Every finding on record at Riverside Care Center

Based on observation, record review and interview the facility failed to ensure Resident #92 was cared for with dignity and respect as evidenced by Resident#92 was observed in the hallway next to the shower room on a shower chair with the left posterior and anterior upper extremity exposed. There were 116 residents residing in the facility at the time of the survey. The findings included:Observation on 06/08/2026 at 9:05 AM Resident #92 was sitting in the hallway, unattended, wearing a gown, next to the shower room on a shower chair with the left posterior and anterior upper extremity exposed. Staff E, Certified Nursing Assistant (CNA), revealed Resident #92 is waiting her turn to use the shower room. On 06/09/2026 at 9:51 AM, Staff C, CNA, interviewed via Spanish Translator revealed residents that are showered in the shower room waited in front of the shower room with their assigned CNAs, fully covered in their gowns and a clean sheet for privacy. Review of the medical records for Resident # 92 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hypertensive Heart Disease without Heart Failure. Record review of Resident #92's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) 06 on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care. Review of the facility policy and procedure titled Dignity/Privacy revision date 01/2026 states: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times.

Based on observation, record review and interviews, the facility failed to protect privacy and confidentiality of resident's medical records as evidenced by one observation of a computer in the 2nd floor new wing hallway being left open and unattended with a resident's information visible. Photo evidence taken. There were 116 resident's residing in the facility at the time of survey. The findings include:Observation on 06/09/2026 at 8:59 AM revealed an Electronic Health Record (EHR) was left open and unattended with a resident's visible information on the 2nd floor new wing computer in hallway. Photo evidence provided. Interview on 06/09/2026 at 10:04 AM the Assistant Director of Nursing (ADON) stated: The computers that are located on the walls in the hallways are used by the Certified Nursing Assistants (CNAs) to chart and document on their residents. The CNAs are also educated to not leave them open with resident information visible.Interview on 06/10/2026 at 2:49 PM; the Director of Nursing (DON) stated: CNAs receive frequent education on resident privacy, especially since many of the staff are new. HIPAA is covered during new employee orientation, and additional education is provided as needed. Staff are reminded that resident information should not be discussed in public areas or in front of other residents, visitors, or unauthorized individuals. The hallway computers are available for CNAs to use for documentation in the electronic health record. Staff are expected to log off the system before leaving a computer unattended to protect resident confidentiality and maintain Health Insurance Portability and Accountability Act (HIPAA) compliance. Ongoing education and monitoring help reinforce these privacy and security practices.Review of the facility's policy titled Confidentiality of Information and Personal Privacy 01/2026 stated Policy Statement - Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.4. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation records reviewed and interviews, the facility's failed to ensure a safe environment free of potential accidents and hazards for one out of four sampled residents, as evidenced by during observation two knives were observed in Resident # 88's room in a plastic container on the overbed table. One razor was observed on the sink in an open unattended shower room on the second-floor unit. There were 116 residents residing in the facility at the time of the survey. The findings included: During observation on 06/08/2026 at 8:53 AM Two knives were observed on the overbed table stored in plastic container in Resident #88's room. On 06/09/2026 at 9:38 AM Resident #88 was in bed awake, no distress noted and refused to be interviewed by the surveyor. On 06/10/2026 at 9:29 AM Resident #88 in the hallway sitting on a rolling walker, no distress noted. 06/10/2026 at 8:35 AM the surveyor showed the Director of Nursing (DON) photo evidence of the knives observed in a resident room and the DON acknowledged the findings. Observation on 06/11/2026 at 10:00 AM in the open and unattended shower room on the second-floor unit a razor was noted on the sink in the shower room. The Facility Staff were notified by the surveyor to remove the razor. On 06/11/2026 at 10:52, the surveyor showed the Director of Nursing (DON) photo evidence of findings (razor in the open unattended shower room) and the DON acknowledged findings.Review of the medical records for Resident #88 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Type Two (2) Diabetes Mellitus with Diabetic Neuropathy.Review of the Physician's Orders Sheet for June 2026 revealed Resident #88 had orders that included but not limited to: Physician certified this resident to require Nursing Care at level of care: Skilled.Record review of Resident # 88's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) 13 on a 0-15 scale indicating the resident is cognitively intact. Section E for Behaviors documented no behaviors exhibited. Section GG for Functional Abilities documented no impairment of upper and lower extremities, uses walker and wheelchair, independent for care. Section N for Medications documented resident is taking Diuretic, Opioid, Hypoglycemic, Anticonvulsant.Record review of Resident # 88's Care Plans Dated 06/07/2026 revealed: The resident has Activities of daily living (ADL) self-care performance deficit related to multiple medical conditions, muscle weakness, balance deficits, Alzheimer's, Major depression. Resident able to ambulate with a four wheeled walker. Interventions include Ambulation program with rollator three to five times weekly. Maintenance Range of Motion to all extremities during daily care by staff. On 06/09/2026 at 9:48 AM ) in an interview via Spanish Translator Staff A, Licensed Practical Nurse (LPN), revealed that during rounds if any items are found that the residents are not allowed to have, the resident and the family are educated. For example, residents are not allowed to have knives stored in their rooms, it is a safety issue. Interview on 06/09/2026 at 9:57 AM Staff D, Certified Nursing assistant stated via Spanish Translator that during rounds the residents are checked on to make sure they are safe, positioned properly and provide needed care. If specifically, a knife or sharp object was found in the residents' room, the object would be removed and the nurse informed because that is a safety issue for the residents. During an interview on 06/11/2026 at 10:52 AM, the DON stated that the procedure after residents are showered in the shower rooms- staff must ensure that the shower rooms are cleaned and free of any personal hygiene items. Razors cannot be stored in the shower room; it is a safety issue for the residents and staff. Review of the facility policy and procedure titled Hazardous Areas, Devices and Equipment revision date 01/2026 states: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and Implementation:As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee.Identification of Hazards1. A Hazard is defined as anything in the environment that has the potential to cause injury or illness.Examples of environmental hazards include, but are not limited to the following:3. Sharp objects that are accessible to vulnerable residents

Based on observations, record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for mental disorder (MD), or Intellectual Disability (ID) was accurately completed for one resident ( Resident #17) out of six residents sampled, as evidenced by Resident #17 Level I PASRR dated 09/15/2023 was not updated to reflect a diagnosis of Anxiety Disorder. The findings included: On 03/03/2025 at 09:22 AM Resident #17 was observed sitting in bed speaking to staff member. Appeared slightly anxious while talking about her current living situation. Record review of Resident #17's Admission and clinical records revealed the resident was admitted to the facility on [DATE]. Medical diagnoses include but not limited to: Major depressive disorder Anxiety disorder Unspecified and insomnia. Review of Resident #17's PASRR Level I dated 09/15/2023 revealed identification of only two mental diagnoses of Depressive Disorder and Insufficient Sleep Syndrome under 1A. Section 1B was not checked for Serious Mental Illness (SMI), Section 2,3 (A/B) and 4 (A/B) were checked. Section II Part A & B were checked. Section IV was completed. Record Review of a Quarterly Admission Minimum Data Set (MDS) Section A (identification) dated 01/08/2025 revealed Resident #17 was not considered by the Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I revealed resident #17 had Anxiety and Depression. Sections O (special treatments and therapy) revealed total number of minutes Psychological Therapy (by any licensed mental health professional) administered for at least 15 minutes to the resident in the last seven (7) days was zero (0). Record Review of Orders dated 12/26/2024 revealed Resident #17 is currently receiving Buspirone HCl Oral tablet 5 mg (milligrams) Directions: Give 1 tablet by mouth two times a day for Anxiety Disorder, Unspecified. Record Review of Care Plan dated 12/26/2024 revealed Resident #17 is at risk for possible adverse side effects of psychotropic medications. Resident is on: Sertraline HCl Oral Tablet 50 mg, START Buspirone HCl Oral Tablet 5 mg. Goals: Demonstrate decreased need for psychoactive medication. Resident will not show signs and symptoms of possible side effects of psychotropic medication such as: hypotension, headache, constipation, nausea/vomiting, dry mouth, dizziness, insomnia, drowsiness, sedation and blurred vision through next review date. Interventions: Monitor and record behavioral symptoms and side effects and relay to MD (Medical Doctor)6 for any changes. Observe mood and behavior pattern. Psychiatry consults as needed to evaluate/ taper/adjust psychotropic medications to lowest possible dose. Pharmacy to review drug regimen monthly, provide non-pharmaceutical intervention as needed . Record Review of Medication Administration Record for January 2025 revealed Resident #17 was receiving Buspirone HCl Oral tablet 5 mg: Give one tablet orally two times a day for Anxiety Disorder, Unspecified- Start Date 12/26/2024. Review of Nurses Progress Notes dated 12/26/2025 revealed the resident was seen and evaluated by the Nurse Practitioner covering for the Psychiatrist and new orders were received to discontinue Seroquel 25 mg by mouth at bedtime and start Buspirone 5 mg by mouth two times a day . Review of Social Worker Progress Notes dated 01/08/2025 indicated: Care plan reviewed, and resident denies feeling sad or anxious . Interview with the Director of Nursing (DON) on 03/06/2025 at 01:52 PM. She stated The process of identifying residents with Mood Disorder or Intellectual Disability starts through PASARR because that will indicate if they are a level I or II. With that, we will know what to expect before they arrive. Together with the PASARR and the referral paperwork for the resident, it will give you the diagnosis and medications. Then after that, we can decide if we are able to take care of the patient or not. If some referral forms show they have high dosage of psychotropic meds, then I ask for psych consultations and notes from the nurses where the patient is coming from. If you do not ask for those behavior notes, then you would not know why they are being given psychotropic medications. We identify them according to their behaviors because then if the mental disorder behaviors are present, the PCP (Primary Care Physician) is called, and he or she will order a psychiatric consult. During a follow up Interview on 03/06/2025 at 02:18 PM , the DON stated: I spoke to the Psychiatric Nurse via telephone, and she stated anxiolytic medications should be a reason to update the PASRR, but she just forgot to update it in the form. Record Review of the facility's Policies and Procedures titled, Pre-Admission Screening and Resident Review (PASRR) not dated revealed Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. (2) The social worker or designee is responsible for making referrals to the appropriate state-designated authority.

