Every finding on record at Salemtowne

Based on record review, and staff, Hospice Nurse, and Nurse Practitioner interviews, the facility failed to prevent a significant medication error when Medication Aide #1 (MA #1) administered Resident #1 Morphine 50 milligrams (mg) instead of the ordered 5 mg (Morphine is an opioid pain medication used in hospice care to relieve moderate-to-severe pain, anxiety, and severe breathlessness at the end of life). This deficient practice affected 1 of 3 residents reviewed for significant medication errors.The findings included: Resident #1 was admitted to the facility on [DATE] with history of multiple strokes and end of life care management. The Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Resident #1 was dependent on staff for all activities of daily living and received hospice care. Review of physician orders showed an order dated 2/24/26 for Morphine 20 mg/milliliters (ml) take 0.25 ml every 4 hours as needed for pain and shortness of breath. Review of narcotic record showed the pharmacy supplied the ordered Morphine 20 mg/ml in a 30ml bottle. Further review showed MA #1 documented on 3/4/26 at 1:55 pm she administered 2.5ml to Resident #1 with 27.50ml remaining in the bottle. During an interview on 3/26/26 at 2:28pm with MA #1 she stated she had worked with Resident #1 several times since his admission. MA #1 reported on 3/4/26 shortly after lunch, a family member came out of Resident #1's room and stated to her that it appeared Resident #1 was having pain or discomfort. MA #1 stated when she entered the room, Resident #1 did appear restless, which was not usual for him. MA #1 reported she returned to the medication cart to retrieve the bottle of Morphine. MA #1 stated she was sure she looked at the bottle label and checked the directions before pouring out 2.5 ml and administering it to Resident #1. MA #1 stated she returned to check on Resident #1 about an hour later and noted he was sleeping and resting comfortably. MA #1 reported Resident #1's chest was rising and falling with no breathing issues and his skin was dry and warm with no discolorations to his lips or fingertips. MA #1 stated she did not realize she had read the instructions on his Morphine order incorrectly until it was brought to her attention 2 days later when Nurse #1 went to administer a second dose to Resident #1. Multiple attempts to reach Nurse #1 were unsuccessful. During an interview with Hospice Nurse #1 on 3/26/26 at 3:44pm, she stated that she arrived at the facility on 3/4/26 at approximately 9:30pm for a routine assessment of Resident #1. Hospice Nurse #1 stated they do not routinely gather vital signs other than oxygen saturation which was 97% on room air when she tested. Hospice Nurse #1 stated she found Resident #1 to be resting comfortably in bed. She noticed no labored breathing and his chest was rising and falling with ease. Hospice Nurse #1 also stated that Resident's skin was dry and warm and there were no discolorations to his lips or fingertips that would indicate he was not getting enough oxygen. Hospice Nurse #1 stated she was not made aware of the medication error until she was contacted by the facility around midnight on 3/6/26 and asked to come out and reassess Resident #1 (she works 5:00pm to 5:00 am) and at that time he was alert, responded to his name being called but did not respond to any of her questions. Hospice Nurse #1 added that Resident #1 seemed to be gradually declining since she had first seen him the week prior, which she had expected. During an interview with the Director of Nursing (DON) on 3/26/26 at 4:05 pm, she stated that Nurse #1 alerted her on 3/6/26 around midnight that Resident #1 was given an incorrect dose of Morphine on 3/4/26. The DON stated she arrived at the facility and assessed Resident #1 to be resting comfortably, skin was dry and warm, and vital signs were stable. The DON stated that when she looked at Resident #1's narcotic sheet with Nurse #1, she saw that MA #1 had documented giving the only dose out of the 30 ml bottle on 3/4/26 and there was 27.50ml remaining in the bottle. Comparing to the order, she stated she could see that Resident #1 should have only received 0.25ml but was administered 2.5ml instead. The DON stated that the current process for counting narcotics was for two staff members to count during each shift change. She stated the nurses will look at the beginning amount, the amount given, and the amount remaining so the error wasn't noted during shift change counts. The DON stated that the error was only discovered because Nurse #1 saw the amount documented as administered on 3/4/26 was 2.5ml and she was getting ready to administer 0.25ml per the order. During an interview with the Nurse Practitioner (NP) on 3/26/26 at 4:30 pm, she stated she assessed Resident #1 on 3/5/26 after the medication error and found him to be alert and responsive to his name but did not respond to her questions. She stated he did not appear to be in any discomfort; his skin was dry and warm with no discolorations. The NP stated that Resident #1 was receiving end of life services and had been gradually declining over the last week, so she expected him to not be very alert or responsive to her questions. The NP stated that even though Resident #1 received a much higher dose of Morphine on 3/4/26 than he should have been administered per the order, it did not affect his outcome and Resident #1 passed away peacefully on 3/7/26. During an interview with the Administrator on 3/26/26 at 5:00pm, she stated the DON made her aware of the medication error on 3/6/26 when it was discovered.

Based on observation, record review, staff interviews, and manufacturer's recommendations, the facility failed to remove an expired insulin lispro kwikpen (an insulin pen) and failed to label the insulin lispro kwikpen with resident information for 1 of 5 medication carts reviewed for medication storage (Mill Place medication cart). The findings included:The manufacturer's 2023 storage recommendation for Insulin Lispro KwikPen stated that the pen should be discarded 28 days after opening.During an observation of the Mill Place medication cart on 12/10/25 at 11:45 a.m., Nurse #4 confirmed that a multidose Insulin Lispro KwikPen, opened on 10/16/25, remained in the cart for use. The pen was not labeled, and no information identified the resident's name or room number. In an interview at 11:54 a.m. on 12/10/25, Nurse #4 acknowledged that the insulin should have been discarded 28 days after opening. She stated that all nurses using the cart were responsible for checking and removing expired medications.In a follow-up interview at 12:06 p.m., Nurse #4 identified the insulin as belonging to Resident #36 and stated that both the KwikPen and its storage box should have been labeled with the resident's name and room number.During an interview on 12/11/25 at 10:57 a.m., the interim Director of Nursing (DON) stated that nurses assigned to the medication cart were responsible for identifying and removing expired medications. She added that the third shift (11 p.m. to 7 a.m.) was designated to check one cart per week. The DON also stated the kwikpen should have the pharmacy label with resident's name and the room number. In an interview on 12/11/25 at 12:58 p.m., the Administrator emphasized that nursing staff must follow the manufacturer's guidelines and audit both the medication cart and the medication room during their shifts.

Based on record review and interviews with staff and family member, the facility failed to follow their infection control policy regarding Clostridium difficile infection (C. difficile) [bacteria that can cause diarrhea and inflammation in the colon, can cause serious complications, and is highly contagious] for hand hygiene after resident care. Two nursing assistants used alcohol-based hand sanitizer and had not washed their hands with soap and water after caring for a resident with C. difficile. The deficient practice affected 3 of 5 staff members (Nursing Assistant (NA) #1, NA #2, and Medication Aide #1) interviewed for hand hygiene specific to C. difficile management (Resident #1). Findings included: The Infection Control Protocol for C. Difficile Policy dated 1/20/25 documented, in part, 1.c. Wash hands with soap and water. Do not use alcohol gels since it does not kill spores (bacteria of C. difficile). Resident #1 was admitted to the facility on [DATE] with diagnoses of C. difficile and dehydration. Resident #1 had the following orders: Enteric precautions for C. Difficile dated 3/31/25. Vancomycin (antibiotic for C. difficile infection) 125 milligram capsule every 6 hours for 4 days starting 3/31/25 and ending 4/4/25. An interview was conducted on 5/19/25 at 12:05 pm with Resident #1's family member. The family member stated she observed nursing staff had used the hand sanitizer from the wall dispenser after providing care when the resident had C. difficile. There were gloves, gowns, and masks available and an enteric precaution sign on the door. She never observed staff washing their hands with soap and water. The family member commented she was aware that hand sanitizer was not effective to kill the C. difficile and had not informed anyone of her concern. The family member stated the resident's C. difficile infection resolved and he was transferred to an adult living facility. An interview was conducted with NA #1 on 5/19/25 at 1:10 pm. NA #1 stated she was assigned to Resident #1 when staff was required to follow enteric precautions for C. difficile. NA #1 stated she used personal protective equipment (PPE) for all care. NA #1 further stated she used alcohol hand sanitizer after care if there was no cleaning of stool when C. difficile was active. NA #1 commented she was not aware that alcohol hand sanitizer does not kill C. difficile. NA #1 stated there was a contact precaution sign on the resident's door to wear a gown, gloves, and mask when providing care. The NA did not recall parameters for hand washing with soap and water on the sign. An interview was conducted with Medication Aid (MA) #1 on 5/19/25 at 1:20 pm. MA #1 stated she was assigned to Resident #1 when he had the C. difficile infection and frequent diarrhea. MA #1 stated you could use hand sanitizer after care when a resident had C. difficile but she preferred to wash her hands with soap and water if there was stool. MA #1 stated she washed her hands with soap and water after incontinence care and always wore the mask, gown, and gloves for all care. MA #1 further stated she was not aware that alcohol hand sanitizer does not kill C. difficile. There was a contact precaution sign on the resident's door, but MA #1 did not recall parameters for hand washing with soap and water on the sign. An interview was conducted with NA #2 on 5/19/25 at 1:55 pm. NA #2 stated she remembered Resident #1 and that he had C. difficile infection in his stool, diarrhea, and was on enteric precautions. NA #2 stated she used a mask, gown, and gloves upon entry into the room and discarded upon leaving. Hand hygiene was hand sanitizer on the wall dispenser which was alcohol. NA #2 stated she was not aware that alcohol hand sanitizer does not kill C. difficile. She had not washed her hands with soap and water after care; she used the hand sanitizer as usual. An interview was conducted with the Director of Nursing (DON) on 5/19/25 at 3:35 pm. The DON stated the Infection Preventionist was not available, and she was covering. The DON stated all nursing staff were educated to wash their hands with soap and water when a resident had C. difficile after all care and this requirement was a facility policy. The DON also stated that Resident #1 had an enteric precaution sign on his door which included the requirement to hand wash with soap and water. The hand sanitizer was alcohol based which was not effective to kill C. difficile spores. There was no spread of C. difficile that she was aware of. The DON further commented that NA #1 and NA #2 were agency staff and were expected to have received education from the agency before working at the facility.

