal area forward toward the vaginal area. During an interview on 01/05/26 at 3:05 PM with NA #1, she revealed being familiar with Resident #4's needs for assistance with toileting care. She elaborated that Resident #4 sometimes wiped herself if she just urinated but always needed perineal care assistance after a bowel movement. On 01/07/26 at 4:33 PM a follow up interview was conducted with NA #1. She stated she remembered during the observation on 01/05/2026 having cleaned Resident #4's anal area first and changed her gloves after doing that. NA#1 explained the usual process for performing perineal care would have been to clean the vaginal area first then the anal area, using a clean side of the wipe each time until the resident was clean. NA #1 further explained she knew not to wipe from the anal area toward the vaginal area, but when Resident #4 had been leaning forward it had been hard to see. NA #1 stated she didn't think she touched Resident #4's anal area when reaching back while cleaning the resident's vaginal area. NA #1 explained she thought she had received perineal care training when she first started at the facility about 5 years ago. She further explained that during the annual skills fair this spring she had practiced perineal care and been checked off. NA#1 explained the skills fair training was to wipe the vaginal area starting in the front and moving back toward the anal area and not wipe more than once without turning to a clean area of the wipe. NA #1 revealed it had been hard to see when wiping Resident #4's vaginal area, she was nervous and had probably been rushing at the end. Record Review of the Nurse Aide Skills Fair Verification Checklist dated 3/31/25 for NA #1. The checklist was marked completed with return demonstration for giving Incontinent/Perineal Care. An interview was done with Nurse Mentor #1 (resident unit Nurse Supervisor) on 01/07/26 4:48 PM. Nurse Mentor #1 stated nurse aides had been taught to begin female perineal care at the vaginal area wiping front to back and then do the anal area from the anus up toward the resident's back using a clean area of the cloth for each wipe. Nurse Mentor #1 revealed the NAs should follow their training when doing perineal care because it was an infection control issue to help prevent urinary tract infections. Nurse Mentor #1 explained that the facility had not had concerns with perineal care that she knew about. She stated she did daily rounds to assist the NAs with resident care and observed perineal care several times a week. Nurse Mentor #1 didn't remember observing NA #1 doing perineal care because their schedules didn't often overlap. During an interview with the Director of Nursing (DON) with the Administrator present on 01/07/26 at 5:22 PM, the DON stated the NAs received annual education at a skills fair which included demonstrating perineal care. The DON explained that standard practice for perineal care was to have wiped the vaginal area from front to back then the anal area from front to back, using a clean surface of the cloth each time. A follow up interview with the DON was done on 01/08/26 at 12:34 PM. The DON explained facility practice was that Nurse Mentors do rounds to observe care and assist staff as needed. If the Nurse Mentors noticed an NA having trouble with a skill they would have done on the spot education and offered suggestions. The DON stated the facility took urinary tract prevention seriously and proper perineal care was a big part of this. The DON further explained that NA #1 was usually a thorough aide and participated in required education but in this case made a choice she shouldn't have.

Based on observations, record reviews, and staff interviews, the facility failed to implement manufacturer instructions and their policy and procedure to disinfect a blood glucose meter (glucometer). Nurse #1 did not allow the individually assigned glucometer to have the required two-minute wet contact time or allow the glucometer to air-dry before returning it to the individual's plastic storage bag. This occurred for 1 of 1 observation of glucometer disinfection (Nurse #1).The findings included: Review of an undated facility document titled Glucometer Cleaning Protocol read in part: Glucometers were assigned to individual residents; they will not be shared by multiple residents. Clean and sanitize glucometer machines after each use. Glucometer will be thoroughly wiped with approved disinfectant and allowed to air-dry after every use. 1 - Use an approved disinfectant wipe after each time the glucometer was used.2 - Wipe all surfaces, top, bottom, and sides. Follow contact time for disinfectant.3 - Allow to air dry. Then place glucometer in a clean area away from contamination.Note: the contact time recommended was two-minutes. A review of the manufacturer's user instruction manual for disinfection using germicidal wipes read in part: Cleaning and Disinfecting Guidelines: Cleaning and disinfecting can be completed by using a commercially available Environmental Protection Agency-registered disinfectant or germicide wipe. To use a wipe, remove from the container and follow product label instructions to disinfect the meter. Many wipes act as both disinfectant and cleaner. With all the recommended meter disinfecting and cleaning methods, it was critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper cleaning time. A review of the disinfecting wipe instructions for use as a disinfectant read in part: Use of the disinfecting wipes was a two-step process. One wipe was required to preclean then a second wipe was used to disinfect. Repeated use of the product may be required to ensure that the surface remains visibly wet for two minutes at room temperature. A continuous observation was conducted on 1/6/26 at 4:30 PM of Nurse #1 obtaining a finger stick blood sugar (FSBS). Nurse #1 returned to the medication cart, wiped the glucometer with an approved disinfecting wipe. She then tossed the wipe into the trash bin, placed the glucometer in a clear plastic storage bag, and placed the open plastic bag in the medication cart. Continuous observation and timing of the glucometer revealed the disinfectant solution did not have a two-minute contact time and the surface was not dry when it was placed in the clear plastic bag. Nurse #1 did not ensure the glucometer remained wet with disinfectant solution for a full two minutes or allow the glucometer to air dry prior to placing the glucometer in the clear plastic bag. An interview with Nurse #1 on 1/6/26 at 4:33 PM revealed her process for cleaning and disinfecting a glucometer was she wiped the glucometer with a disinfectant wipe, immediately placed it into a plastic storage bag, and placed the opened plastic storage bag into the medication cart to air-dry. Nurse #1 indicated she would return later to seal the plastic storage bag closed. She did not like to leave the glucometers on top of the medication cart to dry because they should be locked in the medication cart. Nurse #1 confirmed she worked part-time and was educated on glucometer use, cleaning, and disinfecting at new hire orientation. There had not been a skills fair since she was hired less than one year ago. During an interview on 1/6/26 at 4:36 PM, the House Mentor (Unit Manager) for the Wingfoot unit stated glucometers were only cleaned when visibly soiled with blood. She further revealed staff were trained to clean glucometers only when visibly soiled because each resident was assigned a glucometer for individual use. She did not have any concerns with the way Nurse #1 disinfected and stored the glucometer. The House Mentor did not mention the two-minute contact time for the disinfectant or the need to air dry prior to placing the glucometer into the plastic bag. On 1/6/26 at 4:40 PM, the House Mentor for the Wingfoot unit provided the facility protocol for cleaning and disinfecting glucometers. She directed this surveyor's attention to the section of the protocol that stated glucometers were to be cleaned after every use, not when visibly soiled. On 1/8/26 at 12:24 PM an interview with the Assistant Clinical Mentor revealed all part-time and full-time nursing staff were educated on glucometer use, cleaning, and disinfecting at new hire orientation and then during annual skills fair. The last skills fair was in April 2025. During annual skills fair, a House Mentor would be assigned to a station to provide education with return demonstration. Education included wiping glucometers to be visibly wet and allowed the appropriate dry time in open air before the glucometer was placed in the plastic bag and medication cart. The Assistant Clinical Mentor stated Nurse #1 should have wiped all surfaces on the glucometer with the appropriate disinfectant wipe, let it air dry, and then placed it in the bag. The facility did not have a process in place to measure the two-minute contact time for the disinfectant. During an interview on 1/8/26 at 1:06 PM, the Clinical Mentor stated nurses received education on cleaning and disinfecting glucometers when they were hired and during an annual skills fair. They were educated to use a disinfectant wipe to clean/disinfect a glucometer after each use and ensure the glucometer had air dried before it was placed and sealed into the clear plastic bag. She stated the system failed when Nurse #1 chose not to wait for two minutes and time management also played a role. The Clinical Mentor indicated she would want the cleaning/disinfecting process to stay the same as the facility's current protocol. The Clinical Mentor did not feel there was a failure in the process. On 1/8/26 at 1:24 PM, the Administrator stated licensed nursing staff were trained upon hire and at an annual skills fair. She stated Nurse #1 was hired after the annual skills fair which was in April 2025. The Administrator stated Nurse #1 should have wiped the glucometer with an approved wipe, allowed the glucometer to sit for two minutes, then air dry and store in a clear plastic bag. The Administrator indicated that would be the process for all licensed nursing staff. She did not feel there was a breakdown in the process, but a poor human decision and difficulty transitioning from a hospital setting to long-term care.

Based on observations and staff interviews, the facility failed to secure resident medications left in an unattended medication cart for 1 of 3 medication carts (Hall 100 medication cart). The findings included: An continuous observation on 11/21/24 at 10:15 PM on the 100 hall revealed the medication cart was unlocked and unattended. The locking mechanism in the middle front of the medication cart was observed to be popped out in the unlocked position. Staff and residents were observed sitting near the unlocked medication cart during this time. During an interview on 11/21/24 at 10:19 AM, Nurse #1 returned to the medication cart and stated that sometimes the medication cart does not engage with the keypad lock and that was why the cart's mechanical front lock did not engage. When asked if the cart locked when pushed in manually, she indicated the cart did lock when she pushed in the center locking mechanism manually. During an interview on 11/21/24 at 10:54 AM, Nurse #2 indicated the keypad was not needed to secure the medication cart. The medication carts were secured by the mechanical lock. During an interview on 11/21/24 at 11:51 AM, the DON revealed that the 100 Hall and the 300 Hall medication cart keypads did not work. The Pharmacy was notified and the carts were locked with the center mechanical lock. The DON stated it was expected the center mechanical lock was pushed by the nurse to engage the medication cart lock.