Based on observations, interviews and records reviewed, the facility failed to ensure adequate pain management interventions were followed for one (Resident # 20) out of six sampled residents with the potential for alteration in comfort/pain related to wound care treatments. As evidenced by Resident # 20's order to be medicated 30 minutes before wound care treatment was not followed as ordered, resulting in discomfort during wound care treatment and inadequate assessment interventions to adequately respond to Resident # 20's pain management. The findings included: On 03/05/2025 at 09:10 AM, during observation of Resident # 20's wound treatment care being performed by Staff C, Wound Care Nurse, it was noted that Resident #20 was moaning and yelling it hurts. when Staff C touched the wound. Staff C did not stop to further assess the resident's pain level nor offered any additional pain medication. On 03/05/2025 at 09:39 AM Staff C, Wound Care Nurse for the second floor stated: I call the doctor when there are any wound changes or changes in skin condition. The doctor comes once a week, but if there are any changes, I just call them. If resident refuses care, I just tell her I will return another time. I also ask her if she is in pain first. We explain to the resident what we will be doing before starting dressing change. We also ask if she is in pain. I believe the resident was medicated today for pain. I also assess the pain related to pressure ulcer by touching the wound to make sure. We are always supposed to medicate with pain medication 30-60 minutes prior to wound care. The current wound care treatment for this resident is to clean with normal saline and apply Dakins Solution every shift, apply zinc oxide and Silvadene cream together, then apply wet to moist dressing and cover with border dressing. This resident's pressure ulcer was developed in the facility in February 2025. Review of Resident # 20's demographic sheet revealed an admitted [DATE] with a readmitted [DATE] with diagnosis that include: Stage 4 Pressure Ulcer of sacral region dated 02/24/2025. Record Review of Quarterly Minimum Data Set (MDS) with a reference dated 02/09/2025 revealed Resident #20 is cognitively intact. Resident # 20's Care Plan initiated on 02/09/2025 goals included pressure ulcer will show signs of healing and remain free from infection by or through review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of Physician order for March 2025 revealed an order dated 03/06/2025 for Tylenol 500 milligrams (mg) tablet; give two tablets by mouth 30-60 minutes prior to wound care one time a day for comfort and at bedtime for comfort and as needed for comfort. Review of Resident #20's Electronic Medication Administration Record (EMAR) on 03/05/2025 at 09:44 AM revealed no documentation indicating Tylenol 500 mg for pain was administered as ordered prior to wound care for comfort. The last documented administered dose noted on the EMAR for the pain medication (Tylenol 500 mg) was documented as given on 03/04/2025. On 03/05/2025 at 12:15 PM Resident #20 stated, I get medicated with Tylenol every day before they do my wound care. It helps with the pain, but I am not sure if they medicated me today before the wound care. I was in pain during wound care today. Record Review of the facility's policy titled, Wound Care undated Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1) Verify that there is a physician's order for this procedure, 2) Review the resident's care plan to assess any special needs of the resident. a) For example, the resident may have PRN order for pain medication to be administered prior to wound care. Documentation: 7) How the resident tolerated the procedure, 8) Any problems or complaints made by the resident related to the procedure.

Based on observations, record reviews, and interviews the facility failed to accurately document a nutritional care plan for one resident (Resident #31) out of 12 residents receiving tube feeding, as evidenced by intervention different from the current physician's order for tube feeding formula. The findings included: During an observation on 03/05/25 at 9:41 AM, Resident #31 was seated in a wheelchair next to the bed. Feeding via Percutaneous Endoscopic Gastrostomy Tube (Peg-tube)was in progress at a rate of 50 milliliters per hour (ml/hr.). On 03/06/25 at 8:59 AM Resident#31 was seated in a wheelchair; Peg Tube feeding was in progress at a rate of 50 milliliters per hour (ml/hr.). Record review of Resident #31's demographic sheet revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that include: Attention to Gastrostomy and Dysphagia. Record review of a Significant Change / Medicare - 5 Day Minimum Data Set reference dated 12/22/2024 indicated Resident # 31 is severely impaired cognitively and dependent for Activities of Daily Living, transferring and had a feeding tube. Record review of Resident#31's physician's order sheet revealed an order dated 2/7/25 for Jevity 1.5 at 50 ml/hr. for 20 hours via Percutaneous Endoscopic Gastrostomy (Peg) every shift off at 9:00 AM and on at 1:00 PM. Record review of Care Plan initiated in 12/22/2024 and revised on 02/06/2025 revealed Resident #31 had the potential for nutritional and hydration deficits and interventions that included: Administer tube feeding and flushes as ordered. Isosource 1.5 as ordered. On 03/06/25 at 10:25 AM Staff B, Dietary Technician was interviewed about the Nutritional Care plan and stated, I update the nutritional care plans. [Resident#31] is currently receiving Jevity 1.5. and the care plan interventions states Isosource. I update the care plans quarterly and if there is any change. I didn't update it because I forgot. The Isosource has the same nutritional value as Jevity 1.5. Record review of a Policy titled, Care Plans, Comprehensive Person-Centered Revised March 2022, Revised 2024 Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes.

Based on observation, interview, and record review, the facility failed to have daily nurse staffing posted prior to the beginning of shifts on 2 of 2 nursing stations. This had the potential to affect the 115 residents who resided in the facility at the time of this survey. The findings included: During an observation on the second and third floor nurse's station, on 09/18/23 at 6:42 AM, it was noted that the staffing information was not posted, and both boards were blank. (Photo Evidence) On 09/21/23 at 08:38 AM Staff C, the Certified Nursing Assistant (C N A) Coordinator reported, she has been working in the facility for over [AGE] years and she oversees the CNA's schedule. They have a minimum 8 CNA's in the morning, in the afternoon 6, and at night 5 on each floor. The facility always has one CNA extra in case its needed. The secretary of each floor oversees writing on the board the schedule for every day. During the weekends there are always secretaries who oversee doing that. If there is only one, she must write on the board for the two floors. On 09/21/23 at 09:38 AM Staff D, Unit Clerk, who works on the 3rd floor stated that she has been working in the facility for [AGE] years, she works from 7:00 AM to 3:30 PM. Her job duties during her shift are; to answer the phone, makes doctor's appointments, transportation, write the names of the CNA's and the RN's on the board. Last weekend she stated, I forgot to write it, I do not know what happened, because this weekend I was in charge of both floors. Policy and procedures for Posting Direct Care Daily Staffing Numbers dated July 2016: Policy Statement Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy interpretation Within two (2) hours of the beginning of each shift, the number of licensed nurses Registered Nurses, Licensed Practical Nurse and Licensed Vocational Nurse (RNs, LPNs, LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (access to residents and visitors) and in a clear and readable format. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the administrator.