Based on observations and dietary staff interviews, the facility failed to maintain sanitary conditions in the central kitchen and in 1 of 4 satellite kitchens (Garden/Mill kitchen) by not ensuring staff covered their facial hair during food preparations, by not ensuring pots and pans were stacked clean on the storage rack, and by not ensuring pots, pans, and utensils were sanitized with a chemical sanitizing solution. These practices had the potential to affect food served to residents. Findings included: 1a. During a follow-up tour of the central kitchen on 9/11/24 at 10:43 a.m. accompanied by the Assistant General Manager of Culinary Services and the facility's Chef, the dietary cook was observed transferring pans of baked chicken from the ovens to the bulk transport containers for delivery to the satellite kitchens. The facility's Chef and the dietary cook were observed without covering their facial hair which was approximately half an inch to one inch in length on their faces. 1b. During an observation of the Garden/Mill satellite kitchen on 9/11/24 at 10:58 a.m., the facility's Chef and one dietary staff member were observed in the food preparation area without covering of their facial hair which was approximately half an inch to one inch in length on the lower faces. 2. The observation of the clean and dried pots/pans storage rack on 9/11/24 at 10:50 a.m. in the central kitchen revealed 8 stainless-steel pans with dried, dark brown debris on the inside, were stacked on the racks for use. 3. On 9/11/24 at 12:01 p.m. the three-compartment sink in the Garden/Mill satellite kitchen was observed with pots, pans, and serving utensils immersed in a clear liquid in the sanitizing section of the sink. The dietary staff indicated the pots, pans and utensils observed were immersed in water with sanitizing agent (Quaternary) and it read 200 ppm (parts per million) earlier that day. However, when requested, the dietary staff tested the concentration of the sanitizer in the sink using a sanitizing testing strip. The testing strip did not change color indicating there was no sanitizing agent in the sink containing the pots, pans, and utensils. On 9/11/24 at 12:10 p.m., the Assistant General Manager of Culinary Services directed the dietary staff to discontinue using the three-compartment sink, and wash and sanitize the pots, pans, and utensils in the dishwashing machine. During an interview on 9/11/24 at 12:20 p.m., the Assistant General Manager of Culinary Services revealed that after the demonstration after the three-compartment sink, she contacted the provider for the sanitizing device and a service technician would arrive soon.

Based on record review, resident, staff interviews and student interviews, the facility failed to treat a resident in a dignified manner when a Nursing Assistant (NA) told a resident to use his brief when the resident requested assistance with toileting to the bathroom for 1 of 2 residents reviewed for dignity (Resident #69). Resident #69 stated the NA's statement and lack of assistance made him feel dirty. The findings included: Resident #69 was admitted to the facility 3/30/22 with diagnoses that included other sequelae (medical conditions resulting from stroke) of cerebral infarct, difficulty walking, other lack of coordination, muscle weakness, reduced mobility, and unspecified lack of coordination. Review of Resident #69's Care Plan dated 4/14/22 revealed the problem of history of Urinary Tract Infection (UTI) with risk for Moisture-Associated Skin Damage (MASD) requiring extensive to total assist with toileting/incontinent care. The goal was for Resident #69's skin to remain intact. The interventions included assist Resident #69 to the toilet and provide proper hygiene upon request. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact and was coded as requiring extensive assistance with two staff assist for both bed mobility and toileting. The resident was coded as being occasionally urinary incontinent and always bowel incontinent. The Initial Allegation Report/24-Hour Report dated 9/8/22 written by Nurse #5 (Clinical Lead) revealed an allegation that Resident #69 was neglected. The incident was alleged to have occurred on 9/6/22-9/8/22. The report further revealed the facility became aware of the incident on 9/8/22 at 1:15 PM. The allegation details stated that student NAs reported NA #1 refused to change Resident #69. The report further revealed NA #1 yelled at him that he needed to use his brief. Resident #69 stated he did not want to use his brief and NA #1 continued to scream at Resident #69 stating he needed to use his brief. NA #1 left Resident #69 without assisting him. No bruising or injuries were noted. The Initial Report/24-Hour Report had witness statements from the Instructor of NA Students, NA Student #1, and NA Student #2. a) Witness statement dated 9/8/22 written by the Instructor of NA Students stated she had several students approach her regarding incidents by NA #1 on Mill Place Hall. NA #1 was paired up with students for the week. The Instructor of NA Students reported the incidents to a nurse on Garden Court Hall because there was an agency nurse on Mill Place Hall. The Instructor of NA Students also reported the incidents to the Assistant Director of Nursing (ADON). b) Witness statement dated 9/6/22 written by Student NA #1 revealed the morning of 9/6/22, Resident #69 stated he needed to use the restroom. NA #1 screamed at Resident #69 that he was going to have to use his adult brief. Resident #69 told NA #1 that he did not want to use his brief. The witness statement further stated NA #1 told Resident #69 that she could not help him at that time, and he was going to have to go to the bathroom in his brief. NA #1 walked away. c) Witness statement dated 9/6/22 written by Student NA #2 revealed NA #1 was passing out breakfast trays when Resident #69 indicated he needed to use the bathroom. NA #1 told Resident #69 she did not have time to get him out of bed until after breakfast. Resident #69 repeated his need to use the bathroom and NA #1 told him to just use his brief. The witness statement continued that Resident #69 told NA #1 that he did not want to use his brief and NA #1 continued to tell him she was not going to move him until later. Review of the Five-Working Day Report/investigation submitted 9/13/22 revealed the facility investigated an allegation of neglect by NA #1. The report further revealed the allegation was substantiated. The attached investigative summary written by former Director of Nursing (DON) #2 stated on 9/8/22 the Instructor of NA Students approached Nurse #5 and revealed her students had expressed concerns with NA #1. The Instructor of NA Students obtained written statements from NA students (NA Student #1 and NA Student #2) that described potential resident neglect of Resident #69. The Investigative Summary's conclusion stated the facility substantiated the allegation of resident neglect regarding Resident #69 due to NA #1 telling Resident #69 to use his brief when he requested assistance to use the toilet. NA #1 was immediately suspended and formally terminated on 9/12/22. An interview with Resident #69 on 4/12/23 at 3:14 PM revealed he recalled a nursing staff (name unknown) had told him to go to the bathroom in his brief. Resident #69 could not recall the date of the incident but stated he utilized a talking clock to keep himself informed of the time due to his visual impairment. He recalled having to use his call bell multiple times to get assistance to go to the bathroom, but no staff returned to clean him up after he had a bowel movement (BM). During a second interview on 4/13/23 at 11:25 AM, Resident #69 recalled that the nurse telling him to use his brief after he requested assistance to the toilet made him feel dirty. A phone interview was attempted on 4/13/23 at 2:06 PM and again on 4:51 PM with NA #1. Messages were left and the phone calls were not returned. An interview on 4/13/23 at 2:36 PM was conducted with Social Worker (SW) #2. She recalled that in response to the allegations of neglect of Resident #69, she conducted interviews of cognitively intact residents, asking if they had been abused physically or verbally, if they felt safe, or had any other concerns. A phone interview on 4/13/23 at 4:51 PM Nurse #5 (Clinical Lead) revealed she became aware of an allegation of neglect on 9/8/22 by the Instructor of NA Students. She was informed by the Instructor of NA Students that NA students were uncomfortable being with NA #1. The NA students had given verbal descriptions of witnessing NA #1 tell Resident #69 to use his brief after he requested assistance to the toilet. Nurse #5 stated she had completed the 24-Hour Report, obtained NA students' contact information, and requested written witness statements. She further recalled directing the Instructor of NA Students to the former DON #2 to provide further details. Nurse #5 stated she recalled Resident #69 wore briefs as he was continent with incontinent episodes. Resident #69 was able to communicate his needs and would occasionally have the urge to have a bowel movement (BM) and would ask to use the toilet. Nurse #5 revealed she did not provide Resident #69 incontinent care but thought Nurse #4 had assisted Resident #69. An interview was conducted by phone with Nurse #4 on 4/13/23 at 5:15 PM. She indicated she was assigned to Mill Place unit on day shift 9/8/23. She further stated she recalled several nursing students on the unit, and she was notified by Nurse #5 of the allegation of neglect of Resident #69. Nurse #4 revealed she had not provided Resident #69 incontinent care following the allegation and was unaware if any staff had provided incontinent care. A phone interview was attempted on 4/14/23 at 9:57 AM with Student NA #2. The phone number had been disconnected and was no longer in service. Interview by phone with Student NA #1 on 4/14/23 at 10:00 AM revealed she had witnessed Resident #69 request assistance to use the bathroom and was told by NA #1 she did not have time. NA Student #1 further stated NA #1 referred to Resident #69's brief as a diaper and would tell him to use his diaper. Resident #69 stated he did not want to use his brief and appeared to become visibly upset as evidenced by a grimaced look on his face. Student NA #1 revealed NA #1 denied Resident #69 assistance and walked out of the room. Resident #69 continued to request assistance to use the toilet and was ignored by NA #1. Student NA #1 indicated she notified the Instructor of NA Students of NA #1's refusal to provide Resident #69 incontinent care. Student NA #1 indicated that as a nursing student, she was unable to provide residents incontinent care without the assistance of a NA. Student NA #1 further revealed she provided a written statement of what she had observed. A phone interview on 4/14/23 at 2:55 PM with former DON #2 revealed she recalled a telephone call from the ADON on 4/8/22, who described details provided by the Instructor of NA Students and her students regarding the allegation of neglect by NA #1 toward Resident #69. DON #2 stated she conducted the investigation and substantiated NA #1 neglected Resident #69, who was told to go to the bathroom in his brief, which was not the policy of care for residents. DON #2 revealed she did not recall if someone assisted Resident #69 to the bathroom. An interview with Administrator #1 on 4/14/23 at 3:59 PM revealed the staff were trained to assist a resident to the bathroom when requested, and to never tell a resident to go to the bathroom in their brief. She further revealed if the NA felt they were too busy, the call light should be left on, the resident was to be reassured that the NA was aware of the resident's needs, and that they were going to get assistance of another NA or nurse.