Based on observation, staff interviews, record review and manufacturer's information, the facility failed to maintain the manufacturer's temperature storage parameters of the refrigerator for the flu vaccine, pneumococcal vaccine and insulin multidose vial in 1 (100 hall) of 3 medication rooms and failed to discard expired [MEDICATION NAME] Multidose vial in 1 (300 hall) of 3 medication rooms. Findings included: Review of the manufacturer's storage parameters are as follows: 1. Influenza vaccine individual vials. The packaging insert indicated to store between ,[DATE] degrees F. 2. Pneumococcal vaccine [MEDICATION NAME]. The packaging insert indicated to store between ,[DATE] degrees F. 3. [MEDICATION NAME] multidose vials. The medication packaging indicated do not freeze. 1a. On [DATE] at 10:30 AM., the 100-hall medication room was observed with Nurse #1. The medication refrigerator log showed the following recordings: 1. [DATE] - 30 degrees 2. [DATE] - 28 degrees 3. [DATE] - 28 degrees 4. [DATE] - 28 degrees 5. [DATE] - 32 degrees 6. [DATE] - 32 degrees 7. [DATE] - 32 degrees 8. [DATE]- 32 degrees 9. [DATE] - 28 degrees 10. [DATE] - 32 degrees The refrigerator on 100-hall was observed with 13 influenza vaccine individual vials, 5 pneumococcal vaccine individual vials, and 3 multidose [MEDICATION NAME] vials on [DATE]. At [DATE] 10:30 AM, an interview was conducted with Nurse #1, who stated that the night shift nurse usually checks the med cart and med room temperatures and write the result in the temperature log. On [DATE] 10:53, the unit supervisor confirmed delivery by a drug company for the Influenza vials as [DATE] and the pneumococcal vaccines as [DATE] and were stored in the refrigerator. 1b. An observation on 300 hall medication room on [DATE] at 10:37 AM, there was a [MEDICATION NAME] multidose vial with an opening date of [DATE] and was in the refrigerator. On [DATE] 10:38 AM nurse #2 stated that the pharmacy comes and checks the medication room and cart. She also stated that the ,[DATE] shift will check for expiration date. An interview with the DON was conducted on [DATE] at 2:40 pm. He stated that his expectation was that the night nurses check the refrigerator temperatures and notify maintenance when the temperatures are out of range. An interview with the administrator was conducted on [DATE] at 2:40 pm. She stated that her expectation was that the refrigerator temperatures should be in acceptable range.

Based on staff interviews, resident observation, resident representative interview and record review the facility failed to develop a care plan to address significant weight loss in 1 of 8 residents (Resident #44). Findings included: Resident #44 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed that resident #44 was severely cognitively impaired. The MDS revealed that resident #44 needed extensive assistance with one person for bed mobility, transfers, dressing, toileting, and personal hygiene, limited assistance with one person for eating. Resident #44 was coded for dehydration and having a 5% weight loss in one month without being on a weight loss program. The resident did have speech therapy till 10-25-17 to assist with her dysphagia. The MDS indicated that resident #44 triggered for nutritional status and was to be care planned for her nutrition and weight loss. The Care plan dated 12-5-17 had no plan for resident #44's weight loss, nutrition, or eating needs. A review of resident #44's weights from June 2017 to December 2017 revealed that the resident had a 13.9% weight loss. The weights were: June=115Lbs, July=113, August=114, September=115, October=108, November=101, December=99. An interview with resident #44's daughter occurred on 12-13-17 at 4:30pm. The daughter stated that she did not feel the resident had a choice in what she was given to eat and that the food was not cooked appropriately. She went on to state that resident #44 needed supervision when she was eating because the resident would have choking episodes but that she was told by staff that unless the resident sat at the supervised table the resident could not be supervised. The daughter stated she requested her mother be placed at the supervised table. An interview with the nursing assistant (NA) occurred on 12-14-17 at 12:20pm. The NA stated she did help in the dining room during meal times and that resident #44 had been sitting at the supervised table for 2-3 weeks. She went on to state that prior to that resident #44 was sitting at another table but was closely supervised because the resident would often fall asleep while eating. She stated that some days the resident did not sleep well and would be tired when she came to eat. The NA stated when the resident was offered help by the dining staff the resident would refuse stating I can eat on my own. The NA stated she had not seen the resident choke or have trouble swallowing her food. An interview with the nurse occurred on 12-14-17 at 12:30pm. The nurse stated she was not in the dining room all the time but that she had not seen or heard of resident #44 chocking or having trouble swallowing her food for quite a while. She also denied ever hearing complaints from resident #44's daughter about the food or the resident not receiving help during meal times. An interview with the Minimum Data Set (MDS) coordinator occurred on 12-14-17 at 3:45pm. The MDs coordinator stated she had coded resident #44 to have a care plan for nutrition and weight loss. She looked at the residents care plan and stated resident #44 was not care planned for nutrition or weight loss. The coordinator stated she did not know why this occurred as she was not the one to develop the care plan. She stated she did send the coordination sheet to the care planners to have this completed and did not know why this was not done. An interview with the care plan coordinators (staff #1 and staff #2) occurred on 12-14-17 at 4:00pm. Both coordinators stated that they work together to develop care plans for the residents. They checked the care plan and the MDS for resident #44 and stated that the resident was not care planned for nutrition or weight loss but should have been. Staff #1 stated she missed putting nutrition and weight loss on resident #44's care plan because I was focused on keeping the resident safe and from falling. She went on to state she was aware of the resident's weight loss but again was focused on the resident's safety. Both coordinators also stated that they had met with the resident's daughter to discuss hospice but that the daughter was refusing hospice services at that time. An interview with the Director of Nursing (DON) occurred on 12-14-17 at 4:45pm. The DON stated he had not heard any complaints from resident #44 or the resident's daughter regarding the resident not receiving food choices or the resident not receiving assistance during meal times. The DON also stated that he knew that the resident's daughter was approached regarding hospice services but that the daughter did not want hospice services at that time. An observation of resident #44 occurred on 12-14-17 at 5:05pm. The resident was observed eating supper at the supervised table in the dining room. Resident #44 was offered assistance when it was noted she was having difficulty getting food onto her fork. The resident refused the help stating I don't need help. The observation revealed the resident was able to adapt and ate over half of her meal. No chocking or difficulty swallowing was noted. The resident was noted to be able to finish her meal prior to the other residents at the table. An interview with the Administer occurred on 12-14-17 at 5:30pm. The administrator stated she expected that the care plans be completed correctly and follow what MDS had triggered.