Based on observation, record review and interview, the facility failed to provide the necessary oxygen therapy according to the physician's order for one resident (#54) out of 30 sampled residents as evidenced by resident #54 receiving oxygen therapy via nasal cannula at a rate above the physician orders. This had the potential to affect the 21 residents receiving oxygen therapy at time of survey. The findings included: On 09/18/2023 at 07:37 AM, entered the room of resident #54. The resident was in bed with eyes closed and oxygen running via nasal cannula at a rate of 4.5 Liters per minute (L/min) from an oxygen concentrator located next to resident's bed. A plastic bag to hold tubing was attached to the concentrator and dated 9/17/2023. The resident showed no signs of pain or distress. A call light was within reach. On 09/19/2023 at 09:42 AM, resident #54 was observed in the activities room, sitting in a wheelchair at a table surrounded by four other residents. The resident's eyes were closed, oxygen was in progress via nasal cannula at a rate of 3 Liters per minute from an oxygen tank secured in a holder on the back of resident's wheelchair. On 09/20/2023 at 09:25AM, entered resident #54's room, the resident was smiling and had oxygen via nasal cannula at a rate of 5 Liters per minute from an oxygen concentrator in progress. There were no signs of distress observed. (Photo Obtained) On 09/20/2023 at 11:48 AM, resident #54 was observed sitting in a wheelchair in front of the nursing station being assisted with lunch by one staff member. The staff member was sitting in front of the resident, speaking politely, encouraging the resident to eat. Oxygen was in progress via nasal cannula at a rate of 3 Liters per minute from an oxygen tank secured in a holder on the back of resident's wheelchair. On 09/21/2023 09:55AM, resident #54 was brought into her room by one staff member. Staff B explained to resident the treatment procedure and measured the resident's oxygen saturation. The result was 98%. Review of resident #54's medical records revealed, the resident was admitted on [DATE] and readmitted on date 07/07/2023. The residents medical diagnoses to included Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation and Heart Failure. Review of physician's orders dated 07/28/2023 revealed, respiratory care orders for oxygen via nasal cannula at a rate of 3 Liter per minute, continuously on every shift for shortness of breath. Upon review of resident's Medicare 5-day Minimum Data Set (MDS) dated [DATE], section C (Cognitive Patterns) revealed a Brief Interview for Mental Status score of 04 on a scale of 00 to 15 indicating resident is cognitively impaired. Section G (Functional Status) revealed resident required extensive assistance with bed mobility, transfer and toilet use by two staff and personal hygiene, dressing by one staff and total dependence for locomotion and eating from one staff member. Sections J (Health Conditions, pain) revealed resident had no pain or health conditions for last 5 days. Section O (Special Treatments, Procedures, and Programs) revealed resident received oxygen, physical and occupational therapy for the last 14 days. Review of Care plan reference date 06/15/2023 revealed, resident #54 has a potential for respiratory complication related to diagnosis (dx): Chronic Obstructive Pulmonary Disease (COPD). Interventions included: Oxygen Settings: Oxygen Via Nasal Cannula at 3 L/min continuous. Every shift for Shortness of Breath related to COPD. Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Budesonide Inhalation Suspension 0.5 Milligrams (mg)/2milliliters (mL), 2 ml inhale orally via nebulizer every 12 hours. Keep Head of bed (HOB) elevated. Monitor respiratory pattern/effort. Monitor vital signs. Observe for acute respiratory insufficiency: Anxiety, Confusion, Restlessness, Shortness of breath at rest, Cyanosis, Somnolence. Observe/document for anxiety. Offer support, encourage resident to vent frustrations, fears. Reassure. Give as needed medications for anxiety as ordered. Observe/document/report any respiratory infection: Fever, Chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing. Provide adequate by mouth (PO) fluids with and in-between meals. Provide adequate rest periods between activities. Review of the Nursing Progress Note dated 8/11/2023 at 6:51 PM revealed, resident was stable and had oxygen by nasal cannula at 3 Liters per minute. Interview with Registered Nurse (Staff A) at 09:50AM on 09/21/2023 (translated by Licensed Practical Nurse, Staff B), Staff A stated she was the nurse for resident # 54. Staff A reported, the resident's order for oxygen was 3 Liters per minute continuously. Staff A reported, she checked the resident's oxygen delivery four times a day to ensure it was at the correct setting. Staff A reported, the treatment nurse checked the oxygen saturation for all residents once a shift, enters the result into the treatment record of the Electronic Medication Administration Record, and reports any concern to nursing and the nurse calls the doctor. Staff A reported, the oxygen tubing is changed once a week on Sundays. Staff A reported, the doctor is notified if a change in baseline is observed. Review of the undated Policy and Procedure for Oxygen Administration revealed, Purpose: The Purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the Procedure: 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, record review and interview, the facility failed to dispose of garbage and refuse properly. The finding included: During observation on 09/14/22 at 04:08 PM, the facility's refuse area was toured with the Dietary Technician. The refuse area was located outside and behind the kitchen. The facility had a large garbage compactor. During the observation, a mattress was observed on the ground and the door to the compactor was partially open, approximately 10 inches, where pest could get into the compactor. With the door partially opened, card board boxes and garbage bags were observed inside the compactor. No rats or roaches nor pest were observed, but a rooster was observed on the fence close to the compactor. No odor was smelled. During interview with the Dietary Manager and Dietary Technician on 09/14/22 at 04:15 PM, the Dietary Technician reported, the Maintenance Director told her, a technician was working on the compactor earlier on 09/14/22 and left the door open. The Dietary Technician reported, the Maintenance Director told her the mattress was garbage. During the review of the facility's policy titled, Waste Disposal, revised on January 2021 and Revised 2022. The policy documented, All waste shall be handled and disposed of in a safe and appropriate manner.

Based on observation and interview the facility failed to prepare food and clean dished under sanitary conditions free from potential contaminants as evidenced by fluorescent lights maintained without protective covers or protective sleeves in the food production area and the dish room. and 2) to ensure infection control practices related to hand hygiene was implemented during dining observation. As evidenced by staff failure to sanitize hands between passing of meal trays .This has the potential to affect 100 residents who eat orally out of 116 residents residing in the facility at the time of the survey. The findings included: 02/10/20 09:10 AM Observation on 2/10/20 at 9:10 AM revealed two fluorescent lights in the dish room. One light had two bulbs that were covered with protective sleeves, the other light above the area where soiled dishes were processed had two fluorescent bulbs that did not have plastic covers or protective sleeves over the bulbs. Observation on 2/10/20 at 9:14 AM revealed two fluorescent lights in the food preparation area near the food production equipment. One light had two bulbs that were covered with protective sleeves, but the other light had two bulbs that were not covered by a plastic cover or protective sleeves. Staff was observed preparing food for lunch directly under this light fixture. The light fixture with the protective sleeves had a heavy accumulation of dust. This was also directly above the food preparation area. On 2/13/20 at 9:30 AM the Consultant Registered Dietitian, revealed maintenance is responsible for maintaining the lights and light covers in the kitchen. They should have protective sleeves or covers unless they have shatterproof bulb. I was not aware the florescent bulbs were missing the sleeves in the dish room or above the food preparation area. The Director of Maintenance (DOM) on 2/13/20 at 9:45 AM revealed all the florescent light bulbs must be covered. Either the entire light fixture needs a cover or the florescent bulbs needs to have a protective sleeve. This is an extra precaution in case the bulb breaks. When the electrician was here about two months ago to replace the bulbs, he forgot to put the sleeves over the bulbs. I replaced them yesterday. They should have been replaced when the bulbs were changed. They are located over an area where they prepare food. The DOM stated the bulb were not shatter proof and they needed to be covered. The DOM stated there is no specific policy to address this topic. Review of the facility policy and procedures titled Food Preparation and Service dated (MONTH) 2014 and Food Receiving and Storage dated (MONTH) 2014 revealed the policies did not address the maintenance of the light fixtures. 2-) On 02/10/2020 at 11:50 AM during dining observations on the 2nd floor hallways, Certified Nursing Assistants (CNAs) Staff B and Staff C, did not wash or sanitize their hands between residents while distributing and setting up lunch trays for residents being served in their rooms. On 02/11/20 at 11:43 AM and on 02/12/20 at 12:05 pm during dining observation on the 2nd floor hallway, the CNAs did not sanitize their hands while distributing meal trays at lunchtime for residents dining in their rooms. On 02/13/2020 at 12:18 pm Staff B a CNA revealed that before distributing food to the residents, she washed her hands in the utility room. Staff B went on to explain the steps taken with setting up meal tray for residents that were dining in rooms. Staff B revealed that hands should be washed and stated that sometimes she used the sanitizer instead before taking the food for the next resident. On 02/13/20 at 12:26 PM Staff C, CNA stated that hands should be washed in the utility room before distributing food. Staff C revealed she did not like to use the hand sanitizer and likes better to wash her hands. Record review of Hand washing/Hand Hygiene Policy: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation stated Employee must wash their hands for at least fifteen (15) seconds using anti-microbial or non-anti-microbial soap and water under the following conditions: F) Before and after eating or handling food (hand washing with soap and water) g) Before and after assisting a resident with meals. Procedure: Washing Hands. 1- The following equipment and supplies will be necessary when performing this procedure: a) Running water b) Soap (liquid or bar; anti-microbial or non-anti-microbial); c) Paper towels; d) Trash can; e) Lotion; and f) Alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] 2- Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. 3- Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch .inside the sink.