Based on observations, resident representative interview, staff interviews and record review, the facility failed to provide a dignified dining experience by standing over a resident while providing assistance with feeding for 1 of 8 residents (Resident #3) reviewed for assistance with dining. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change in condition Minimum Data Set assessment dated [DATE] revealed Resident #3 had severely impaired cognition. She required limited assistance with eating. An activities of daily living care plan updated 8/10/21 revealed, Provide encouragement for intake and may require limited assist at meals. On 11/15/21 at 1:07 PM Resident #3 was observed in her bed in an upright seated position. A lunch tray was in front of her on the overbed table. At 1:13 PM Nurse Aide (NA) #3 entered the room and began feeding the resident. NA #3 stood next to the resident's bed as she provided the resident with feeding assistance. NA #3 stood above eye level of the resident for the duration of the meal while she fed Resident #3. NA #3 asked the resident if she wanted to feed herself, to which the resident replied, No. The resident indicated she didn't want any more food. NA #3 offered to get some cake for the resident and Resident #3 agreed. At 1:16 PM NA #3 returned to the room and fed a piece of cake to Resident #3 while she stood next to the bed. NA #3 exited the resident's room at 1:19 PM. An interview was completed with NA #3 on 11/16/21 at 1:20 PM, during which she stated Resident #3 needed assistance when she ate her meal. She said she stood up when she fed Resident #3 because she knew she probably wouldn't eat much and added she also had to complete her medication pass. NA #3 reported she was aware she needed to be seated when she fed a resident. On 11/17/21 at 9:10 AM Resident #3 was observed lying in her bed. NA #4 entered the resident's room, sat the resident in an upright position in the bed and placed a clothing protector on her. NA #4 set up the breakfast tray and fed Resident #3. NA #4 stood above eye level of the resident for the duration of the meal while she fed the resident. At 9:18 AM the resident indicated she was finished eating and NA #4 removed the breakfast tray. In an interview with NA #4 on 11/17/21 at 9:25 AM she stated the resident needed to be fed her meals and she normally stood when she fed Resident #3 since there was not a chair in the room that could be placed next to the bed. She explained the facility didn't say either way if staff were to sit or stand when they fed a resident. An observation of Resident #3's room during the interview with NA #4 revealed there was a chair located near the foot of the resident's bed. Resident #3's representative was interviewed by phone on 11/16/21 at 11:26 AM. She thought Resident #3 would want staff to be seated when they fed her to promote a more dignified dining experience. During an interview with the Director of Nursing on 11/18/21 at 10:13 AM, she explained staff should be seated when they fed a resident and would not expect them to be standing. She was unsure if protocol for feeding residents was included in the new hire orientation process. An interview was completed with the Clinical Education Director on 11/18/21 at 10:20 AM during which she said staff were supposed to be seated when they fed residents. She shared the information was included in the new hire orientation process but was unsure if it was included in the annual training of nursing staff. During the orientation process she instructed nursing staff they were to be seated when they fed a resident so they were at eye level and were not to stand over a resident when feeding them.

Based on observations, record review and staff interviews, the facility failed to implement care planned Interventions for pressure reducing devices for 1 of 2 residents reviewed for positioning (Resident #43) and 1 of 2 residents reviewed for pressure ulcers (Resident #28). The findings were: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment dated [DATE] revealed Resident #43 had severely impaired cognition and required extensive assistance to total dependence of 1-2 people for bed mobility and transfers, was non-ambulatory and incontinent of bowel and bladder. She was at risk of pressure ulcer development and had no current pressure ulcers. The care plan reviewed on 9/30/21 included a focus area of risk for pressure ulcers related to a history of pressure ulcers to left great toe and left heel. Interventions included heel protectors to be worn every shift while in bed. Resident #43 ' s care guide listed heel protectors while in bed under skin precautions. The November 2021 physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/16/21 at 3:45 PM, Resident #43 was observed in bed with no heel protectors on. On 11/17/21 at 4:00 PM, Resident #43 was observed in bed with no heel protectors on. On 11/18/21 at 1:31 PM, Resident #43 was observed in bed with no heel protectors on. Two heel protectors were observed on the windowsill of the room. On 11/18/21 at 2:28 PM, NA #1 was interviewed. She stated Resident #43 does wear heel protectors. When asked why she wasn ' t wearing them, NA #1 stated the night shift gets her out of bed in the morning and takes them off. NA #1 added she does put the heel protectors on when she is assigned to the resident. On 11/18/21 at 11:45 AM, the Director of Nursing was interviewed. She stated the nursing assistants should be applying heel protectors and the nurses are responsible for making sure the care planned interventions are implemented. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #28 had severely impaired cognition, required extensive assistance of one person for bed mobility and eating, extensive assistance with two people for transfers and toileting. Resident #28 was always incontinent of bladder and frequently incontinent of bowel. Resident #28 was at risk for pressure ulcers and had no unhealed pressure ulcers during the look back period. Resident #28 ' s care plan (date not obtained) indicated a focus problem of pressure ulcers due to failure to thrive and weight loss. Interventions included treatments as ordered and float heels while in bed. Resident #28 ' s care guide for skin precautions listed float heels when in bed. On 11/17/21 at 4:00 PM, Resident #28 was observed in bed with his heels flat on the mattress and not floated. On 11/18/21 at 7:51 AM, Resident #28 was observed in bed with his heels flat on the mattress and not floated. On 11/18/21 at 11:01 AM, an interview was conducted with NA #2. She stated she has never floated Resident #28 ' s heels because the nurse has never told her to. She stated she went into his room and checked on him but has not floated his heels. On 11/18/21 at 11:45 AM, the Treatment Nurse was interviewed. She stated she has educated nursing assistants and nurses about Resident #28 needing to have his heels floated. On 11/18/21 at 11:45 AM, the Director of Nursing was interviewed. She stated the nursing assistants should be floating Resident #28 ' s heels and the nurses should be making sure care planned interventions are implemented.

