Every finding on record at San Luis Transitional Care

Based on observation, interview and record review, the facility failed to maintain one of one evaporative cooler (a device for cooling air) located in the kitchen, in safe operating condition when the manufacturer's recommended preventive maintenance was not performed. This failure had the potential for the unit to transmit mold, mildew, bacteria, and other allergens on resident's food and affect the facility's indoor air quality resulting in respiratory issues or exacerbating existing health conditions for residents and staff.During a concurrent observation and interview on 7/30/25 at 4:48 p.m. with Maintenance Director (MD), an evaporative cooler was observed to be located on a kitchen window that was blowing air directly on clean dishes and towards the stove cooking area. MD stated the filters are changed every six months but could not provide maintenance records for the evaporative unit. MD stated the filter cleaning/replacement is not documented. During a concurrent interview and record review on 7/31/25 at 09:15 a.m., with MD, the facility's policy and procedure (P&P) titled Heating, Ventilation and Air Conditioning Systems, undated, and the manufacturer maintenance instructions (MMI) titled Bonaire [NAME] 4500E Owner's Manual, undated, were reviewed. The P&P indicated in part, Policy: It is the policy of this facility to properly maintain and service the heating, cooling, and ventilation system(s) as to ensure a comfortable environment for our patients as free as possible of air pollutants and odors .Procedure: Air filters and Air Record - check all air filters monthly .Record inspection, cleaning, and/or replacement, and the date in the Maintenance Log and Air Filter Log. The MMI indicated in part, Gently hose down pads from both sides to remove any buildup of salts, dust and pollen.Check the water distributor, making sure it is clear and free from blockage.Keep the water tank clean and free from sediment and algae growth.Check that the fan spins freely and that there is no build up on the blades. Check the motor for corrosion and spray with an anti-corrosive agent if necessary . MD acknowledged and confirmed the facility is not performing the preventive maintenance that is listed on the Bonaire [NAME] MMI.

Based on record review, observation, and interview, the facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections when staff did not follow handwashing protocol per infection control standards to provide hand hygiene to five of eight sampled residents (Residents 25, 24, 2, 9 and 7) before residents began eating their lunch.These facility failures had the potential to transmit and spread infection to residents, visitors, and staff.During an observation on 7/28/25 at 12:11 p.m., Certified Nursing Assistant (CNA 1) placed a lunch tray on Resident #25's bedside table and did not offer hand sanitizer or hand washing before the resident started eating. Subsequently, observed Registered Dietitian (RD) distribute Resident 7's meal tray and did not offer hand sanitizer or hand washing. During an interview on 7/28/25 at 12:30 p.m. with Resident #24, the resident stated staff normally do not offer handwashing before or after meals. During an observation on 7/30/2025 at 12:05 p.m. during meal tray distribution, RD distributed meal trays to Residents #2 and #9. The residents began eating their meals and RD walked out of the rooms without offering hand hygiene. During an interview on 7/30/2025 at 12:15 p.m. with RD, the RD acknowledged hand sanitizer and hand washing was not offered to Residents #2 and #9 when meal tray was distributed. During a concurrent observation and interview on 7/30/2025 at 12:33 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 wheeled Resident #24 to room upon arrival to the facility from a doctor's appointment. CNA 2 positioned the resident to eat lunch, removed the meal tray lid, and offered to heat the food as the meal tray had been sitting on the bedside table for approximately 20-30 minutes. Resident 24 lifted the hamburger bun with uncleaned right hand and with the other hand touched the meat patty and said, You don't need to warm it up, it still feels warm. CNA 2 acknowledged hand washing or hand sanitizer was not offered before Resident 24 touched the food. During a review of the facility's policy and procedure (P&P) titled Standard Precautions, dated 2001, the P&P indicated in part, a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water.b. Hand hygiene is performed with ABHR or soap and water.g. Personnel assist the residents with hand hygiene before meals, after toileting and when indicated.