Based on observation interviews and record review the facility failed to ensure infection control practices related to hand hygiene was implemented on hallways for one out of two floors observed during dining. As evidenced by staff failure to wash/sanitize hands between passing of meal trays. This deficient practice has the potential to cause cross contamination and affect all residents residing in the facility. There were 115 residents residing in the facility at the time of this survey. On 02/10/2020 at 11:50 AM during dining observations on the 2nd floor hallways, Certified Nursing Assistants (CNAs) Staff B and Staff C did not sanitize their hands while distributing and setting up lunch trays for residents being served in their rooms. On 02/11/20 at 11:43 AM and on 02/12/20 at 12:05 pm during dining observation on the 2nd floor hallway. The CNAs did not sanitize their hands while distributing meal trays at lunchtime for residents dining in their rooms. 02/13/2020 at 12:18 pm Staff B, CNA revealed that before distrusting food to the residents, she washed her hands in the utility room. Staff B went on to explain the steps taken with setting up meal tray for the residents dining in rooms. Staff B stated that hands should be washed again and sometimes she used sanitizer before taking the food for the next resident. On 02/13/20 at 12:26 PM Staff C, CNA explained hands should be washed in the utility room before distributing food. Staff C revealed she did not like to use the hand sanitizer and likes better to wash her hands. Record review of Hand washing/Hand Hygiene Policy: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation stated Employee must wash their hands for at least fifteen (15) seconds using anti microbial or non-anti microbial soap and water under the following conditions: f) Before and after eating or handling food (hand washing with soap and water) g) Before and after assisting a resident with meals. Procedure: Washing Hands. 1- The following equipment and supplies will be necessary when performing this procedure: a) Running water b) Soap (liquid or bar; anti-microbial or non-anti microbial); c) Paper towels; d) Trash can; e) Lotion; and f) Alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME]. 2- Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. 3- Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch . inside the sink.

Based on record review and interview the facility failed to follow their Abuse Policy for an allegation of abuse for one resident (resident # 3) out of four residents sampled for allegations of abuse. The findings included: Record review of the facility's Abuse Policy and Procedure not dated revealed: The facility will make reasonable efforts to ensure that residents are free from verbal, sexual, physical and mental abuse .to maintain a resident's physical and mental health and that their property will not be misappropriated. The facility will report all allegations or information that creates a reasonable cause to believe that a resident was abused as soon as possible not to exceed 24 hrs to the appropriate jurisdictional authorities, resident's physician, the resident's responsible party or proxy. A prompt and thorough investigation will be conducted immediately. Record review of the facility letter dated (MONTH) 1, 2019 revealed: No abuse incidents have been reported from (MONTH) 1, 2019 to date. Record review of the facility incident log dated (MONTH) 9, 2019 at 2:32 PM revealed resident # 3 was in activities and resident was hit by another resident. Medical Doctor was notified. Family was notified. Record review of the face sheet revealed that resident # 3 was admitted on [DATE]. Record review of the nurse's notes for resident # 3 dated 10/09/2019 at 3:51 PM revealed while playing bingo resident # 3 started arguing with another resident, the activity aid intervened but the other resident hit her on the right arm. No apparent injury, resident # 3 denied pain at that time. Physician Assistant for resident # 3 was notified and no new orders at that time. Physician Assistant for resident # 3 advised to continue to monitor resident # 3 and call him back if there were any changes in condition. Resident # 3 niece was notified. Record review of the face sheet revealed that resident # 4 was admitted on [DATE]. Record review of the nurse's notes for resident # 4 dated 10/09/2019 at 4:00 PM revealed that resident # 4 was playing bingo and started arguing with another resident, activity staff intervened, but they continued, and resident # 4 hit the other resident on the right arm. Action: Resident # 4 was redirected by staff and reinforced to report any issue with other residents and the staff could intervene and not hit anybody. Response: Resident # 4 verbalized understanding. Resident # 4 agreed to be moved to the other side of the bingo table and continued playing with no further abnormal behavior. Interview on 10/18/2019 at 2:13 PM with resident # 3 in her in room revealed that she had been at this facility for years. Resident # 3 was alert to name, place and time. Resident # 3 was asked about the incident with resident # 4 in the activity area in (MONTH) 2019: Resident # 3 stated she was playing bingo and resident # 4 was next to her. Resident # 4 hit her in the chest area during bingo. There were no injuries. Resident # 3 stated that she felt this. Resident # 3 stated that resident # 4 was jealous, she thought. Resident # 3 noted that resident # 4 did not like her lip stick. Resident # 3 stated: Everyone saw this happen, everybody was there. This was the first time this happened and resident # 3 mentioned that resident # 4 stated she did not like her. When resident # 3 was asked if she thought this was abuse by resident # 4. Resident # 3 replied Yes and noted that resident # 4 was confused. Resident # 3 explained that she did not want resident # 4 around her, but felt safe now. Resident # 3 stated that resident # 4 had told her she hated her before. Resident # 3 mentioned that she did not tell anyone though that resident # 4 hated her. Resident # 3 stated that resident # 4 never tried anything again, and she was far away from her. Interview on 10/18/2019 at 2:22 PM with Staff A, a Licensed Practical Nurse (LPN) regarding resident # 3 revealed that she was alert to name, place and time. Staff A, a LPN noted that she worked with resident # 3 before. Resident # 3 needed total assistance for Activities of Daily Living care. LPN ,Staff A noted that she did not work on 10/09/2019 and was reading through the nurse's notes for that day. Staff A, LPN stated that if this was an intentional physical contact, then this would be abuse. Staff A, LPN stated that she had not seen anything that happened with resident # 3 and resident # 3 never mentioned that resident # 4 did not like her. Interview on 10/18/2019 at 2:49 PM with Staff B, a Registered Nurse (RN) and Staff C, a Certified Nursing Assistant (CNA) revealed that resident # 4 was very nice and alert to person and place but not time. Resident # 4 was confused sometimes. Resident # 4 needed assistance with taking a shower and transfers to the wheel chair. Staff B, a RN and Staff C, a CNA read the nurse's notes, Staff B, RN noted that resident # 4 had hit resident # 3 right arm. Resident # 4 was redirected and verbalized understanding and continued bingo with no abnormal behavior. Staff B, RN stated that she did not remember if she worked that day but did not work in that area. Staff C, CNA noted that she did not work at that time, but started the next shift. Staff C, CNA stated that she never saw resident # 4 hit resident # 3 before. Staff C, CNA noted that she never heard resident # 4 say to resident # 3 that she did not like her. Staff B, RN noted that she had never seen abuse by resident # 4 against resident # 3. Interview on 10/18/2019 at 3:04 PM with resident # 4 with Spanish translation by Staff B, RN revealed that resident # 4 was not alert. Resident # 4 did not know the name of the place or the date. Resident # 4 was in her room in a wheel chair and was well groomed. Interview on 10/18/2019 at 3:12 PM with Activities Director regarding resident # 3 revealed that she was reading through the notes dated 10/09/2019 at 3:51 PM in which resident # 3 was hit on the arm. The Medical Doctor and niece were notified. The Activity Director stated that she was not there on 10/09/2019. The Activity Director noted that on 10/09/2019 they were serving coffee before bingo started at 2:30 PM. The Activity Director noted that the Activity Aid told her that resident # 3 had a plastic cup with a napkin and finished her coffee. Resident # 4 tried to take the napkin from the cup resident # 3 had. Resident # 3 stated that this was her cup and resident # 4 swung her hand against resident # 3. The Activity Director stated that this was an accident. Resident # 3 had no injuries to her knowledge and this had never happened before. The Activity Director noted that what resident # 4 did to resident # 3 was not abuse, since resident # 4 had dementia and did not know what she was doing. The Activity Director noted that resident # 3 never stated that this was abuse. Phone interview on 10/18/2019 at 3:30 PM with Activitties staff( Staff D), with Spanish translation by Activity Director regarding the incident that occured with resident # 3 and resident # 4 on 10/09/2019, revealed that she was in the activity area at the time. There was bingo in activities after 2:00 PM. Before bingo, resident # 3 had a napkin in the cup. Resident # 4 took out the napkin and resident # 3 had stated that this was hers. Resident # 3 told resident # 4: This is mine, don't touch. Resident # 4 moved her arm toward resident # 3. Resident # 4 knocked against resident # 3 with her arm. Resident # 4 was not aggressive and resident # 3 had a strong personality when she spoke. Staff D, Activity staff noted that this was an accident by resident # 4. Resident # 3 was alert to name, place and time. Staff D, Activity Staff noted that she never heard resident # 4 say anything to resident # 3 that she did not like her. Activity staff explained that this was not abuse and this was an accident. Resident # 3 and resident # 4 played bingo like always and after that they were separated in different places. Interview on 10/18/2019 at 4:01 PM with Administrator, Social Service Director, Chief Nursing officer, Director of Nursing and Risk manager regarding the incident on 10/09/2019 with resident # 3 and resident # 4 during the bingo game: They were told by the activity assistant that resident # 3 screamed at resident # 4, since resident # 4 had grabbed her napkin. Resident # 4 threw the napkin and hit resident # 4 arm, accidentally, this was not intentional. Resident # 3 did not have any injuries and no discomfort. They were separating resident # 4 and resident #3 while they were in activities. This was the first time that this happened. The doctor and the family member were called. This was not reported to any State Agency. This was not an allegation of abuse, since this was an accident. They did an investigation. Resident # 3 was upset, screamed at resident # 4 for grabbing the napkins and resident # 4 reacted by throwing the napkins at her, and her hand hit resident # 3 arms. This was not intentional. Resident # 4 was alert to name and had no history of aggressive behavior and was friendly. Resident # 3 was alert and oriented and had a strong character. Resident # 3 had told her she was hit in her chest and Staff D; Activity staff told her no she was only hit on the arm. Resident # 3 was assessed and they checked her chest and arms and there was no redness. They were not aware of resident # 4 stating to resident # 3 that she did not like her. They were not aware that this was abuse for resident # 3.