Based on observation, staff interview and resident interview, the facility failed to promote dignity during dining by routinely serving beverages in disposable foam cups for 20 residents. Eight of 20 residents stated that they would prefer a plastic glass over a disposable foam cup. Findings included: During dining observations at lunch on 11/14/16 at 12:36 PM, disposable foam cups were used for a resident who could not be interviewed in room [ROOM NUMBER]. The resident had honey thickened tea in two disposable foam cups. Four residents were observed dining in the dining room with disposable foam cups. A resident in room [ROOM NUMBER] had a disposable foam cup with lunch on 11/14/16 at 12:38 PM. The resident in room [ROOM NUMBER] had one disposable foam cup with the lunch meal on 11/14/16 at 12:40 PM. During dining observations at breakfast on 11/15/16 disposable foam cups were used. Three trays on Pebble Beach 1 hall cart had disposable foam cups on them at 11/15/16 at 8:32 AM. Two residents in the TV area were observed dining with disposable foam cups with lids and straws on them. A resident in room [ROOM NUMBER] stated she would like to have a glass, but the disposable foam cup did not bother her on 11/15/16 at 8:46 AM. The resident had two disposable foam cups with liquid in them with lids and straws. Interview with Nurse Aide (NA) #1 on 11/16/2016 at 8:36 AM revealed some residents get orange juice in disposable foam cups because it is easier for them to hold the disposable foam cups. The Lead Homemaker for Pebble Beach hall said some residents do better with disposable foam and a straw. She said it was not on a tray card, but they know by observing them. On 11/16/2016 at 8:49 AM NA #2 was observed opening the cart to pass trays on Pebble Beach hall. All of the trays had a disposable cup on it. NA #2 said she had worked at this nursing home for six years and they have always put juice in a disposable foam cup. On 11/16/2016 at 12:07 the Nutrition Mentor said the nursing home had always used disposable foam cups. He said he had worked at the nursing home for eight years. He added that the home had been looking into purchasing reusable plastic cups, but they had just purchased new domes and lids and have a brand new kitchen. On 11/17/2016 at 7:37 AM the Nutrition Mentor said 15 - 20 residents were served breakfast in their rooms on Pebble Beach hall and none were served in their room on a routine basis on Wing Foot hall. On 11/17/2016 at 8:23 AM the Food Service Director said he understood the dignity issue. He added that disposable cups had never been addressed as an issue before and it was a long standing practice. On 11/16 and 11/17/16 the Nutrition Mentor initiated actions to resolve the problem and obtained resident preferences for plastic versus foam cups. He reported that eight of the twenty residents preferred plastic cups. On 11/17/16 at 1:01 PM, interview with the Administrator revealed her expectation that residents should drink out of the same kind of glass they would drink from at home.

Based on observation, record review and staff interview, the facility failed to implement the care plan for functional exercises and did not move the bed to the lowest position during one observation for 1 of 3 sampled residents reviewed for activities of daily (ADL). Findings included: Resident #62 was admitted to the nursing home on 2/18/16. Her date of birth was 1/21/1922. Resident #62 had a significant change Minimum Data Set assessment dated [DATE]. She had moderate cognitive impairment. She had no rejection of care and behavior was noted to be worse than before. She was coded as needing extensive assistance for all activities of daily living except walking in room and eating which was supervision and limited assistance from one person respectively. Her current [DIAGNOSES REDACTED]. She had two falls without injury; 1 fall with injury and 1 fall with major injury. Her medications included an anxiety drug and an antidepressant. She received 173 minutes of physical therapy. A decision was made to proceed with a care plan for falls and activities of daily living. On 6/30/16 a referral was made from physical therapy to restorative nursing. It indicated that as of 7/1/16 a daily exercise program would be initiated. Patient to work on LE (lower extremity) strengthening as part of her functional maintenance program while she's waiting for her L (left) UE (upper extremity) cast to come off. In the meantime, patient can work on the following: B (bilateral) knee extensions with 3 pound weights B leg lifts with 3 pound weights Hip abduction with Red T-band Hip adduction with squeeze ball Four sets of 12 with rest between sets. Her precautions were listed as fall risk and weight bearing as tolerated. It said to alert the therapist if patient refuses or if she had a status change. It indicated the Nurse Mentor received instruction. A Quarterly Review was done on 9/27/16. Resident #62's cognition had declined. She required limited assistance to walk in the