Based on observation, interview, and record review, the facility failed to ensure one expired package of Maxorb II alginate wound dressing (material applied directly onto an open wound to keep the wound clean and promote healing) was discarded and not readily available for staff use. This failure had the potential for residents to receive expired and ineffective wound dressings. During a concurrent observation and interview on [DATE] at 11:20 a.m., with the Director of Nursing (DON), one open package of Maxorb II Alginate wound dressing with an expiration date of [DATE] was observed stored in the treatment cart. DON acknowledged the Maxorb II Alginate wound dressing is expired and should have been discarded. DON stated, it was missed. During a review of the facility's policy and procedure (P&P) titled, Medication Storage: ID1: Storage of Medications, dated [DATE], the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers .are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a tool used to assess all residents in Medicare or Medicaid certified nursing homes) assessment accurately reflected the assessment for 2 of 8 sampled residents (Resident 11 and Resident 24) when:1. Resident 11's functional limitations in range of motion indicated the resident had no impairment for upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, ankle, foot).2. Resident 24's functional limitations in range of motion indicated the resident had upper extremity limitations but no impairment in the lower extremities. These failures had the potential to result in inaccurate care plans, inappropriate interventions, and unmet needs. 1. During a review of Resident #11's admission Record (AR), dated 7/30/25, the AR indicated the diagnoses included a fracture (a break in a bone) of left pubis (pubic bone on the pelvis area), acute pain due to trauma, history of falling and difficulty walking. During a review of Resident 11's Physical Therapy (PT) notes, dated 7/9/25 - 8/07/25, indicated the resident functional mobility assessment as follows:Bed mobility (roll left to right, sit to lying, lying to sitting on side of bed): substantial/maximal assistanceTransfers (sit to stand, chair/bed to chair transfer): Partial/moderate assistanceAmbulation (walk): Dependent During a review of Resident 11's MDS section GG for Functional Abilities, dated 7/11/25, section GG0110 indicated there was no range of motion limitations for upper (arms, hands, and shoulders) and lower (legs, feet, and hips) extremities which were contrary to the PT notes. 7/30/25 10:03 AM During a concurrent interview and review on 7/30/25 at 10:03 a.m. with Director of Nursing (DON), Resident 11's MDS section GG0110 was reviewed. The DON stated MDS section GG0110 was coded incorrectly and confirmed Resident 11 had lower extremity range of motion limitations from the pubic bone fracture and GG0110 should have been coded as a one for lower extremity impairment on one side. 2. During a review of Resident #24's admission Record (AR), dated 7/30/25, the AR indicated the diagnoses included encounter for surgical after care following surgery of the circulatory system (heart, blood vessels, blood, lymph, and lymphatic vessels and glands), embolism (obstruction by a clot of blood or air bubble) and thrombosis (a clot obstructing blood flow) of lower extremity arteries, and unspecified atherosclerosis of right leg arteries. In further review of Resident 24's History and Physical (H&P), dated 7/19/25, the H&P indicated the resident was discharged from the hospital post thromboembolectomy (surgical removal of a blood clot) with staples intact in the right groin/thigh area. During a review of Resident 24's MDS section GG for Functional Abilities, dated 7/20/25, section GG0110 was coded as 1 meaning impairment on one side of upper extremity and the lower extremity was coded as 0 meaning no impairment on either side. During a concurrent interview and record review on 7/30/25 at 3:56 p.m. with DON and Assistant Administrator (AA), Resident #24's MDS section GG0110 dated 7/30/25 was reviewed. The DON stated that Resident 24 does not have upper extremity ROM limitations but does have lower extremity range of motion limitations on one side due to post femoral (relating to femur or thigh) surgery. AA stated the MDS was not coded appropriately - upper extremity should have been coded as zero for no impairment and lower extremity should be coded as one for one side impairment. During a review of the facility's policy and procedure (P&P) titled, MDS Policy, dated October 2024, the P&P indicated Staff assigned to complete designated sections of the MDS assessments and tracking forms will do so following the coding guidance and instructions of the MDS 3.0 RAI User's Manual to insure OBRA and PDPM compliance for timeliness and accuracy of assessments.MDS nurses and coordinators will.communicate this to designated facility staff in a timely manner following established procedures. MDS Sections are assigned as follows.GG - Qualified clinicians including MDS nurse, Rehab lead or designee, DON or DON designee.

Based on observation, interview, and record review, the facility failed to have the most recent recertification survey results posted and readily accessible to residents, family members, and to the resident's legal representatives.This facility failure denied the opportunity for residents, family members, and resident legal representatives to be aware of the facility's survey results.During a concurrent observation and interview on 7/30/25 at 8:56 a.m. with Administrator Assistant (AA), the survey results or survey binder were not visible in the facility areas that are prominent and accessible to the public and residents. AA stated the survey results were in a binder that is kept inside the Administration office. AA further added, the Administration office is locked after normal business hours. During a concurrent interview and review on 7/30/25 09:34 a.m. with AA, federal requirement 483.10(g)(11) was reviewed. The regulation indicated in part, The facility must (i) Post (referring to survey results) in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. AA acknowledged and confirmed the survey results were not posted in a location that was readily accessible. During a review of the facility's policy and procedure (P&P) titled, Right to Survey Results/Advocate Agency Information, undated, the P&P indicated in part, Residents may examine the results of the most recent survey of the facility conducted by Federal or State surveyors. This will include any plan of correction in effect. The facility shall make the results of the most recent survey available for examination in a place readily accessible to residents.