Based on record review and interview the facility failed to report an allegation of abuse for one resident (resident # 3) out of four residents sampled for allegations of abuse. The findings included: Record review of the facility Abuse Policy and Procedure not dated revealed: The facility will make reasonable efforts to ensure that residents are free from verbal, sexual, physical and mental abuse .to maintain a resident's physical and mental health and that their property will not be misappropriated. The facility will report all allegations or information that creates a reasonable cause to believe that a resident was abused as soon as possible not to exceed 24 hrs to the appropriate jurisdictional authorities, resident's physician, the resident's responsible party or proxy. A prompt and thorough investigation will be conducted immediately. Record review of the facility letter dated (MONTH) 1, 2019 revealed: No abuse incidents have been reported from (MONTH) 1, 2019 to date. Record review of the facility incident log dated (MONTH) 9, 2019 at 2:32 PM revealed resident # 3 was in activities and resident #3 was hit by another resident. Medical Doctor (MD) was notified. Family was notified. Record review of the face sheet revealed that resident # 3 was admitted on [DATE]. Record review of the nurse's notes for resident # 3 dated 10/09/2019 at 3:51 PM revealed while playing bingo resident # 3 started arguing with another resident, the activity aid intervened but the other resident hit her on the right arm. No apparent injury, resident # 3 denied pain at that time. Physician Assistant for resident # 3 was notified and no new orders at that time. Physician Assistant for resident # 3 advised to continue to monitor resident # 3 and call him back if there were any changes in condition. Resident # 3 niece was notified. Record review of the face sheet revealed that resident # 4 was admitted on [DATE]. Record review of the nurse's notes for resident # 4 dated 10/09/2019 at 4 PM revealed that resident # 4 was playing bingo and started arguing with another resident, activity staff intervened, but they continued, and resident # 4 hit the other resident on the right arm. Action: Resident # 4 was redirected by staff and reinforced to report any issue with other residents and the staff could intervene and not hit anybody. Response: Resident # 4 verbalized understanding. Resident # 4 agreed to be moved to the other side of the bingo table and continued playing with no further abnormal behavior. Interview on 10/18/2019 at 2:13 PM with resident # 3 in her in room revealed that she had been at this facility for years. Resident # 3 was alert to name, place and time. Resident # 3 was asked about the incident with resident # 4 in the activity area in (MONTH) 2019: Resident # 3 stated she was playing bingo and resident # 4 was next to her. Resident # 4 hit her in the chest area during bingo. There were no injuries. Resident # 3 stated that she felt this. Resident # 3 stated that resident # 4 was jealous, she thought. Resident # 3 noted that resident # 4 did not like her lip stick. Resident # 3 stated: Everyone saw this happen, everybody was there. This was the first time this happened and resident # 3 mentioned that resident # 4 stated that she did not like her. When resident # 3 was asked if she thought this was abuse by resident # 4. Resident # 3 replied Yes and noted that resident # 4 was confused. Resident # 3 explained that she did not want resident # 4 around her, but felt safe now. Resident # 3 stated that resident # 4 had told her she hated her before. Resident # 3 mentioned that she did not tell anyone that resident # 4 hated her. Resident # 3 stated that resident # 4 never tried anything again, and she was far away from her. Interview on 10/18/2019 at 2:22 PM with Staff A, Licensed Practical Nurse (LPN) regarding resident # 3 revealed that she was alert to name, place and time. Staff A, a LPN noted that she worked with resident # 3 before. Resident # 3 needed total assistance for her Activities of Daily Living care. Staff A, a LPN noted that she was not working on 10/09/2019 and was reading through the nurse's notes for that day. Staff A, a LPN stated that if this was an intentional physical contact, then this would be abuse. Staff A, LPN stated that she had not seen anything that happened with resident # 3 and that resident # 3 never mentioned that resident # 4 did not like her. Interview on 10/18/2019 at 2:49 PM with Staff B, Registered Nurse (RN) and Staff C, Certified Nursing Assistant (CNA) revealed that resident # 4 was very nice and alert to person and place but not time. Resident # 4 confused sometimes. Resident # 4 needed assistance with taking a shower and transfers to the wheel chair. Staff B, RN and Staff C, CNA were reading the nurse's notes and Staff B, RN noted that resident # 4 had hit resident # 3 right arm. Resident # 4 was redirected and verbalized understanding and continued bingo with no abnormal behavior. Staff B, RN stated that she did not remember if she worked that day but did not work in that area. Staff C, CNA noted that she did not work at that time, but started the next shift. Staff C, CNA stated that she never saw resident # 4 hit resident # 3 before. Staff C, a CNA noted that she never heard resident # 4 say to resident # 3 that she did not like her. Staff B, RN noted that she never saw abuse by resident # 4 against resident # 3. Observation and interview on 10/18/2019 at 3:04 PM with resident # 4 with Spanish translation by Staff B, RN revealed resident # 4 was in her room sitting in a wheel chair and was well groomed. Resident # 4 was not alert. Resident # 4 did not know the name of the place or the date. Interview on 10/18/2019 at 3:12 PM with Activities Director regarding resident # 3 revealed that she was reading through the notes dated 10/09/2019 at 3:51 PM in which resident # 3 was hit on the arm. The Medical Doctor and niece were notified. The Activity Director stated that she was not there on 10/09/2019. The Activity Director noted that on 10/09/2019 they were serving coffee before bingo started at 2:30 PM. The Activity Director noted that the Activity aid told her that resident # 3 had a plastic cup with a napkin and had finished her coffee. Resident # 4 tried to take the napkin from the cup resident # 3 had, then resident # 3 stated that this was her cup and resident # 4 swung her hand against resident # 3. Activity Director stated that this was an accident. Resident # 3 had no injuries to her knowledge and this had never happened. The Activity Director noted that what resident # 4 did to resident # 3 was not abuse, since resident # 4 had dementia and did not know what she was doing. The Activity Director noted that resident # 3 never stated that this was abuse. Phone interview on 10/18/2019 at 3:30 PM with Staff D, Activity staff, with Spanish translation by Activity Director regarding the incident with resident # 3 and resident # 4 on 10/09/2019 revealed that she was in the activity area at the time. There was bingo in activities after 2:00 PM. Before bingo, resident # 3 had a napkin in the cup. Resident # 4 took out the napkin and resident # 3 had stated that this was hers. Resident # 3 told resident # 4: This is mine, don't touch. Resident # 4 moved her arm towards resident # 3. Resident # 4 knocked against resident # 3 with her arm. Resident # 4 was not aggressive and resident # 3 had a strong personality when she spoke. Staff D, Activity staff noted that this was an accident by resident # 4. Resident # 3 was alert to name, place and time. Staff D, Activity Staff noted that she never heard resident # 4 say anything to resident # 3 that she did not like her. The Activity staff explained that this was not abuse and this was an accident. Resident # 3 and resident # 4 played bingo like always and after that they were separated and in different places. Interview on 10/18/2019 at 4:01 PM with Administrator, Social Service Director, Chief Nursing officer, Director of Nursing and Risk manager regarding the incident on 10/09/2019 with resident # 3 and resident # 4 during the bingo game: They were told by the activity assistant that resident # 3 screamed at resident # 4, since resident # 4 had grabbed her napkin. Resident # 4 threw the napkin and accidentally hit resident # 4 arm, this was not intentional. Resident # 3 did not have any injuries and no discomfort. They were separating resident #3 and resident #4 while they were in activities. This was the first time that this happened. The doctor and the family member were called. This was not reported to any State Agency. This was not an allegation of abuse, since this was an accident. They did an investigation. Resident # 3 was upset, screamed at resident # 4 for grabbing the napkins and resident # 4 reacted by throwing the napkins at her hand and hit resident # 3 arms. This was not intentional. Resident # 4 was alert to name and had no history of aggressive behavior and was friendly. Resident # 3 was alert and oriented and had a strong character. Resident # 3 told her that she was hit in her chest and activity staff (Staff D) told her she was hit only on the arm. Resident # 3 was assessed and they checked her chest and arms and there was no redness. They were not aware of resident # 4 stating to resident # 3 that she did not like her. They were not aware that this was abuse for resident # 3.