room. No behaviors were noted. Her balance was not steady. She had upper extremity impairment on one side. She was short of breath. She had two falls without injury and one with injury. She took an antidepressant. Her care plan dated 11/9/16 read, I will have assistance with my bathing, dressing, grooming, transfers, toileting, ambulation and locomotion daily during the next 90 days. Encourage and assist to toilet as needed/requested. Provide incontinence care as needed. Supervise ADL tasks, but provide as much autonomy as needed. It also read, I will not experience any major injuries from falls during next 90 days. Check on (resident) every hour and PRN (as needed). Encourage use of walker and assist as needed with transfer and ambulation. Ensure (resident) wears proper footwear for transfers and ambulation. Functional maintenance LE Strengthening exercise program daily per PT recommendations. Eff. 7-12-16 Bilateral Knee extensions and bilateral leg lifts with 3 pound weights. Perform hip abductions with red T Band and hip adductions with squeeze ball. Each exercise set = 12 repetitions. Perform each set x 4 with rest between sets. Document acceptance of program and # of minutes used for program. Keep bed in low position and room clutter free. Keep call bell in reach at all times. Encourage use of call bell for assistance as needed. Remind resident to feel for chair before sitting. Bed alarm while on bed. Chair alarm while in W/C (wheel chair). When resident has increase confusion notify MD/NP (medical doctor/nurse practitioner) for possible UTI (urinary tract infection). Check alarm to make sure not broken parts. Resident #62 was observed on 11/16/2016 8:31 AM in the dining room. She was seated in a wheel chair that had anti-tippers. She was wearing tennis shoes and used oxygen. She was observed again on 11/16/2016 at 11:21 AM in bed sleeping. Her oxygen was on. The bed was in a low position. The two upper side rails were up. She said, I used my walker yesterday for the first time to dining room and it felt so good. She was observed again on 11/17/2016 at 8:30 AM eating breakfast while seated in her wheel chair. On 11/17/2016 10:25 NA #2 said she did not walk her to breakfast today. On 11/17/2016 at 10:25 AM resident #62 was observed asleep in bed. Two side rails were up and oxygen was on. The bed was not in the low position. On 11/17/2016 at 10:35 AM NA #2 showed the kiosk that included the aide ' s instructions for caring for residents. NA #2 said, It includes everything that should be done for her. She did not see or show the functional maintenance exercises. NA #2 was shown that the bed was not in low position. She said, I did not put her to bed and then moved the bed to its lowest position. The restorative program documentation included entries to demonstrate Resident #62 was walked to the dining room for 15 minutes on Tuesday (11/15/16) and Wednesday (11/16/16). NA #2 and LPN #1 said they did not know about exercise prescription. On 11/17/2016 at 11:00 AM PTA #2 said we would give the functional exercise prescription to the nursing supervisor and nursing would carry it out. On 11/17/2016 at 11:04 AM the Nurse Mentor (Nursing Supervisor) was interviewed about the functional maintenance exercises on the care plan. She said she was aware of it and probably was responsible for putting it on the care plan. She was unable to show that any aides had been instructed on how to carry out the exercises. The MDS Nurse joined the conversation and said the information flowed to the nurse aides. She showed a printed copy of the November 2016 Flow Sheet. Ten minutes of activity was recorded on November 2, 2016. The activity was initialed on four of 16 days by three different nurse aides. The Nurse Mentor said, I think this was supposed to be temporary until she went back to therapy. The Nurse Mentor added that she wanted to see if the nurse aides could walk her at least twice a week and start her on a walk to dine program. We have to see if she could do it. I believe the care plan is being implemented. When the Nurse Mentor was told about the position of the bed, she said she could use her remote control to raise or lower the bed herself. I believe we have cut down on her risk for falls. We have done a lot of interventions. On 11/17/2016 at 12:00 PM, the DON asked NA #3 to come to the kiosk and show interventions. NA #3 said the functional exercises were not showing up. She said, I had her (Resident #67) last week and they were not there. She added, I have never done the functional exercises with her. On 11/17/2016 at 12:51 PM NA #3 was shown the November 2016 Flow Sheet. She said, I honestly don't know why my initials are there. She said she had not given those exercises. On 11/17/2016 at 12:51 PM NA#4 was shown the flow sheet and said I never gave those exercises. On 11/17/2016 at 1:01 PM the Administrator said her expectation was that if an approach was in the care plan, then it should be carried out. She added that the care plan needed to be reasonable.