Based on observations, resident and staff interviews, and record reviews, the facility failed to provide activities based on individual interest to include 1:1 activities and group activities for 1 of 1 sampled resident reviewed for activities. (Resident #38) Findings included: Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact and primarily dependent on staff for ADL's due to having impairments of both his upper and lower extremities. His daily preferences for his customary routine included significant importance of having a bathing preference, having reading material available, listening to music, participating in group activity, the ability to choose his favorite activity, go outside, and participate in religious services. The comprehensive plan of care revealed Resident #38 did not included a plan of care for activities. The activity interaction notes revealed Resident #38 was scheduled to have 25 activity interactions during the month of August; however, there was no documentation related to the resident receiving any activity interactions. The activity interaction note for the month of (MONTH) was not completed for review. A review of the social services notes revealed Resident #38 had no indicators of behaviors or refusals of care since admission. The documentation further revealed the social work interactions with Resident #38 were isolated to discharge planning. The physical therapy discharge summary revealed ability to be transferred safely to a wheelchair to improve Resident #38's functional mobility. During an observation on 9/16/19 at 11:38AM, Resident #38 was alone in his room lying in bed on his back with his knees bent to the side at a 90-degree angle. He was able to exhibit slight movement of his right foot. During an interview with Resident #38 on 9/16/19 at 11:38 AM, Resident #38 stated he has been in the bed since admission despite making request to get out of bed. He explained that he has not been allowed to interact with other members of this community in the facility. He explained he was a professor with a graduate degree and enjoyed interacting with people and writing. He revealed he had made request to get out of bed on multiple occasions but had been denied. He stated he would be in the bed the rest of his life and it made him feel disgusted and disappointed that staff did not get him out of bed, and it made him feel like he is just existing and has no quality of life. He stated he felt very depressed because he was in bed all the time and had limited visitors. He reported he was unable to transfer independently, he could not walk, and relied on staff for all activities of daily living. (ADL's) A second observation of Resident #38 on 9/17/19 at 5:03PM, revealed the resident alone in his room lying in bed. An interview with Nurse Aide #1 (NA) on 9/19/19 at 9:03AM revealed she was not aware if Resident #38 had been out of bed or attended activities since admission. She indicated she had never provided him with any activities. An interview was conducted with NA #2 on 9/19/19 at 9:30AM. During the interview she revealed she had never invited Resident #38 to activities or gotten him out of bed to attend any scheduled activities since admission. Interview with the Director of Nursing (DON) on 9/19/19 at 10:06AM revealed she was aware Resident #38 had not been out of bed since admission due to paralysis. She further stated that he was admitted with contact precautions, but they were discontinued on 8/27/19. She explained that all residents are to be offered activities and gotten out of bed to attend preferred activities. She was not aware of any activities Resident #38 had attended since admission. She further explained that she was aware that Resident #38 was more dependent on staff because he was not getting out of bed. During an interview with Social Worker #1 on 9/19/19 at 11:51 AM, she revealed she had met with Resident #38 in his room regarding discharge planning on several occasions. She further explained she was not aware any activities Resident #38 had attended. On 9/19/19, an interview was attempted with the Activity Aide for Resident #38's unit during the survey, but attempts were unsuccessful as the Aide was not working and unavailable. Telephone interview with the Life Enrichment Director on 9/19/19 at 3:20PM revealed she was the campus Activity Director. She stated she does not come to the skilled building and does not provide any activities for the skilled portion of the campus because they are assigned to the individual activity aide. She continued to explain the activity aide designated to Resident #38's skilled unit had been out on Family Medical Leave Act (FMLA) for the majority of September. She stated that the activity aide must provide her with a cumulative count sheet for activity interactions monthly. She stated these are to be broken down into the following individual or group categories: Personal, Social, Spiritual, and Intellectual interactions. She stated she was unable to provide any detail information of the activities provided or attended by Resident #38 as he was admitted in to the facility for short term rehabilitation care and his interactions were not listed on the (MONTH) monthly interaction report she was provided. She further stated that the units direct care staff should be providing activities to Resident #38. During interview with nurse #1 on 9/19/19 at 4:35PM, she revealed she was Resident #38's day shift nurse. She further stated Resident #38 had not attended any activities since he was admitted because he was initially on contact precautions for [MEDICAL CONDITION] and his paralysis. She further stated nursing and nurse aides do not provide any activities for Resident #38 due to him not getting out of bed or coming out of his room. Interview with the Administrator on 9/19/19 at 5:42PM revealed he was unaware of any in-room or group activities that Resident #38 had been offered or attended. He further revealed he would like for all residents to have enough engagement to attain or maintain a high quality of life and going forward he would formulate a resident specific plan for Resident #38's activities and ensure compliance with the regulation.

Based on observation, resident and staff interviews, and record reviews, the facility failed to honor a resident's preference for showers for 1 of 2 residents reviewed for choices. (Resident #38) Findings included: Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact, dependent on staff for bathing, and as having impairments of both his upper and lower extremities. His daily preferences for his customary routine was assessed as being significantly important to him in choosing between a tub bath, shower, bed bath, or sponge bath. The comprehensive plan of care dated 8/14/19 revealed Resident #38 was to have bathing, hygiene, dressing, and grooming provided per resident preference. Record review of the bathing assignment sheet revealed that Resident #38 was scheduled to receive showers/baths twice a week on Wednesday and Saturday. The physical therapy discharge summary indicated Resident's #38's has the ability to be safely transferred to a wheelchair to improve functional mobility and to allow for decrease physical dependence. During an observation on 9/16/19 at 11:38AM, Resident #38 was lying in bed on his back with his knees bent to the side at a 90-degree angle. He was able to exhibit slight movement of his right foot. During an interview with Resident #38 on 9/16/19 at 11:38 AM, Resident #38 stated he has only received sponge baths since his admission. He stated he had made repeated request since admission to get out of bed for showers; however, a shower had not been provided to him. He explained he lived alone and was independent with activities of daily living (ADL's) prior to his hospitalization earlier this year. He stated he would be in the bed the rest of his life and it made him feel disgusted and disappointed that staff did not get him out of bed, and it made him feel like he is just existing and has no quality of life. He reported he was unable to transfer independently, he could not walk, and relied on staff for all transfers and bathing. An interview with Nurse Aide #1 (NA) on 9/19/19 at 9:03AM revealed that she has only ever given Resident #38 a bed bath and has never offered him a shower. An interview was conducted with NA #2 on 9/19/19 at 9:30AM. During the interview she revealed she provided Resident #38 a bed bath on 9/18/19, which was a scheduled shower day. She further explained that she had always given him a bed bath and had never offered him a shower. An interview with nurse #1 on 9/19/19 at 9:48AM, she revealed she was Resident #38's day shift nurse. She stated Resident #38 had only received bed baths since he was admitted because he was initially on contact precautions for [MEDICAL CONDITION] and his paralysis. She further stated the facility did not have any other alternative equipment available for offering showers to residents with physical impairments. She stated he would need equipment that would allow him to shower without having to straighten his lower extremities and the facility did not have a shower bed or reclining shower chair that she was aware. She also revealed that he has become more dependent on staff for all his ADL's since admission due to not getting out of bed. Interview with the Director of Nursing (DON) on 9/19/19 at 10:06AM revealed she was aware Resident #38 had received only bed baths since admission. She further stated that the contact precautions for Resident #38 were discontinued on 8/27/19. Additionally, the DON indicated that all residents in the facility should be offered a tub bath or shower at a minimum of twice a week. She further explained that she was aware that Resident #38 was more dependent on staff because he was not getting out of bed. Interview with the Administrator on 9/19/19 at 5:42PM revealed he was unaware that Resident #38 had not been offered alternatives to bed baths. He further revealed he was unaware of any concerns that had been filed by Resident #38. He explained that Resident #38 would be offered alternatives to bed baths on his scheduled days with resident specific equipment to fit his needs.