Based on observation, interview and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illnesses for eleven out of eleven residents, when food debris and a cup of apple sauce were observed under the kitchen stove. This failure had the potential to result in food contamination by attracting insects and rodents that can spread pathogenic microorganisms (germs which can cause diseases) to residents through food prepared in the facility kitchen. Findings: During a review of the facility's census (a periodic count of the facility's population), titled, (Name of facility), dated June 10, 2024, the facility census indicated there were eleven residents admitted to the facility. During a concurrent observation and interview on June 10, 2024, at 8:13 AM with the Registered Dietitian (RD- experts in the disciplines of food and nutrition) and Kitchen [NAME] (KC) inside the facility kitchen, there were food debris and a cup of apple sauce observed under the kitchen stove. The KC stated the floor should be kept clean and free from debris or food items. During a concurrent observation and interview with the Dietary Supervisor (DS) on June 11, 2024, at 11:45 AM, inside the kitchen during tray line (a system of food preparation used in facilities), the DS was observed preparing lunch trays for residents. The DS stated food services for all residents were prepared in the kitchen. During an interview on June 12, 2024, at 10:07 AM with the RD, the RD stated the kitchen area should always be kept clean, including the undersides of equipment. The RD stated the food debris and cup of apple sauce under the stove had the potential to attract insects, rodents, and pests. During a concurrent interview and record review on June 12, 2024, at 11:08 AM, with the Assistant Administrator (AA), the facility's policy and procedure (P&P) titled, Cleaning and Sanitation of Dining and Food Service Areas, modified 2022, was reviewed. The P&P indicated, Policy: The food and nutrition service staff will maintain the cleanliness and sanitation of the dining and food service areas . The AA stated the expectation the kitchen will be maintained clean was not met and the facility policy was not followed. A review of the Food and Drug Administration Federal Food Code 2022, 4-402.12 titled, Fixed Equipment, Elevation or Sealing, indicated, The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food.

Based on interview and record review, the facility failed to ensure the cleaning and disinfection of the blood glucose (BG) meter (a device to test for blood sugar level) was done per facility policy. This facility failure had the potential to cause blood-borne illness as a result of cross contamination. Findings: The facility policy and procedure titled Infection Prevention and Control revised 3/1/18, indicated, in part . The infection prevention and control must include, at the minimum, the following elements: They will be tested with glucose solution daily and cleaned per manufacture's recommendations. Review of the manufacturer's instructions (MFUs) for the BG meter indicated, in part . The EvenCare G3 Meter should be cleaned and disinfected between each patient. To clean the meter, use a moist (not wet) cloth lint-free cloth dampened with a mild detergent. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for: at least 30 seconds for Medline Micro - Kill Bleach, at least 1 minute for Dispatch and Clorox Healthcare, at least 2 minutes for Medline Micro - Kill. During an interview and concurrent record review of the MFUs for the BG meter with a licensed nurse (LN 1), on 9/30/19 at 2:56 p.m., LN 1 confirmed the MFUs have not been followed by LN 1. LN 1 had been performing the disinfection, but not the cleaning of the BG meter. During an interview and concurrent record review of the MFUs for the BG meter with a licensed nurse (LN 2), on 10/1/19 at 9:19 a.m., LN 2 confirmed the MFUs have not been followed by LN 2. LN 2 could not verbalize the correct cleaning or disinfection procedures for the BG meter. During an interview with the Director of Nursing (DON), on 10/1/19 at 11:10 a.m., the DON confirmed the MFUs for cleaning and disinfecting the BG meters should be followed.

Based on interview and record review, the facility failed to initiate a baseline plan of care for two of 12 sampled residents (Resident 120 and Resident 72) within 48 hours of admission for the following resident admission Diagnoses: [REDACTED]. Gastrointestinal Reflux [MEDICAL CONDITION](A digestive disease in which stomach acid or bile irritates the food pipe lining). 2. Diabetes (A group of diseases that result in too much sugar in the blood (high blood glucose). This failure has the potential of not allowing all staff caring for the residents to be aware of the plan of care required for each of the residents, this could result in decline of the residents' health. Findings: The facility policy and procedure titled Baseline Care Plan revised 3/1/18, indicates facility will develop and implement a baseline care plan within 48 hours of admission for each resident that includes the instructions needed to provide effective and person centered care of the resident .and includes minimum healthcare information necessary to properly care for the resident . 1. During a concurrent interview and record review on 10/2/18, at 3:32 p.m., Licensed Nurse (LN 2 ) confirmed Resident 120's care plan did not include any problems related to gastrointestinal reflux disease (GERD) and it should have as resident 120 was subsequently hospitalized with a [MEDICAL CONDITION]. 2. During a concurrent interview and record review on 10/2/18, at 2:58 p.m., Licensed Nurse (LN 1) confirmed a care plan was not developed since admission for diabetes. During an interview and concurrent record review on 10/2/18, at 3:00 p.m., the Director of Nursing (DON) confirmed there was no indication of the diabetes on the resident's care plan, and there should have been.