Based on record review and interview the facility failed to investigate an allegation of abuse for one resident (resident # 3) out of four residents sampled for allegations of abuse. The findings included: Record review of the facility Abuse Policy and Procedure not dated revealed: The facility will make reasonable efforts to ensure that residents are free from verbal, sexual, physical and mental abuse .to maintain a resident's physical and mental health and that their property will not be misappropriated. The facility will report all allegations or information that creates a reasonable cause to believe that a resident was abused as soon as possible not to exceed 24 hrs to the appropriate jurisdictional authorities, resident's physician, the resident's responsible party or proxy. A prompt and thorough investigation will be conducted immediately. Record review of the facility letter dated (MONTH) 1, 2019 revealed: No abuse incidents have been reported from (MONTH) 1, 2019 to date. Record review of the facility incident log dated (MONTH) 9, 2019 at 2:32 PM revealed resident # 3 was in activities and resident #3 was hit by another resident. Medical Doctor was notified. Family was notified. Record review of the face sheet revealed that resident # 3 was admitted on [DATE]. Record review of the nurse's notes for resident # 3 dated 10/09/2019 at 3:51 PM revealed while playing bingo resident # 3 started arguing with another resident, the activity aid intervened but the other resident hit her on the right arm. No apparent injury, resident # 3 denied pain at that time. Physician Assistant for resident # 3 was notified and no new orders at that time. Physician Assistant for resident # 3 advised to continue to monitor resident # 3 and call him back if there were any changes in condition. Resident # 3 niece was notified. Record review of the face sheet revealed that resident # 4 was admitted on [DATE]. Record review of the nurse's notes for resident # 4 dated 10/09/2019 at 4 PM revealed that resident # 4 was playing bingo and started arguing with another resident, activity staff intervened, but they continued, and resident # 4 hit the other resident on the right arm. Action: Resident # 4 was redirected by staff and reinforced to report any issue with other residents and the staff could intervene and not hit anybody. Response: Resident # 4 verbalized understanding. Resident # 4 agreed to be moved to the other side of the bingo table and continued playing with no further abnormal behavior. Interview on 10/18/2019 at 2:13 PM with resident # 3 in her in room revealed that she had been at this facility for years. Resident # 3 was alert to name, place and time. Resident # 3 was asked about the incident with resident # 4 in the activity area in (MONTH) 2019: Resident # 3 stated she was playing bingo and resident # 4 was next to her. Resident # 4 hit her in the chest area during bingo. There were no injuries. Resident # 3 stated that she felt this. Resident # 3 stated that resident # 4 was jealous, she thought. Resident # 3 noted that resident # 4 did not like her lip stick. Resident # 3 stated: Everyone saw this happen, everybody was there. This was the first time this happened and resident # 3 mentioned that resident # 4 stated that she did not like her. When resident # 3 was asked if she thought this was abuse by resident # 4. Resident # 3 replied Yes and noted that resident # 4 was confused. Resident # 3 explained that she did not want resident # 4 around her, but felt safe now. Resident # 3 stated that resident # 4 had told her she hated her before. Resident # 3 mentioned that she did not tell anyone that resident # 4 hated her. Resident # 3 stated that resident # 4 never tried anything again, and she was far away from her. Interview on 10/18/2019 at 2:22 PM with Staff A, Licensed Practical Nurse (LPN) regarding resident # 3 revealed that she was alert to name, place and time. Staff A, a LPN noted that she worked with resident # 3 before. Resident # 3 needed total assistance for her Activities of Daily Living care. Staff A, a LPN noted that she was not working on 10/09/2019 and was reading through the nurse's notes for that day. Staff A, a LPN stated that if this was an intentional physical contact, then this would be abuse. Staff A, LPN stated that she had not seen anything that happened with resident # 3 and that resident # 3 never mentioned that resident # 4 did not like her. Interview on 10/18/2019 at 2:49 PM with Staff B, Registered Nurse (RN) and Staff C, Certified Nursing Assistant (CNA) revealed that resident # 4 was very nice and alert to person and place but not time. Resident # 4 confused sometimes. Resident # 4 needed assistance with taking a shower and transfers to the wheel chair. Staff B, RN and Staff C, CNA were reading the nurse's notes and Staff B, RN noted that resident # 4 had hit resident # 3 right arm. Resident # 4 was redirected and verbalized understanding and continued bingo with no abnormal behavior. Staff B, RN stated that she did not remember if she worked that day but did not work in that area. Staff C, CNA noted that she did not work at that time, but started the next shift. Staff C, CNA stated that she never saw resident # 4 hit resident # 3 before. Staff C, a CNA noted that she never heard resident # 4 say to resident # 3 that she did not like her. Staff B, RN noted that she never saw abuse by resident # 4 against resident # 3. Observation and interview on 10/18/2019 at 3:04 PM with resident # 4 with Spanish translation by Staff B, RN revealed resident # 4 was in her room sitting in a wheel chair and was well groomed. Resident # 4 was not alert. Resident # 4 did not know the name of the place or the date. Interview on 10/18/2019 at 3:12 PM with Activities Director regarding resident # 3 revealed that she was reading through the notes dated 10/09/2019 at 3:51 PM in which resident # 3 was hit on the arm. The Medical Doctor and niece were notified. The Activity Director stated that she was not there on 10/09/2019. The Activity Director noted that on 10/09/2019 they were serving coffee before bingo started at 2:30 PM. The Activity Director noted that the Activity aid told her that resident # 3 had a plastic cup with a napkin and had finished her coffee. Resident # 4 tried to take the napkin from the cup resident # 3 had, then resident # 3 stated that this was her cup and resident # 4 swung her hand against resident # 3. Activity Director stated that this was an accident. Resident # 3 had no injuries to her knowledge and this had never happened. The Activity Director noted that what resident # 4 did to resident # 3 was not abuse, since resident # 4 had dementia and did not know what she was doing. The Activity Director noted that resident # 3 never stated that this was abuse. Phone interview on 10/18/2019 at 3:30 PM with Staff D, Activity staff, with Spanish translation by Activity Director regarding the incident with resident # 3 and resident # 4 on 10/09/2019 revealed that she was in the activity area at the time. There was bingo in activities after 2:00 PM. Before bingo, resident # 3 had a napkin in the cup. Resident # 4 took out the napkin and resident # 3 had stated that this was hers. Resident # 3 told resident # 4: This is mine, don't touch. Resident # 4 moved her arm towards resident # 3. Resident # 4 knocked against resident # 3 with her arm. Resident # 4 was not aggressive and resident # 3 had a strong personality when she spoke. Staff D, Activity staff noted that this was an accident by resident # 4. Resident # 3 was alert to name, place and time. Staff D, Activity Staff noted that she never heard resident # 4 say anything to resident # 3 that she did not like her. The Activity staff explained that this was not abuse and this was an accident. Resident # 3 and resident # 4 played bingo like always and after that they were separated and in different places. Interview on 10/18/2019 at 4:01 PM with Administrator, Social Service Director, Chief Nursing officer, Director of Nursing and Risk manager regarding the incident on 10/09/2019 with resident # 3 and resident # 4 during the bingo game: They were told by the activity assistant that resident # 3 screamed at resident # 4, since resident # 4 had grabbed her napkin. Resident # 4 threw the napkin and accidentally hit resident # 4 arm, this was not intentional. Resident # 3 did not have any injuries and no discomfort. They were separating resident #3 and resident #4 while they were in activities. This was the first time that this happened. The doctor and the family member were called. This was not reported to any State Agency. This was not an allegation of abuse, since this was an accident. They did an investigation. Resident # 3 was upset, screamed at resident # 4 for grabbing the napkins and resident # 4 reacted by throwing the napkins at her hand and hit resident # 3 arms. This was not intentional. Resident # 4 was alert to name and had no history of aggressive behavior and was friendly. Resident # 3 was alert and oriented and had a strong character. Resident # 3 told her that she was hit in her chest and Staff D; Activity staff had told her she was hit only on the arm. Resident # 3 was assessed and they checked her chest and arms and there was no redness. They were not aware of resident # 4 stating to resident # 3 that she did not like her. They were not aware that this was abuse for resident # 3.