Based on staff and family interviews and medical record review, the facility failed to notify the responsible party of an injury that occurred during a transfer for 1 of 3 residents (Resident #1) reviewed for notification of condition change. Findings included: 1. Resident #1 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired short term and long term memory and severely impaired decision making skills. He was totally dependent for transfers and required two persons to assist. A review of the care plan updated [DATE] revealed Resident #1 was at risk for falls and needed a full body lift for transfers. A care plan intervention with a start date of [DATE] included, Continue total mechanical lift for transfers. A review of an incident report dated [DATE] AT 6:30 PM revealed, Resident received bilateral lower extremity skin tear during transfer. Resident was placed in sit to stand for transfer by nurse's aide (NA). Resident received bilateral lower extremity skin tears to front of lower legs. This nurse cleansed area with normal saline, applied triple antibiotic ointment, and non-adherent dressing with tape. A review of a physician request form dated [DATE] revealed, Resident received bilateral lower extremity skin tears during transfer. Wound nurse notified. A review of a nurse's note dated [DATE] at 6:55 PM revealed, Spoke with resident's daughter about residents' skin tears. Reassured daughter that nurse's aide (NA) was educated on transfer technique, also that wound nurse was made aware. Ongoing monitoring to continue. A review of a nurse's note correction/addendum dated [DATE] at 3:15 PM revealed, Resident received bilateral lower extremity skin tears during transfer. Cleansed with normal saline, triple antibiotic ointment and island dressing applied. Resident tolerated well. Wound nurse notified, physician request form completed, oncoming nurse notified to contact family. An interview was completed with the Assistant Director of Nursing (ADON) on [DATE] at 4:37 PM. She reported that Resident #1 sustained some scrapes on his legs from where his legs pushed against the cushion of the sit to stand lift. An interview was completed with Resident #1's family member (Family Member #1) on [DATE] at 10:29 AM. She stated she was not notified by staff when the resident sustained [REDACTED]. She said she did not learn about the skin tears until she came to visit the next day and observed bandages around his legs and asked the nursing staff about the injury. An interview was completed with Nurse #2 on [DATE] at 11:35 AM. She stated Resident #1 required a mechanical lift with two person assist for transfers. She recalled she was at the nurse's station when NA #2 told her Resident #1 had skin tears on both of his shins from when she transferred him with the sit to stand lift. Nurse #2 said she assessed and treated the injury, emailed the wound nurse and completed an incident report. She stated she told the next shift nurse what happened and the oncoming nurse stated she would notify the resident's family member. Nurse #2 stated whenever there was a skin tear, fall or change in condition the responsible party/family member was to be notified. Nurse #2 further stated she couldn't remember if she was the nurse the family member approached and asked about how the resident obtained the skin tears. An interview was completed with Nurse #3 on [DATE] at 2:40 PM. She was the nurse who came on duty after Resident #1 sustained skin tears during a transfer. She stated Nurse #2 told her that staff used a sit to stand lift instead of a mechanical lift when Resident #1 was transferred. Nurse #3 said, It was passed on to me in report. It happened prior to my shift. Nurse #3 said she couldn't remember if Nurse #2 called and notified the family of the skin tears. Nurse #3 further reported she did not notify the family. She stated that a skin tear was something that needed to be communicated to the family and that she wasn't asked to call the family and assumed everything was taken care of. An interview was completed with the ADON on [DATE] at 3:25 PM. She stated she would have expected the nurse to notify Resident #1's family member of skin tears he sustained in the transfer. An interview was completed with the Administrator on [DATE] at 3:50 PM. He said he expected the nurse to have notified the family of the skin tears Resident #1 obtained when he was transferred.

Based on staff and family interviews and medical record review, the facility failed to follow the care plan to use a mechanical lift for transfers for 1 of 3 residents (Resident #1) reviewed for accidents. Findings included: 1. Resident #1 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired short term and long term memory and severely impaired decision making skills. He was totally dependent for transfers and required two persons to assist. A review of the care plan updated [DATE] revealed Resident #1 was at risk for falls and needed a full body lift for transfers. A care plan intervention with a start date of [DATE] included, Continue total mechanical lift for transfers. A review of an incident report dated [DATE] revealed, Resident received bilateral lower extremity skin tear during transfer. Resident was placed in sit to stand for transfer by nurse's aide (NA). Resident received bilateral lower extremity skin tears to front of lower legs. This nurse cleansed area with normal saline, applied triple antibiotic ointment, and non-adherent dressing with tape. An interview was completed with NA #1 on [DATE] at 3:58 PM. She stated that two staff were needed when either a sit to stand or mechanical lift was used for transfers. She said a resident's care plan was reviewed to determine what kind of help a resident required for transfers and included the type of lift that was used. An interview was completed with Resident #1's family member (Family Member #1) on [DATE] at 10:29 AM. She stated the resident had been transferred with a mechanical lift for about 18 months. Family Member #1 said that two people were supposed to help with transfers for Resident #1. An interview was completed with NA #2 on [DATE] at 11:18 AM. She said she had worked at the facility for [AGE] years and was currently employed on an as needed basis. She had worked with Resident #1 in the past when he used a sit to stand lift for transfers. NA #2 stated, When I transferred him I initially used a sit to stand lift because that's the lift he was on previously when I worked with him. NA #2 said she assumed the resident still used the sit to stand lift since that was what she used in the past. She stated she was not notified that he needed a total mechanical lift and said there was no information in his room that indicated what type of lift he needed for transfers. An interview was completed with Nurse #2 on [DATE] at 11:35 AM. She stated Resident #1 required a mechanical lift with two person assist for transfers. She said the information on how much help a resident needed with transfers was located on the care plan. She recalled she was at the nurse's station when NA #2 told her Resident #1 had skin tears on both of his shins from when she transferred him with the sit to stand lift. Nurse #2 said she informed NA #2 that Resident #1 required a mechanical lift for transfers and NA #2 told her she didn't know that information. Nurse #2 said she told NA #2 she needed to look at the care plans in the computer for the care information on the resident. An interview was completed with the MDS Nurse on [DATE] at 12:08 PM. She stated Resident #1 needed a total mechanical lift for transfers, not a sit to stand lift. She indicated information on transfers and lifts was on the paper care guides that were printed daily for NAs to use. She said the care plan reflected Resident #1 needed a total mechanical lift for transfers. An interview was completed with the ADON on [DATE] at 1:19 PM. She said she received a report that NA #2 had not worked with Resident #1 in a while and was not aware he had progressed to a mechanical lift and had instead, used a sit to stand lift when she transferred the resident. The ADON stated, We did an investigation and NA #2 said she didn't realize he was a mechanical lift at the time she transferred him. The ADON said information on transfers was in the care plan and care guides which were located in the computer system. She stated NA #2 should have gone in to look for the care plan and/or care guide and determined what kind of transfer help he needed so she could have used the appropriate equipment. A second interview as completed with the MDS Nurse on [DATE] at 3:00 PM. She said information on the type of lift needed for Resident #1 (mechanical lift) was updated on the care plan as of [DATE]. An interview was completed with the Administrator on [DATE] at 3:50 PM. He said he expected the staff to follow the care plan and use the correct lift to transfer Resident #1. He stated the facility met with the family after the incorrect lift was used and implemented corrections.