Based on record review, interview, and observation, the facility failed to ensure Resident 3's request to have a female caregiver was accommodated. This failure had the potential to result in patient not being able to maintain or achieve independent functioning, dignity, and well being to the extent possible in accordance with the resident's own needs and preferences. Findings: The facility policy and procedure titled Accommodation of Needs Procedure, dated 8/12, on the procedure part of the policy indicated, Make every reasonable effort to accommodate resident's individual needs and preferences. Adapt schedules .to accommodate residents' preferences, desires and unique needs. Adjust staff assignments to meet residents' emotional needs (i.e. assigning a female aide to a female resident). During an interview with Resident 3, on 12/28/17, at 9:15 a.m., Resident 3 indicated she was admitted to the facility for rehabilitation due to back surgery. Resident 3 is unable to go to the bathroom by herself. When she gets out of bed she states, my private area is sometimes exposed and that's embarrassing. She notified the nursing staff she wanted a female aide to provide her care. Especially, when she needs assistance to go to the restroom. Resident 3's request for a female aide was not accommodated most of the time. Resident has been assigned a male aide even when female aides were working on that day. A review of Resident 3's clinical record, revealed Resident 3's [DIAGNOSES REDACTED]. Resident 3's Brief Interview for Mental Status (BIMs) score was 15. The BIMS test is used to get a quick snapshot of residents cognitive functioning. A score of 15 means resident is cognitively intact. The minimum data set (MDS), dated [DATE], revealed resident required extensive assistance with transfer from surfaces, dressing, and ambulation. During an interview with licensed nurse (LN 1), on 12/28/17, at 12:10 p.m., LN 1 acknowledged being aware of Resident 3's request for a female aide to assist her with her care. During an interview with certified nursing assistant (CNA 1), on 12/28/17, at 12:12 p.m., CNA 1 acknowledged being aware of Resident 3's request for a female aide to assist her with her care. During an interview with licensed nurse (LN 2), on 12/28/17, at 12:15 p.m., LN 2 acknowledged being aware of Resident 3's request for a female aide to assist her with her care. During an interview with the administrator (Admin), 12/28/17, at 12:30 p.m., Admin acknowledged being aware of Resident 3's request for a female aide to assist her with her care. Admin stated, I know Mrs (Resident 3's last name) wants a female CNA. A review of the facility's staffing for four days from 12/25/17 to 12/28/17 revealed most of the time Resident 3 was assigned a male CNA.