Based on record review and staff interviews, the facility failed to develop a care plan to address the use of an anticoagulant medication for 1 of 5 sampled residents (Resident #65) reviewed for unnecessary medications. The findings included: Resident #65 was admitted to the facility on [DATE] from a hospital. The resident ' s cumulative [DIAGNOSES REDACTED]. A review of Resident #65 ' s medical record revealed the resident ' s 8/21/14 admission medication orders included the following: 2.5 milligrams (mg) [MEDICATION NAME] (an anticoagulant medication) given as one tablet by mouth once a day; and 75 mg [MEDICATION NAME] (an anti-platelet medication) given as one tablet by mouth once a day. A review of Resident #65 ' s admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. He required extensive assistance with bed mobility, transfers, and dressing; required supervision with toilet use and personal hygiene; and was independent with eating. The MDS assessment also indicated the resident ' s medications included an anticoagulant on 7 out of the previous 7 days. A review of Resident #65 ' s care plan (initiated on 8/21/14 and last revised on 9/5/14) revealed a problem area related to the use of an anticoagulant medication was not addressed for Resident #65. The resident was care planned for a history and risk of falls. An interview was conducted with Nursing Assistant (NA) #1 on 9/25/14 at 9:05 AM. NA #1 worked on the first shift and was assigned to care for Resident #65. During the interview, the NA demonstrated how she accessed Resident #65 ' s electronic Care Guide and received information on interventions put into place for the resident. The Care Guide did not include bleeding precautions or alerts for Resident #65. An interview was conducted with Nurse #1 at on 9/25/14 at 1:47 PM. Nurse #1 was the staff nurse assigned to care for Resident #65. Upon inquiry, the nurse reviewed Resident #65 ' s electronic medical record (Care Plan/Care Guide). Nurse #1 confirmed that no notations were made in the electronic Care Plan/Care Guide in regards to use of an anticoagulant medication for this resident. A follow-up interview was conducted with NA #1 on 9/25/14 at 2:00 PM. Upon inquiry, NA #1 reported she was not aware that Resident #65 was on an anticoagulant medication. The NA stated that if she knew a resident was on an anticoagulant, she would need to watch for signs of bleeding and bruising and alert the nurse if these signs were seen. NA #1 noted that Resident #65 did have, " a lot of bruising. " An interview was conducted with the facility ' s Administrator on 9/25/14 at 2:40 PM. When asked what her expectation would be if a resident was on an anticoagulant medication, the Administrator indicated that she would expect a problem area related to the use of the anticoagulant to be included in that resident ' s plan of care. An interview was conducted with the facility ' s Interim Director of Nursing (DON) on 9/25/14 at 2:45 PM. During the interview, the Interim DON indicated that although Resident #65 ' s anticoagulation was being monitored with appropriate lab work, the care plan piece had been missed. A follow-up interview was conducted with the Interim DON on 9/25/14 at 3:06 PM. Upon inquiry, the Interim DON stated that Resident #65 tended to have bruising on his arms and legs and did have bruising on his abdomen from a recent fall. The Interim DON reported that the Care Plan and Care Guide were revised that afternoon (9/25/14) to include a care area on the use of an anticoagulant medication for Resident #65.

Based on observations, record review and interview with facility staff, the facility failed to code the Minimum Data Set correctly for Resident #18 as having an indwelling catheter when coded as continent, failed to code Resident #65 as taking an antidepressant and coded Resident #53 as served a therapeutic diet and not a mechanical soft diet that was ordered for three of 14 sampled residents for accuracy of the Minimum Data Set. (Residents #18, #65 and #53) The findings included: 1) Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) dated 4/15/14 coded the resident as continent and did not indicate the resident had an indwelling catheter. Record review of the hospital history and physical dated 4/5/14 revealed that the resident developed acute [MEDICAL CONDITION] and a urinary catheter was placed. He was discharged to the facility with the urinary catheter for 10 days until a follow up with the urologist. The urinary catheter was discontinued by the urologist on April 18, 2014. Interview with the nurse mentor on 9/25/14 at 4:25 PM revealed that the MDS nurse who prepared the admission MDS had not worked for the facility since April, 2014. The nurse mentor had taken over the MDS preparation since April, 2014. Interview with the Administrator dated 9/25/14 at 4:27 PM revealed that her expectation was that the MDS would be coded correctly. 2) Resident #65 was admitted to the facility on [DATE] from a hospital. The resident ' s cumulative [DIAGNOSES REDACTED].#65 ' s admission orders [REDACTED]. A review of Resident #65 ' s August and September 2014 Medication Administration Record [REDACTED]. Resident #65 ' s admission Minimum Data Set (MDS) assessment was dated 9/3/14. A review of Section N (Medications) of the MDS assessment revealed the resident was not coded as having received an antidepressant medication during the previous 7 days. Resident #65 ' s September 2014 Medication Administration Record [REDACTED]. An interview was conducted on 9/25/14 at 1:33 PM with the Interim Director of Nursing (DON). The interim DON stated he would have expected [MEDICATION NAME] to have been coded on the MDS as an antidepressant medication. An interview was conducted on 9/25/14 at 4:26 PM with the Nurse Mentor who was responsible for the unit Resident #53 was residing on. The Nurse Mentor reported that she assumed responsibility for completing Section N on the 9/3/14 MDS assessment for Resident #65. The Nurse Mentor stated that if Resident #65 was not coded as having received an antidepressant, then she, " missed it. " Upon inquiry, the Nurse Mentor indicated that [MEDICATION NAME] should have been coded as an antidepressant on a resident ' s MDS assessment. 3) Resident #53 was admitted to the facility on [DATE] from a hospital. The resident ' s cumulative [DIAGNOSES REDACTED]. A review of Resident #53 ' s medical record revealed the resident was referred to the facility ' s Speech Language Pathologist (SLP) for an evaluation and treatment of [REDACTED]. No therapeutic dietary restrictions were prescribed for Resident #53. Resident #53 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. A review of Section K (Swallowing/Nutritional Status) of the MDS assessment revealed the resident was not coded as having received a mechanically-altered diet (defined as a diet which required change in texture of food or liquids; e.g., pureed food, thickened liquids) during the previous 7 days; the resident was coded as having received a therapeutic diet (e.g., low salt, diabetic, low cholesterol) during the previous 7 days. An interview was conducted on 9/24/14 at 4:40 PM with the Nurse Mentor who assumed responsibility for the unit Resident #53 was residing on. The Nurse Mentor indicated that she herself completed many sections of the MDS assessment for Resident #53. However, she reported that Section K of Resident #53 ' s MDS assessment was completed by the Nutrition Mentor. Upon inquiry, the Nurse Mentor stated that she would have expected Resident #53 to be coded as having received a mechanically-altered diet. An interview was conducted on 9/25/14 at 9:39AM with the facility ' s Nutrition Mentor. The Nutrition Mentor confirmed that Resident #53 was currently prescribed a Mechanical Soft diet with Nectar-Thickened Liquids (initiated on 8/11/14). The Nutrition Mentor acknowledged that she had completed the 9/3/14 Section K on Resident #53 ' s MDS assessment. Upon review of the records, the Nutrition Mentor indicated that the MDS was coded incorrectly and should have reported the resident received a mechanically-altered diet instead of a therapeutic diet.