Based on staff and family interviews and medical record review, the facility failed to use two staff persons for transfers and failed to use the correct lift device according to the plan of care which resulted in skin tears to bilateral shins for 1 of 3 residents (Resident #1) reviewed for accidents. Findings included: 1. Resident #1 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. A review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired short term and long term memory and severely impaired decision making skills. He was totally dependent for transfers and required two persons to assist. He had impairment on one side of his upper extremity and impairment on both sides of his lower extremities. A review of the care plan updated [DATE] revealed Resident #1 was at risk for falls and needed a full body lift for transfers. A care plan intervention with a start date of [DATE] included, Continue total mechanical lift for transfers. A review of an incident report dated [DATE] revealed, Resident received bilateral lower extremity skin tear during transfer. Resident was placed in sit to stand for transfer by nurse's aide (NA). Resident received bilateral lower extremity skin tears to front of lower legs. This nurse cleansed area with normal saline, applied triple antibiotic ointment, and non-adherent dressing with tape. An interview was completed with NA #1 on [DATE] at 3:58 PM. She stated that two staff were needed when either a sit to stand or mechanical lift was used for transfers. She said a resident's care plan was reviewed to determine what kind of help a resident required for transfers and included the type of lift that was used. An interview was completed with the Assistant Director of Nursing (ADON) on [DATE] at 4:37 PM. She reported that Resident #1 sustained some scrapes on his legs from where his legs pushed against the cushion of the sit to stand lift. An interview was completed with Nurse #1 on [DATE] at 4:35 PM. She said that information on transfer needs were listed on care guides which were printed every night for the following day. She stated the NAs picked up a care guide in the morning when they came on duty. An interview was completed with Resident #1's family member (Family Member #1) on [DATE] at 10:29 AM. She stated the resident had been transferred with a mechanical lift for about 18 months. Family Member #1 said that two people were supposed to help with transfers for Resident #1. An interview was completed with NA #2 on [DATE] at 11:18 AM. She said she had worked at the facility for [AGE] years and was currently employed on an as needed basis. She had worked with Resident #1 in the past when he used a sit to stand lift for transfers. NA #2 stated, When I transferred him I initially used a sit to stand lift because that's the lift he was on previously when I worked with him. NA #2 said she assumed the resident still used the sit to stand lift since that was what she used in the past. She stated she was not notified that he needed a total mechanical lift and said there was no information in his room that indicated what type of lift he needed for transfers. NA #2 stated she used the sit to stand lift by herself to transfer Resident #1. She reported she had him strapped in very secure and as I began to use the lift to transfer him, his feet lifted up off the platform. She stated Resident #1's shins ended up on top of the cushion instead of resting against the cushion and he sustained skin tears to both of his shins. NA #2 said she then opened the door to the room and called for another NA to help. NA #2 further stated, I was always under the impression that it was a one person transfer but was educated that it was a two person. NA #2 said she immediately told the nurse about the skin tears once she assisted Resident #1 into a comfortable position. An interview was completed with Nurse #2 on [DATE] at 11:35 AM. She stated Resident #1 required a mechanical lift with two person assist for transfers. She said the information on how much help a resident needed with transfers was located on the care plan. She recalled she was at the nurse's station when NA #2 told her Resident #1 had skin tears on both of his shins from when she transferred him with the sit to stand lift. Nurse #2 said she informed NA #2 that Resident #1 required a mechanical lift for transfers and NA #2 told her she didn't know that information. Nurse #2 said she told NA #2 she needed to look at the care plans in the computer for the care information on the resident. Nurse #2 further stated that Resident #1 had contractures and there was No way he could have gripped the hand rails because of the contractures in his hands and legs. An interview was completed with the MDS Nurse on [DATE] at 12:08 PM. She stated Resident #1 needed a total mechanical lift for transfers, not a sit to stand lift. She indicated information on transfers and lifts was on the paper care guides that were printed daily for NAs to use. She said the care plan reflected Resident #1 needed a total mechanical lift for transfers. A second interview was completed with the ADON on [DATE] at 1:19 PM. She said she received a report that NA #2 had not worked with Resident #1 in a while and was not aware he had progressed to a mechanical lift and had instead, used a sit to stand lift when she transferred the resident. The ADON stated, We did an investigation and NA #2 said she didn't realize he was a mechanical lift at the time she transferred him. The ADON said information on transfers was in the care plan and care guides which were located in the computer system. She stated NA #2 should have gone in to look for the care plan and/or care guide and determined what kind of transfer help he needed so she could have used the appropriate equipment. A second interview as completed with the MDS Nurse on [DATE] at 3:00 PM. She said information on the type of lift needed for Resident #1 (mechanical lift) was updated on the care plan as of [DATE]. An interview was completed with the Administrator on [DATE] at 3:50 PM. He said he expected the staff to follow the care plan and use the correct lift to transfer Resident #1. He stated the facility met with the family after the incorrect lift was used and implemented corrections.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) for the presence of behaviors on the MDS assessments for 2 of 5 residents reviewed for unnecessary medications. (Resident #107, Resident #15) Findings included: 1.) Resident #15 was admitted to the facility 10/22/13. Active [DIAGNOSES REDACTED]. Review of Resident #15's observation reports dated 2/3/17, 2/4/17, 2/6/17, and 2/7/17 revealed Resident #15 had behaviors of delusions daily. Review of Resident #15's most recent Minimum Data Set assessment dated [DATE] coded as a quarterly assessment revealed the resident was assessed as severely cognitively impaired. Resident #15 was assessed to have no behaviors or delusions. During an interview on 5/24/17 at 2:48 PM Nurse Aid #1 stated Resident #15 had, in the past, had delusions often. During an interview on 5/25/17 at 11:40 the Social Worker stated that she reviewed the resident's nurse's notes and filled out section E for behaviors of the Minimum Data Set assessments. She further stated that if a resident did have behaviors of delusions she would capture that in the Minimum Data Set. She further stated that she completed the Minimum Data Set for Resident #15 dated 2/8/17. The Social Worker, upon review, stated that the assessment dated [DATE] should have reflected Resident #15's delusions. During an interview on 5/25/17 at 1:08 PM the Director of Nursing stated that if a resident did exhibit behaviors during the look back window of a Minimum Data Set assessment then she would expect it to be reflected in that MDS assessment. She further stated that the MDS dated [DATE] should have reflected Resident #15's documented behavior of delusions. 2.) Resident #107 was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Review of Resident #107's behavior report from 2/16/17 to 2/22/17 revealed on 2/18/17 and 2/22/17 the resident was physically resistant to care. Review of Resident #107's most recent Minimum Data Set assessment dated [DATE] coded as an annual assessment revealed Resident #107 was assessed to have not rejected care during the previous seven days. During an interview on 5/24/17 at 2:38 PM Nurse #3 stated she had worked in the facility since January and that Resident #107 had refused care often during his stay. During an interview on 5/24/17 at 2:48 PM Nurse Aid #1 stated Resident #107 would often refuse care a few times a week and had behaved that way since he had been at the facility. During an interview on 5/25/17 at 11:40 AM the Social Worker stated that she reviewed the resident's nurse's notes and filled out section E for behaviors of the Minimum Data Set assessments. She stated she did not use the nurse aid documentation because the nurse aids told the nurses about rejection of care and the nurses would put that information in the nurse ' s notes. She further stated that if a resident rejected care she would capture that in the Minimum Data Set assessment. The Social Worker, upon review, stated that the assessment dated [DATE] should have reflected Resident #107 ' s rejection of care of and did not. During an interview on 5/25/17 at 1:08 PM the Director of Nursing stated that if a resident did exhibit behaviors during the look back window of a Minimum Data Set assessment then she would expect it to be reflected in that MDS assessment. She further stated that the MDS dated [DATE] should have reflected Resident #107's documented behavior of rejecting care.

Based on observation, record review and staff interview, the facility failed to: wash dishes at the proper temperature and effectively sanitize dishes running through the dish machine; and prepare the three compartment sink with sanitizer for one of two opportunities to observe dishwashing and 79 of 79 residents. Findings included: 1. On 6/3/15 at 1:14 P.M. dietary staff were observed in the process of washing dishes. The dish machine was set up as a high temperature dish machine (heat sanitization). The machine had three dial gauges to read wash, rinse and final rinse temperatures. In addition, the vendor had installed a digital monitor that provided digital temperature readings and other information to analyze performance of the machine. Both dial and digital readings appeared to be close. Manufacturer ' s information indicated that operating temperatures for high-temp machines indicated wash temperatures at 160 degrees Fahrenheit (F) and sanitizing rinse at 180 degrees F. During observations between 1:14 P.M. and 1:27 P.M., wash temperatures reached 127 degrees. Final rinse temperatures were around 165 degrees F, except for a duration of a couple of seconds when it climbed to 179.5 degrees F, as several racks of dishes and cutlery were passed through the machine. It could not maintain and reach 180 degrees F. The Executive Chef (EC) had the dishwashing staff to drain and then refill the machine. No effective change was noted in the temperatures. The dish machine temperature log was reviewed. There were no lunch dishwashing temperatures recorded. There was a morning log entry that recorded a 165 degree wash and a 190 degree final rinse temperature. The Executive Chef said the dish machine was only about six months old and was a water efficient model. The EC said he would have to call the vendor to service the machine. On 6/4/15 at 8:57 A.M. a second observation of dishwashing was made. The Director of Dining Services said the problem was worked on with the vendor yesterday until about 7:30 P.M. last night. He reported scores of cycles ran at the appropriate temperature with intermittent lower temperatures. He said plumbers were working on the problem now and they think cold water is mixing in. Observation revealed water coming in through the hot tap across from the dish machine had cold water flowing from it. He said the wash tank is on a separate element and is running okay. He said, It's been fine, but just a few minutes ago, it was not at the right temperature. Plumbing engineers were here early. We are getting ready to wash by hand. We also have electrical engineers here. We were getting ready to call the folks who service the booster heater. When the Director of Dining Services was told that staff did not log the temperatures prior to washing lunch dishes, he said, The alarm did not go off. Interview with the dish machine vendor on 6/4/15 during the 8:57 A.M. observation of the kitchen revealed he was servicing the machine. He said the digital device helps him analyze the performance of the dish machine. He said that he could read information from June 3, 2015 that indicated low wash and rinse temperatures around 12:15 P.M. He said water should come in around 135 degrees or higher in the wash tank. Interview with the administrator on 6/4/15 at 10:36 A.M. revealed, We are washing dishes in a three compartment sink and converting to a low temperature machine. 2. On 6/1/15 at 10:33 A.M. water was tested in the three compartment pot washing sink. The facility used a quaternary ammonia product. A test strip revealed no color change when it was dipped into the third sink. The pot washer then drained the water from the sink and dispensed sanitizer into the sink. A retest showed an appropriate amount of sanitizer in the range of 200 - 400 parts per million. On 6/3/15 at 1:27 P.M., the third sink of the three compartment sink was prepared with the appropriate amount of sanitizer. The reading was between 200- 400 parts per million.