Based on observation, record review, staff interview, the facility failed to store clean linen properly. The facility failed to have appropriate Personal Protective Equipment for sorting soiled linen in order to prevent cross contamination. The findings include: Observation of the clean laundry room on 12/06/2018 at 12:10 PM Laundry Staff A was noted folding clean linen. There was uncovered clean folded linen resting on a rack touching the wall. Observation of laundry Staff B on 12/06/2018 at 12:20 PM was noted sorting soiled linen and wearing a vinyl apron with upper arms, shoulders and back exposed. The facility did not have impervious gowns to sort soiled linen. An interview conducted with the Laundry Staff A on 12/06/2018 at 12:10 PM revealed, she was folding clean linen and allowing them to accumulate on the rack prior to placing them inside the covered laundry cart. An interview conducted with the Laundry Staff B on 12/06/2018 at 12:20 PM revealed, she was sorting soiled linen wearing a vinyl apron with upper arms, shoulders and back exposed. The laundry staff stated she wears the Personal Protective Equipment to sort soiled linen. An interview conducted with the Laundry Director on 12/06/2018 at 12:25 PM confirmed, the clean linen stacked on a rack uncovered touching the wall. The laundry staff sorting soiled linen wearing a vinyl apron with upper arms, shoulders and back exposed. An interview conducted with the Infection Control Nurse on 12/06/2018 at 12:30 PM confirmed, the clean linen should be covered and stored appropriately. The facility did not have the appropriate Personal Protective Equipment for sorting soiled linen in order to prevent cross contamination. Review of the facility's Policy and Procedure for Environmental Services- Laundry dated 2001- revised 2011 noted, the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Preparation: Assemble the equipment and supplies needed. General Guidelines: 1. Consider all soiled linen to be potentially infectious. 6. Handle soiled linen as little as possible to prevent agitation. 17. Personnel should use proper personal protective equipment to avoid coming into contact with the clean linen. 18. Make sure clean linen does not come in contact with dirty areas. i.e., the floors, personnel's body)

Based on interviews, observations and record review, the facility failed to safeguard resident's rights to be free from physical restraints for one resident (Resident # 117) investigated for the use of bilateral mittens, out of 25 sampled residents. The facility failed to ensure adequate monitoring, assessment and justification for the continued use of the physical restraint after the resident was readmitted from the hospital. This facility practice has the potential to have an adverse effect on all 114 residents in the facility at the time of the survey. The Findings Included: Record review of the facility's Use of Restraint policy revised on (MONTH) 2008, revealed the policy statement: restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) . The Policy interpretation and implementation noted: Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 6. Prior to placing a resident in restraints, there shall be a pre-training assessment and review to determine possible causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.). 8. Orders for restraint will not be enforced for longer than twelve hour unless the resident's condition requires continued treatment . Observation on 12/03/18 at 10:30 A.M. and on 12/03/18 at 11:02 A.M., revealed, resident # 117 was in the activity room. The resident had bilateral mittens securely placed on both hands. No signs of distress was noted. Observation on 12/04/2018 at 8:55 A.M. revealed, resident # 117 was lying in bed. One of the mittens was on the bed, next to the resident. The mitten remained on top of the resident's blanket and was visible from the hallway. Observation and interview on 12/05/2018 at 7:54 A.M. revealed, resident #117 was in her bed sitting in her wheelchair, well dressed and nicely groomed. The resident did not have mittens on her hands. The mittens were not visible around the resident's room. Record review of the care plan for resident #117 revealed, the focus: Resident {#117} with potential for infection of Percutaneous Endoscopic Gastronomy (PEG) site due to presence of Percutaneous Endoscopic Jejunostomy (PEJ-tube) for nutritional purposes diagnosis (DX) of Dysphagia. Update dated 10/4/2018 noted: J-tube out, transferred to hospital for evaluation. Update dated 10/22/2018 noted, Read (readmitted ) S/P (status [REDACTED]. Update dated 12/05/2018 noted, Resident noted with hyper granulation to J tube site. The Goal was, Resident will be free of any signs or symptoms (s/s) of peg site infection all thru next review date. The interventions included, Resolved: Apply mittens to BILATERAL HANDS. Release every two hours for 15 minutes and during supervised activities. Date initiated 10/23/2018 and Resolved on 11/30/2018. Interview on 12/05/2018 at 1:19 P.M. with Staff D, a Certified Nursing Assistant (CNA) revealed, Staff D reported she was familiar with resident #117 and usually cared for her during the morning shift. According to the staff D, Resident #117 was agreeable and never refused care, with the exception of her dentures. The CNA explained, the resident had the mittens on both hands when she received her on Monday morning, 12/03/2018. The CNA removed the mittens off the resident later that day, after she learned from looking in computer that the resident was not supposed to use them. Interview on 12/05/2018 at 1:50 P.M. with Staff C, an Activity Staff revealed, resident #117 used to have mittens, she stated; Monday, she came in here with then, but then they took it off, because we were told that she did not need them anymore. During an interview on 12/05/2018 at 3:38 P.M. with staff E, a Licensed Practical Nurse (LPN) reported, resident #117's mittens were discontinued on 11/30/2018. The LPN was unable to present any documentation that showed valid justification for the continuous use of the restraint. She explained, the facility discharged Resident #117 to the hospital, after she pulled her peg on (10/4/2018). Resident #117 was readmitted with the mittens on 10/23/ (YEAR). The LPN explained, a nurse reviewed all hospital discharge orders (which included the order for use of physical restraints) with the MD (Medical Doctor), and he decided whether to continue or discontinue the order. The LPN added that the restorative nurse was in charge of completing the assessments needed to justify the use for physical restraints. Interview on 12/06/2018 with Staff G, a Restorative Registered Nurse (RN) revealed, the Restorative Nurse reported, she assessed residents and coded the MDS (Minimum Data Set) for the use of physical restraints. According to the RN, the mittens were not a restraint. Neither the resident nor the family signed a consent because it was not needed. The RN explained, resident #117 was admitted with the order of mittens to prevent her from pulling the tube. The resident was confused and disoriented at the time of admission and moving her hands involuntarily. The nurse explained, she discontinued the order for the use of [REDACTED]. The RN did not present any documentation to show that the resident had behaviors from the time of admission 10-23-2018 through the day it was discontinued, on 11/30/2018 or that the facility attempted to use a less restrictive option. The RN added, Staff should not have been using it by the weekend anymore. During an interview with the Assistant Director of Nursing ( ADON) and the RN on 12/06/2018 at 3:59 P.M. they both explained the facility practice; they did not view mittens as a physical restraint if deemed medically necessary to prevent injury. During the interview, we reviewed the nurses notes, behavior notes and psych consults, none of which showed any evidence that resident #117 had behaviors that warranted the use of bilateral mittens. Record review of the CNAs flowsheets and Medication Administration records for the month of (MONTH) (YEAR) revealed, facility staff applied the mittens on resident #117, every day, and released every two hours in accordance to the discharge order. The MAR indicated [REDACTED]. He added, resident #117's behaviors had progressed and the resident no longer needed the mittens.

Based on interviews and observations, the facility failed to ensure the safe use of a portable oxygen tank for one resident (resident #1) that required continuous oxygen therapy, out of 25 sampled residents. This facility practice has the potential to result in an accident that could negatively affect all 114 residents in the facility at the time of this survey. The Findings included: Dining room observations on 12/03/2018 at 11:59 A.M. revealed, resident # 1 walked to her table with the use of a rolling walker. The resident received oxygen therapy from a portable tank placed on her walker. The tank holder had a thumbscrew located on the side that was lose. The oxygen tank appeared loosely placed in the tank holder. (Photo 1) Observation on 12/04/2018 at 8:45A.M. revealed, resident #1 was sleeping in her bed. The resident continued to receive oxygen therapy from the tank placed on her walker. The oxygen cylinder remained loosely placed on the tank holder; the thumbscrew remained lose. (Photo 2) Observation and interview on 12/04/208 at 3:55 P.M. with Staff H, a Case Worker and Registered Nurse revealed, Staff H agreed to check the oxygen tank. She began by easily removing the cylinder out of the tank holder and placing it on the floor, demonstrating that the thumbscrew was not securely holding the cylinder in place. Observation on 12/05/18 at 8:03 A.M. revealed, resident #1 was sleeping in bed. The oxygen cylinder remained loosely placed on the tank holder; the thumbscrew remained lose. Observation and interview on 12/05/2018 at approximately 9:35 AM with staff J, a Registered Nurse (RN) revealed, the RN witnessed that the oxygen tank used by resident #1 easily moved in and out of the tank holder, indicating that the cylinder was lose. The RN later agreed that the thumbscrew should have been for safety, to keep the tank secured in place. Interview with the Assistant Director of Nursing (ADON) on 12/06/2018 at 3:59 P.M. revealed, upon discussion of the above mentioned observations; the ADON agreed with the safety concerns. The ADON explained, that the thumbscrew found on the tank holder should be tightened to hold the oxygen tank in place.