Based on observations, staff interviews and facility record review the facility failed to label and date food items in the baking area, freezer, prep cooler, dessert refrigerator, a la Carte cooler, warming box, walk-in refrigerator and Main kitchen area. The facility also failed to label and date food, in the " Pebble Beach 1 " and " Pebble Beach 2 " kitchens. This was also evident in the " Wing Foot " kitchen. Findings include: On 5/28/13 at 11:30 am through 12:45 pm observations of the main kitchen revealed the following: In the Main Kitchen there were 60 spices which were open with no label that indicated when the spice was opened. The outer covering of the containers were covered with a sticky substance and 1 metal container with small holes on the top cover had a rust like hardened substance on the top of the container. There were 3 large containers of flaked spices which did not indicate when they were opened and the outside of the container had a greasy substance covering them. There were 3 "full size" pans (4 inch) with seafood breader, bread crumbs, and another container with a brown food which the staff could not identify. Observation of the "A La Carte" cooler contained a large pan of carrots covering opened, container of pineapple and one container of shredded coconut, (the Dietary Manager (DM) stated it was parmesan cheese) and 1 container with vinaigrette, all of which were not labeled/ and or dated. The cooler also contained 1 container of crushed garlic, 1 bunch of Kale, several [MEDICATION NAME] sprigs, loose parsley flakes in a container, crushed avocado, 1 package of spinach wraps, 1 opened container of cut up potatoes, 1 container of 2 -3 pound of sliced yellow cheese, and a container which was unidentifiable and a container of vendor samples of gluten free foods (per the DM) assorted vegetables, all of which were not labeled/dated and or covered. Observations of assorted desserts and produce in the walk-in refrigerator were not labeled and dated as follows: 1 gallon of orange juice concentrate, opened, 1 gallon opened of lemonade concentrate, 1 jar of capers opened with no date, 1 large container of opened mustard, 1 opened gal container of cranberry juice and 1 gallon opened of sweet and sour sauce. An observation of the baking area revealed a "cookie box" (large tall metal cabinet) which contained 12 large sheet pans of cookies with no covering on the cookies, labels or dates. Near the bottom of the "box" there was blue linen shoved to the back of a tray and a personnel radio. An interview with the DM revealed he did not know why these items were in the box. The DM also stated when asked about the cookies being not covered he stated, "There is a door on the container," indicating that it was acceptable to have no coverings on the sheets of cookies. An observation of a container of chocolate curls, opened with no date, 1large bin of flour, baking flour, pastry flour and rice all with no date. On the counter the following items were found to have no labels/dates and opened: 1 Large bag of pecans,1 bag white chocolate chips,1 large bag of cinnamon chips, 1 large bag of crushed walnuts, 1large bag of Oreo cookie crumbs,1 large bag of shredded coconut, 2 and 1/2 dozen sugar free tart shells, 1 can of pan coating (1/2 full) with no cover and no date. Under a counter was 1 large 1/2 full bucket of apricot glaze dated 1/5/11 with no use by date and no date when opened, and the top of the container had crusted , brown matter on the lid. Observation of the dessert refrigerator revealed the following with no labels/dates and or uncovered: 1 large yellow frosted cake with no covering/date/label, 1tray of apple fritters, 1 large tray of eclairs, 1 large yellow/white cake, and 1 tray of roasted nut bars. Observation of the shelf above the baking area counter top revealed several bottles of food coloring, opened with a sticky substance covering the bottle with no dates, bottles of flavoring opened and no date 1 container of brown sugar and butter. with no date/label. Observation of a walk-in refrigerator revealed a cart with a large tray of uncooked biscuits, uncovered with no date, 1container of butter and uncooked eggs,1 pan of sausage links and pureed sausage, 4 trays of diced potatoes, and 2 containers of baked sliced apples, all with no dates. Observation of a walk in freezer contained a cart with 12 large trays of frozen breads, uncovered, no label and no dates. Observation of the " prep cooler" revealed 1 4-5 pound bag of brioche with no label and no date, and 1 large bag of broken hamburger buns with no label and no date. An interview with the Executive Chef on 5/28/13 at 1:15 pm revealed his expectation was that all opened food needed to be covered and have a label and date. He further stated that the cooks in the kitchen were responsible for the labeling and dating. On 5/28/13 at 12:30 pm an interview with the cooks # 1 and #2, stated their responsibility was to ensure labeling and dating the food in the kitchen including spices and other condiments, and bottles. An interview with the DM on 5/28/13 at 1:30 pm stated it was his expectation that products/food in the kitchen need to be dated and labeled. When the DM was asked about referring to the SOM (State Operating Manual) he was unaware of what the SOM was and stated he goes by " FDA recommendations " . On 5/29/13 at 10:30 am an interview with the Administrator