Based on policy review, observations, and interviews the facility failed to dispose of expired medications in one of three Medication Rooms (located on the 200 hall) and one of eight Medication Carts (located on the 200 hall, Cart #2). Findings include: The facility ' s policy titled Storage of Medications , dated 01/01/2009, read in part: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. 1.a An observation made on 06/02/2015, at 8:45 AM of the 200 Hall Medication Room revealed 1 vial (10 ml) of sterile water that showed an expiration date of 06/01/2013. The vial was observed in a plastic storage bin labeled IV (intravenous) supplies . The storage bin was located on the left side of the room on top of a two drawer filing cabinet. The observation also revealed 1 plastic bag of injectable Levaquin (antibiotic), with an expiration date of 03/11/2015. The Levaquin was located in a locked cabinet which contained a supply of intravenous fluids and medications. b. An observation made on 06/02/2015, at 9:30 AM of a Medication Cart, (Cart #2), on the 200 Hall revealed a 2-pack of Epi-Pens, (Epinephrine Injections), with an expiration date of 03/31/2015. The pens were located in the bottom drawer of the cart. On 06/02/2015, at 8:50 AM, the Director of Nursing, (DON), stated that the plastic storage bin containing the vail of sterile water contained overflow IV supplies , and that it was created by a staff member a number of years ago, but was no longer used for anything except holding extra supplies. The DON further stated that it was possible that a staff member might use those supplies. On 06/02/2015 at 3:40 PM an interview was conducted with the facility Director of Nursing and the facility Pharmacist. The DON stated that the facility pharmacy provided the policy regarding the medication storage and expired medications and that they, (pharmacy), were responsible for reviewing and updating the policy. The DON further stated that the pharmacy is responsible for medications in the facility and that the pharmacy sent a Quality Assurance Nurse Consultant, to the facility and that she was responsible for checking all medications for date and quality. The DON said that the third shift, (11:00 PM-7:00 AM), nurses were responsible for checking medication in the carts and the medications rooms every Monday, Wednesday and Friday evenings. She stated that it was the expectation of the facility that all staff check medications for date before using and to remove any expired medications as soon as they were identified. She said that she did not think it was likely that any expired medication would be used by a staff member but that it was technically possible. The Pharmacist started that a Nurse Consultant came into the facility monthly to review and update medications. She also stated all staff, including herself, were responsible for checking every medication before use. The pharmacist stated that it was possible for an expired medication left in the supply to be used by a staff member.

Based on observation and interviews, 2 of 4 medication nurses failed to follow the facilities hand washing policy and procedures while administering medications. The policy Infection Control- Hand Hygiene dated 9/25/2009 and reviewed December 2010 was provided by the facility revealed in part, ? Hand hygiene shall be practiced before and after each resident contact( even if gloves are worn). ? For routine resident care (contacts) liquid lotion soap in the dispenser shall be used for hand washing. ? Antiseptic (antimicrobial) hand washing products or alcohol hand rub shall be used for hand hygiene prior to performance of high risk procedures, Hand hygiene will be performed after contact with residents or their environment. ? Gloves shall be worn when exposure to blood or any other body fluids, excretions or secretions is likely. ? For a given resident, site care shall start at the cleanest site (e.g., mouth care) and progress to the dirtiest site (e.g., urinary catheter care). When going from a dirty site to a clean site, hands shall be washed or an alcohol hand rub applied between sites. ? Use of alcohol hand rubs may result in a sticky residue on the hands. Wash with soap periodically to remove the hand rub residue. The policy and procedure provided by the facility dated April 2011 and entitled Preparation and general guidelines IIA 2: Medication Administration -General Guidelines, revealed in part: Procedures A. #2 The person administering medications adhere to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal and [MEDICATION NAME] preparations and medications given via enteral tubes. Examination gloves are worn when necessary (refer to specific administration procedures for each route). #8 Hands are washed before and after and examination gloves worn for administration of topical, ophthalmic, injections, enteral, rectal, and vaginal medications. 1.During observation of medication pass on 1/10/12 beginning at 3:32pm, nurse #1 passed oral medication to Resident #31,the head of the bed was raised the call bell was touched to orient resident to placement, and the door knob when leaving the room. Nurse #1 then went to the medication cart documented the medication then began removing the medication for Resident #21 these medications were discarded, Resident #21 was not available. Nurse #1 then checked the next resident was in their room and began to retrieve the medications for Resident #22 at 3:36 pm. The medication was poured and administered; the call bell was touched as was the bed and the door. Nurse #1 then returned to the cart documented and began to pour medications for Resident #42, an oral mouthwash in which Resident#42 spit back into the cup held by nurse #1. The eye drops were administered using bare hands and a tissue by nurse #1. No hand washing or use of hand sanitizer was observed during the medication pass by nurse #1. During an interview with nurse #1 on 1/10/12 at 3:53pm, indicated hand washing or use the antiseptic gel should be done between each patient. 2.During a med pass observation on 1/11/12 at 8:50AM Nurse # 4 was observed administering both oral medications and eye drops to Resident #31. Nurse#4 applied gloves and then proceeded to reposition the resident, raise and lower the head of the bed and then assist the resident in taking the oral meds. The nurse still wearing the same gloves administered eye drops without washing her hands or changing her gloves. Nurse #4 on 1/11/12 at 10:20am performed chest clapping, cleansed and redressed the PEG (Percutaneous Gastrostomy Tube) site for Resident #18. The nurse still wearing the same pair of gloves administered the ordered medications via the PEG without washing her hands or changing her gloves. During an interview on 1/11/12 at 11:48am, the director of nursing indicated the use of hand sanitizer was to be used between resident contact and between resident tasks.

Based on observation, staff interviews and documentation, the facility failed adequately to monitor food storage areas and failed to store pans dry. 1. During the initial tour on 2/7/11 beginning at 6:26 PM, one reach-in cooler contained a container of chili dated "1/28" and one pan of gelatin dated "2/2". Another reach-in cooler contained had a container of bing cherry filling dated "1/25". The walk-in cooler contained 2 containers of punch with no date. The Dietary Director stated during an interview on 2/7/11 at 6:31 PM that items which are out-dated are thrown out each Tuesday. Foods were to be used by 3 days or discarded. He stated that the chefs check foods to be discarded. A chef was interviewed on 2/8/11 at 11:17 AM. He stated that foods which have been cooked have a shelf life of 3 days. He stated that the left over foods were not being monitored but should have been gone through daily. 2. On 2/8/11 beginning at 11:00 AM, 21 of 49 tray pans stacked on top of one another in storage were wet inside. During an interview with a dishwasher on 2/8/11 at 11:10 AM, he stated that he had been taught to let pans air dry before stacking. The Dietary Director stated during an interview on 2/9/11 at 11:14 AM that staff have been trained that pans are to air dry before being stacked for storage.

Based on observations, staff interviews, and record review, the facility failed to provide privacy of residents' Medication Administration Records (MAR) for 1 of 10 residents. (Resident #5) During a medication pass on 2/9/2011 at 8:00 AM, Nurse # 2 was observed in Resident #6 's room away from her assigned medication cart. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR for the resident receiving medication was observed to be uncovered. The resident's personal information was open to full view. Other residents, visitors, and staff were observed to be in the hallway with access to the MAR indicated [REDACTED]. The resident's name, date of birth, diagnoses, medications and allergies [REDACTED]. Staff nurse # 1was interviewed on 2/9/2011 at 6:10 PM. He indicated medication nurses are expected to keep the resident's personal information safe during medication pass. He stated the MAR indicated [REDACTED]. During an interview with the Director of Nursing on 2/9/2011 at 8:00 PM she stated it was her expectations nurses would follow facility protocol during medication administration and keep the MAR indicated [REDACTED].