Based on observation, interview and record review, the facility failed to store food under sanitary conditions as evidenced by storage of drinking water in close proximity to chemicals and cleaning supplies. This has the potential to contaminate the drinking water distributed for use in dispensing coolers located throughout the facility. The findings included: Observation during the initial kitchen tour conducted on 12/03/18 at 9:45 AM revealed, a storage area located outside of the kitchen. The storage area was used for storage of chemicals and cleaning supplies. Five gallon bottles of drinking water was stored in the same storage area in close proximity to the chemicals. Observation on 12/06/18 at 1:30 PM revealed, the five gallon containers of drinking water stored in the same storage area. The bottles were stored on their sides on racks which were on a wooden pallet. The chemicals were stored on the floor directly to the right side of the bottled water and also on a shelf unit located behind the bottled water. The chemicals and cleaning supplies were stored approximately two feet from the water. The chemicals included bleach, lime away, multi-purpose cleaner, solid dish detergent, germicidal cleaner, chlorine sanitizer, grout, disinfectant cleaner and all-purpose degreaser. Interview with the Registered Dietitian (RD) on 12/06/18 at 1:38 PM revealed, this bottled water is used for drinking and is rotated from the storage room to be used in the water dispensing machines in the facility. The RD stated, chemicals should not be stored close to food items, then confirmed this water was used for drinking and distributed throughout in the facility. The RD stated, she would have the water moved so it was not stored near the chemicals. Review of the policy and procedure titled, Food Receiving and Storage revised (MONTH) 2008 revealed, pesticides and other toxic substances and drugs will not be stored in the kitchen area. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. (Photos submitted)

Based on observation, interview, and record review, the facility failed to 1) ensure that 14 out of 28 resident rooms observed for environmental concerns were in good condition related to walls, floors, baseboards, and air conditioning (AC) units being in disrepair. The findings included: 1) Record review of the facility's policy and procedures titled, Maintenance and Housekeeping Service, dated 2001, Revised on 01/2017, revealed, Maintenance and housekeeping service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. Room 313: Observation on 11/13/2017 at 10:42 am of Room 313 revealed that the air conditioning (AC) unit had multiple cracks in the caulking at the top of the unit. Further observation revealed that the baseboard panel on the left side of the residents' bathroom was detached, and there was a crack in the wall. Room 309: Observation on 11/13/2017 at 11:00 am of Room 309 revealed that on the right side of the AC unit the wall was in disrepair, with paint missing and a hole in the wall. Room 304: Observation on 11/14/2017 at 9:03 am of Room 304 revealed that the baseboard panel was detached on the left side of the AC unit. There was chipped paint along the walls of the windows walls around the window. Further observation of the residents' bathroom revealed that the door frame had chipped paint and cracked wood. Room 303: Observation on 11/14/2017 at 9:17 am of Room 303 revealed that the vents on the top of the AC unit were bent and twisted. Room 301: Observation on 11/14/2017 at 9:52 am revealed that the one of the vents of the AC unit was loose and able to be removed. The floor at the base of the AC unit was stained and discolored. Further observation of the room revealed chipped paint and cracked wood in the baseboards around the bedroom. The residents' closet had deep indentations and holes in the wood. Room 307: Observation on 11/14/2017 at 10:02 am of Room 307 revealed deep indentations in the wall above the AC unit. The vents of the AC unit had thick coats of dust on them, and the unit was making a noise. The baseboard panel around the room had chipped paint and the wood was cracked. Room 311: Observation on 11/14/2017 at 1:22 pm of Room 311 revealed that the floor at the base of the AC unit had discoloration with dark marks in the tile; the vents of the AC unit were bent. Interview with the Charge Nurse on 2nd Floor (Staff F) on 11/15/2017 at 11:41 am revealed that on her floor she had to check around the unit, and in residents' rooms, for any environmental problems that would need to be fixed by maintenance. If there were any identified problems, she would call the maintenance immediately, and write a maintenance work order. The maintenance director checked the maintenance work orders log on the floor daily. She not only wrote the work orders, but other nursing staff on the floor could write them too and notify maintenance. Interview with the Charge Nurse on 3rd Floor (Staff G) on 11/15/2017 at 11:51 am revealed that if there any problems on the unit related to the environment they would write a maintenance work order and report it to the Maintenance Director. Even if maintenance staff were not in the facility, nursing staff could call them and maintenance would come; however, there was always maintenance staff in the building. Interview with the Maintenance Director on 11/15/2017 at 12:08 pm, via translation by the Compliance Officer, revealed he was responsible for ensuring that was everything was okay and functioning properly in the building. Also, he ensured that the kitchen, the laundry, and the air conditioning (AC) throughout the facility was working good too. He checked the maintenance work orders daily, and nursing staff would also notify him of any problems. Aside from this, the maintenance director and his staff checked the residents' rooms daily, and reported them at the head department meetings. All issues discussed were fixed immediately. Record review of the Maintenance Work Orders on the 2nd and 3rd floors for the months of September 2017 to November 2017 revealed no maintenance work orders related to the environmental concerns in observed in the residents' rooms. Observational tour with the Maintenance Director and Compliance Officer on 11/17/2017 conducted between 12:14 pm and 12:53 pm revealed that all of the observed environmental concerns in the residents' rooms were confirmed by the staff members and noted that repairs were needed. Room 205 Observation on 11/13/17 at 12:37 pm of Room 205 revealed the baseboards were in disrepair and not in good condition. The baseboards paint were chipped with black markings. Room 208 Observation on 11/14/17 at 10:38 am of Room 208 revealed the wall behind bed B in disrepair with white markings on it and the flooring under the air conditioning (AC) unit was in disrepair and not in good condition. Room 213 Observation on 11/14/17 at 11:53 am of Room 213 revealed walls and flooring were in disrepair. The wall had a white-color painting on top of the green color. Flooring was in disrepair and not in good condition under the AC unit and the flooring had yellowish-brown stains in front of the resident's bed A. Room 211 Observation on 11/14/17 at 12:38 pm of Room 211 revealed the flooring under the AC unit was in disrepair and not in good condition. Room 215 Observation on 11/14/17 at 2:28 pm of Room 215 revealed the flooring under the AC conditioning unit in disrepair and not in good condition. Room 222 On 11/14/17 at 8: 41 AM, Room 222 was noted with a wall in disrepair. The wall by the window was painted blue and at the bottom there was another piece of wood from a different blue that was in disrepair. By the wall, there was an air conditioner that had pieces of wood under it. Room 328 Observation on 11/13/2017 at 2:06 PM, in room 328 revealed, four holes on the wall facing the resident's beds. The holes appeared to be nail holes from items that previously hung on the wall.

Based on observation, interview, and policy review, the facility failed to store food at the appropriate temperature in the Walk-in Freezer, Ice Cream Box and Reach-in Freezer. This has the potential to affect ninety-four residents who eat orally out of one-hundred and nineteen residents residing in the facility. Findings include: Record review of the Refrigerators and Freezer Policy and Procedure (written 2001; Revised January 2017) revealed: Policy Statement-This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation and will observe food expiration guidelines: Policy Interpretation and Implementation: 1) Acceptable temperatures should be 35 degrees Fahrenheit (F) to 40 degrees F for refrigerators and 0 degrees F or less for freezers. Observation of the initial kitchen tour on 11/13/17 at 9:06 am with the Dietary Manager (DM) and Consultant Registered Dietitian (RD) revealed, the Walk-in Freezer with desserts, meats and vegetables, inside temperature was 8 degrees F. Interview with the Dietary Manager on 11/13/17 at 9:07 am confirmed the Walk-in Freezer temperature was 8 degrees F. She stated, Temperature should be 0 degrees or below 0 degrees F. Observation of the kitchen on 11/13/17 at 9:08 am with the DM and Consultant RD revealed, the Ice cream box with miniature ice cream containers temperature inside was 12 degrees F. Interview with the Dietary Manager on 11/13/17 at 9:09 am confirmed the Ice cream box temperature was 12 degrees F. She stated, Temperature should be 0 degrees or below 0 degrees F. Observation of the kitchen on 11/13/17 at 9:10 am with the DM and Consultant RD revealed the Reach-in Small Freezer with desserts for the tray line outside temperature was 1 degrees F and inside temperature was 29 degrees F. Interview with the Dietary Manager on 11/13/17 at 9:11 am confirmed, the Reach-in Freezer temperature was 29 degrees F. She stated, Temperature should be 0 degrees or below 0 degrees F. Second observation of the kitchen on 11/14/17 at 8:07 am with the DM and Consultant RD revealed: Walk-in Freezer inside temperature was 0 degrees F, Ice Cream Box inside temperature was 0 degrees F and Reach-in Small Freezer inside temperature was 0 degrees F.