indicated it was her expectation that all food/bottles/containers in the Main Kitchen were to be labeled and dated. On 5/29/13 at 10:45am through 11:30 am temperatures of food in the Main Kitchen that was to be served for lunch revealed the following: (all temperatures taken were measured in degrees farenheit: Fish - 166 degrees farenheit, spring rolls - 169, Beans - 161, Fried Rice 151, cooked cabbage 158, chicken gravy 163, mashed potatoes 168, baked chicken 130, and beef stir fry 130, Prince Edward medley (vegetables) 158. The beef stir-fry and baked chicken had to be reheated to the appropriate temperature. A second observation was completed in the main kitchen on 5/29/13 at 10:45 am revealed the following: Walk in Freezer contained 12 trays of breads on a cart revealed they were still unwrapped, with no label and date, 1 Large Bin of flour, pastry flour, sugar and rice was still not dated. The DM stated that " he had not gotten to that yet " . Temperatures taken at 4:30 PM for the dinner service revealed: asparagus soup 194 degrees Farenheit stuffed peppers 154 degrees Fahrenheit macaroni and cheese- 158 degrees Fahrenheit Steamed asparagus 160 degrees Fahrenheit Mashed potatoes 150 degrees Farenheit baked fish 147 degrees Fahrenheit Barbecue chicken thighs 155 degrees Fahrenheit Baked sweet potato pureed- 163 sweet pot.- 168 degrees Fahrenheit salted brussel sprouts with garlic 158 degrees Fahrenheit pureed asparagus - 152 degrees Fahrenheit ground chicken- 153 degrees Fahrenheit pureed chicken- 154 degrees Fahrenheit brown gravy157degrees Fahrenheit cream of asparagus soup 161 degrees Fahrenheit On 5/29/13 at 5:45 pm observation of Wing Foot temperatures revealed degrees Fahrenheit temperatures were as follows: Tilapia 180.3 Baked Sweet Potatoes 180.4 Asparagus soup 125* second try after iced thermometer 170.6 Brussel sprouts 184.4 Baked chicken 169.5 Baked Macaroni 192.8 Asparagus 200.8 Gravy 180.4 Mashed Potatoes 156.5 Stuffed Peppers 166.9 Observation of a resident ' s dinner tray temperature, who complained the food was cold, was taken and the temperature was not acceptable to the resident. The food was reheated in the microwave and the temperature was rechecked. The resident was satisfied. Observation of Wing Foot Kitchen on 5/29/13 at 6:30 pm revealed: 1 jar of mustard use by date, 12/29/12 1 circle of Mexican chocolate drink wafer, 3.15 oz. no date 2 1/4 filled ketchup containers with no dates, 1, 4 quart sugar container, no label/ date, 3 opened containers of decorating sauce on the shelf, room temperature, had an expiration date of 2012, with no label/date and all required refrigeration, 3 loaves of bread on the counter top were opened with no label/date. Observation in the refrigerator on WIng Foot contained the following containers with no label/date: 1 pan of egg salad 1 pan of tuna fish salad 1 pan of shredded carrots 1 pan of chicken salad 1 pan of sliced pickles 1 package of yellow sliced cheese 1 package of sliced turkey (turkey was falling out of the wrapping) 1 package of sliced ham On 5/29/13 at 6:00 pm an interview with the nurse mentor #1of Wing Foot indicated he would be discarding the above items and his expectation was that all opened food must be labeled and dated. The Administrator was present at the time and agreed with the Nurse Mentor #1. An interview on 5/29/13 at 6:30 pm with Home Maker #3 stated the decorating sauces were sugar free and each item contained according to the label contained 20 grams, 18grams and/ or 17grams.of sugar. He stated he was told when he first started at the facility that the toppings were sugar free and he puts the sauce on ice cream which he served to the residents. An Interview with Executive Chef on 5/29/13 at 6:45 pm revealed he would be discarding all of the above and stated the toppings should have been refrigerated as well. He further stated that all of the above needed to be labeled correctly as well. One 3 quart container of dry pancake mix dated " use by 5/29/13 " was also discarded by the Executive Chef. An observation of 3 loaves of bread on the counter was opened with no label/date. Observation of the Pebble Beach 1 and 2 kitchens on 5/29/13 at 6:48 PM revealed the ice cream freezer contained crystallization of ice cream resembling freezer burn. Ice cream flavors included strawberry, butter pecan, chocolate, and french vanilla in 3 gal containers. The freezer had a buildup of frost 1/4 inch thick with icecicles on the top inside door. Observation of the reach in refrigerator had a package of mushy, black strawberries, a mushy cucumber, container of unlabeled coleslaw, speared pickles, carrots, cucumbers, tomatoes, blue cheese dressing, sweet pickles slices, dill pickle slices, and shredded cheese. A-1 sauce date of 2/01, cinnamon 3 oz. unlabeled and no date, Mexican spice no date, and 1 piece of tomatoe wrapped with no label/date was discarded, An Interview with the nutrition mentor stated it was her expectation that all foods are labeled and dated and food on the shelves should be labeled and dated if opened. She continued that the Home maker in charge #4, was the person in charge of this area and he was not in the facility at the time of the investigation. Attempts to contact the Home Maker #4 in charge were unsuccessful. An Interview with the Executive Chef revealed it was his expectation that all foods be labeled and dated and expired food be discarded.