Based on observation, record review and interviews, the facility failed to promote resident dignity while dining by standing over 1 of 1 sampled resident needing feeding assistance during 2 of 3 meal observations in the dining room. (Resident #4) Findings include: Resident #4 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A significant change MDS was completed on 10/22/10 and noted that Resident #4 required supervision for eating with 1 person physical assist. The resident's most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated that he needed supervision for eating with set up help and that the resident had lost weight and was not on a physician prescribed weight loss regimen. The clinical record included the Resident Assessment Protocol (RAP) summary dated 10/28/10. For ADL (Activities of Daily Living)/Falls and [MEDICAL CONDITION] Drug Use, it stated: "Resident triggered due to needing supervisions with eating, extensive assist with bed mobility and totally dependent for locomotion, dressing, eating, toilet use and hygiene." The Care Plan for ADLs dated 10/28/10 listed as an approach: "Provide the assistance of 1-2 people with ADLs daily as necessary, encouraging him to participate as much as possible, allow him extra time to perform tasks." This was reviewed on 1/14/11 with a note to continue care plan x (times) 90 days. The Care Plan for Nutrition dated 10/22/10 listed as an approach: "Allow resident adequate time to eat if cannot fed self-feed meals." This was reviewed on 1/6/11 with a notation to "continue goal and approaches." During breakfast on 2/9/11 in the dining room, Nurse #6 was observed at 8:23 AM standing by the resident as she fed him bites of his breakfast. She continued to feed him until he asked for more juice. At that time, she left and went over to prepare him thickened juice. At 8:29 AM, Nurse #6 was observed to return to Resident #4 and lean on the corner of the table with her left hand and used her right hand to feed the resident. The resident picked up a spoon from the table and began to get food off his plate and fed himself a bite of food. Nurse #6 then fed the resident another spoon of food after he began to self feed. Resident #4 then picked up his cup and took a sip of juice. Nurse #6 left the resident at this time to prepare coffee for another resident. At 8:35 AM, Nurse #6 returned to Resident #4's side. She stood by his chair, leaning on the arm of his wheel chair, as she began feeding him again. Nursing Assistant (NA) #3 went over to Resident #4 during this breakfast on 2/9/11 at 8:39 AM and stood over him, giving him juice and feeding him food as she rested her hand on the back of his chair. During lunch on 2/9/11, Nurse #2 was observed at 12:02 PM standing over Resident #4 as he ate his meal. She continued standing over him, talking to him and prompting him to eat more while he fed himself. Nurse #2 was interviewed on 2/9/11 at 8:49 AM. She stated that Resident #4 was able to feed himself most of the time, but that he had to be prompted to eat more. She stated that he got tired easily and would quit eating. She stated he usually started out feeding himself and then staff takes over to help him to eat more. NA #2 stated that Resident #4 will start feeding himself and then he would stop eating. She stated that when staff asked him if he wanted help, he would allow staff to feed him. She stated that when he was being fed, staff was to get at his eye level and feed him until he told them he was finished. The Director of Nursing (DON) stated on 2/9/11 at 5:30 PM that it was expected that staff who feed or assist residents with their meals would sit at eye level with the resident while feeding or assisting.

Based on observations, interviews with staff and record review the facility failed to include the resident in the care plan meeting for 1 of 10 residents (Resident #15). Findings include: 1. a. Resident # 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment completed on 12/8/10 revealed the resident had decreased communication skills in the areas of speech A significant change resident assessment instrument (RAI) was completed on this resident 9/17/2010. The RAI indicated the resident had adequate vision which enabled her to see fine detail including regular print and newspapers. The quarterly assessment completed on 12/8/10 indicated the resident had decreased communication skills in the areas of speech clarity and the ability to understand others or have others understand her. Observations of the resident on 2/7/2011 at 6:15 PM, on 2/8/2011 at 12:15 and 4:40 PM and on 2/9/2011 at 9:00 AM revealed the resident was able to verbally communicate the words " yes " , " no " , and " hello " in a garbled form. The rest of the resident's speech pattern consisted of repetitive sounds of " ga, ga, ga " . The quarterly assessment also revealed the resident's vision had deteriorated to highly impaired, indicating the resident's ability to identify objects in her environment was in question but the resident's eye movements appeared to be following objects. The usual test for vision on the RAI was to have the resident to read some type of printed material. The RAI stated residents who were unable to communicate should be observed for eye movements to see if their eyes followed movements of objects or people. This provided a gross measure of visual acuity. An interview was conducted on 2/9/11 at 1:10 PM with Nurse #5 who assessed the resident for the significant change and quarterly review. She indicated the resident was assessed on 9/17/2010 by observation of her moving about in her environment. The assessment conducted on 12/8/2010 was an actual physical test which utilized eye movements and provided a more detailed evaluation. The more detailed visual evaluation done on 12/8/2010 indicated to Nurse #5 the resident's visual acuity had declined. Care plans updated and signed off by staff as approved on 12/14/2010 were reviewed on 2/8/2011 at 8::55AM. No care plan had been initiated for the change in vision since the last RAI on 9/17/2011. The change of vision was not addressed in the interventions for fall prevention. The care plan noted the resident had fallen on 1/28/11 and 1/29/11. 1. b Resident # 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change resident assessment instrument (RAI) was completed on this resident 9/17/2010. A quarterly review RAI was conducted on 12/8/10 which indicated the resident had increased in her abilities to comprehend, had intact short and long term memory, and assisted staff with her activities for daily living. The quarterly assessment revealed the resident had decreased communication skills in the areas of speech clarity and the ability to understand others or have others understand her. Observations of the resident on 2/7/2011 at 6:15 PM, on 2/8/2011 at 12:15 and 4:40 PM and on 2/9/2011 at 9:00 AM revealed the resident was able to verbally communicate the words " yes " , " no " , and " hello " in a garbled form intermittently. The rest of her speech pattern consisted of repetitive sounds of " ga, ga, ga " . A review of the resident's medical record on 2/8/2011 at 11:25 AM revealed a doctor's order written on 11/22/10 that instructed, " DO NOT WEAR SHOES " . The order was written in capital letter and underlined on the order form signed by the MD. Further review of the record revealed an order on 9/17/2010 to " Leave R shoe off to relieve pressure. Heels floated. TEDs (pressure stockings) as ordered " No order to discontinue the TED hose or to allow shoes was found in the medical record. Observations of the resident on 2/7/2011 at 6:15 PM in her motorized wheelchair, on 2/8/11 at 12:15 PM at her bedside, at 2/8/11 at 4:40 PM in the unit TV area, and 2/9/11 at 12:20 PM in the beauty shop revealed the resident was wearing shoes but no TED hose. Care plans updated and signed off by staff as approved on 12/14/2011 were reviewed on 2/8/2011 at 8:55AM. Interventions listed under falls included - DO NOT WEAR SHOES - MD order. Interventions listed under the care plan for incontinence and skin care included TEDS as ordered, leave R shoe off to relieve pressure, and heels floated. These same interventions were listed on the back of the resident's closet door. Staff called these the " closet care plans " . These interventions were intended for the daily care of the resident by Nursing Assistants (NA). On 2/9/2011 at 12:00 PM NA # 2 was interviewed while assisting Resident #5 in her room. NA # 2 indicated she had taken care of the resident several times. She stated the resident always wore shoes. The NA reported she did not know anything about TED hose for the resident and had never seen her wearing them. On 2/9/2011 at 12:20 PM the Unit Manager was asked to review the MD orders for shoes and TED hose. She stated there were no orders to discontinue the TED hose or to allow the resident to wear shoes. The Manager revealed Resident #5 had a stasis ulcer on her right lower leg that had been healed for some time. She indicated if the resident did not wear TEDs then the doctor needed to discontinue the order. The Unit Manager stated the resident often refused care and probably wanted to wear her shoes. On 2/9/2011 at 2:00 PM the DON stated NA #2 had not been working at the facility but a few weeks. She indicated the NA was probably nervous and made statements about Resident #5 she was not sure about. NA #2 later stated she had only had Resident #5 two or three times and was not as familiar with her care as some of the other staff. NA #2 revealed the resident had not worn any TED hose the times she cared for her and always wanted to wear shoes. NA #2 stated Resident #5 would point at the shoes and indicate she wanted to wear them. Nursing Assistant (NA) #1 was interviewed on 2/9/2011 at 3:00 PM. NA # 1 was a primary care giver for Resident #5. The NA stated the resident did not always wear shoes. NA revealed Resident #5 had many friends in the facility. She indicated the resident probably did not want her friends to see her without shoes so she requested staff to put them on. NA #1 reported the resident became very upset if she could not wear the shoes or other items she preferred. The NA noted the resident often refused care and did not like to wear the TED hose. She reported the resident had refused to wear the hose and no pressure stockings had been in her room for a long time. NA #1 stated Resident #5 would take the TED hose off and throw them in the trash can. An interview with the Director of Nursing (DON) on 2/9/2011 at 8:00 PM revealed it was her expectation staff would report any refusals or resident requests that contradicted the care plan and have the doctor either discontinue the order or the care plan would be updated.