Based on record review, observation, and interview, the facility failed to follow physician orders [REDACTED].>1. Float heel order was never initiated for one of 10 sampled resident (Resident 1). 2. No instruction provided regarding the use of incentive spirometry (medical device used to help patients improve the functioning of their lungs) for three out of 10 sampled residents (Resident 3, 5, and 6). 3. [MEDICATION NAME] (a prescription drug used to treat moderate to severe pain) 10/325 mg. tablet was not administer in a timely manner for one out of 10 residents (Resident 9). 4. Pad and tab alarms were not in bed and wheelchair for two out of 10 sampled residents (Resident 3 and 4). These deficient practices placed resident at risk for complications and injury, Findings: Review of Potter and Perry, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician orders [REDACTED]. 1. Review of Resident 1's clinical record revealed Resident 1 had a left knee joint replacement surgery, and physician ordered to float heel as tolerated, on 9/22/17. During an observation and concurrent interview with Resident 1, on 10/4/17, at 8:40 a.m., Resident 1 was lying in bed with left knee in brace, and right lower extremity swollen. No float heel measures in place. Resident 1 revealed that staff never tried to elevate the feet off the bed. During an interview with license nurse (LN 3), on 10/4/17, at 8:48 a.m., LN 3 acknowledged physician order [REDACTED]. 2. Review of Resident 3's clinical record revealed Resident 3 had a fall which resulted to a left side subdural hematoma (collection of blood outside the brain), and had a neck collar brace in place. Physician order [REDACTED]. During an interview with Resident 3, on 10/4/17, at 9 a.m., Resident 3 revealed not receiving any teachings from the nurses to use incentive spirometry. Resident 3 further explained, incentive spirometry was not used. During an interview with LN 3, on 10/4/17, at 9:13 a.m., LN 3 acknowledged Resident 3 was not given instruction on how and when to use the incentive spirometry. Review of Resident 5's clinical record revealed Resident 5 was admitted for a fractured vertebrae. Physician ordered on [DATE], to encourage patient to use incentive spirometry 10 breaths every 1 hour while awake. During an interview with Resident 5, on 10/4/17, at 9:36 a.m., Resident 5 explained no staff explain how many times to use incentive spirometry. During an interview with license nurse (LN 2), on 10/4/17, at 9:40 a.m., LN 2 acknowledged not providing instruction nor encouragement to use the incentive spirometry. Review of Resident 6's clinical record revealed Resident 6 had a fracture of the [MEDICATION NAME] vertebrae (T7 - vertebrae found in the middle of the chest between the seventh and eighth pairs of ribs. It plays important roles in the support of the spinal cord, ribcage, and muscles of the chest) to T8 vertebrae. Physician ordered incentive spirometry 10 breaths every 1 hour while awake, dated 9/18/17. During an interview with Resident 6, on 10/4/17, at 11:52 a.m., Resident 6 explained no staff explain how many times to use incentive spirometry. 3. Review of physician order [REDACTED]. Review of narcotic count sheet dated 10/1/17, revealed Resident 9 received [MEDICATION NAME] - [MEDICATION NAME] 10 mg - 325 mg tablet every two hours. On 10/2/17, Resident 9 received two tablets of [MEDICATION NAME] - [MEDICATION NAME] 10 mg - 325 mg at 4:33 a.m. During an interview with LN 3, on 10/5/17, at 12:34 p.m., LN 3 acknowledged having no documentation regarding wasting medication or notifying physician to change order. Further explains that based on narcotic count sheet, it is a medication error. During an interview with the director of nursing (DON), on 10/5/17, at 12:39 p.m., DON acknowledged physician order [REDACTED]. 4. Review of Resident 3's clinical record revealed Resident 3 had a fall which resulted to left side subdural hematoma (collection of blood outside the brain), and had a neck collar brace in place. Physician order [REDACTED]. During an observation and concurrent interview with Resident 3, on 10/4/17, at 9:06 a.m., Resident 3's tab alarm was clipped to the pillow. Resident 3 revealed staff clipped the tab alarm to the pillow. During an interview with LN 3, on 10/4/17, at 9:11 a.m, LN 3 acknowledged the tab alarm was not attached to the resident and explained that if resident got out of bed, the alarm will not alert the staff. Review of Resident 4's clinical record revealed Resident 4 had a right total knee replacement and physician ordered pad alarm in bed and wheelchair on 9/22/17. During an observation and concurrent interview with LN 2, on 10/4/17, at 9:39 a.m., Resident 4 had no pad alarm in bed and in wheelchair. LN 2 acknowledged Resident 4 had no pad alarm in bed and in wheelchair.

Based on record review, observation, and interview, the facility failed to provide (audio) music player per resident preference to one out of 10 sampled residents (Resident 9). This failure had a potential to result in Resident 9 not reaching the highest practicable level of physical, mental, and psychosocial well being. Findings. Review of Resident 9's care plan indicated, Provide TV channel guide, in room music or movies, books, magazines or new papers or other items as requested to promote independent use of leisure time. Clinical record revealed Resident 9 is legally blind on the left eye and wears hearing aids on the left and right ear. During an observation on 10/4/17, at 10 a.m., Resident 9 had only a right hearing aid in place. No music player in the bedside. During an interview with license nurse (LN 3), on 10/5/17, at 9:04 a.m., LN 3 revealed Resident 9 has one hearing aid on the right, the left hearing aid was broken. During an interview with social worker (SW 1), on 10/5/17, at 9:24 a.m, SW 1 was unaware of Resident 9's broken hearing aid and was not notified about the broken hearing aid. During an interview with the activity director (AD 1), on 10/5/17, at 9:27 a.m., AD 1 attempted to set up a music player but Resident 9 cannot hear the music. AD 1 acknowledged failure to communicate hearing aid concern to SW 1, and acknowledged the activity or need of Resident 9 was not met. During an interview with Resident 9, on 10/5/17, at 9:38 a.m., Resident 9 revealed, staff attempted to provide music player but the sound was not working. Resident 9 expressed love of music but no music player was provided. Instead, staff turned on television, contradictory to Resident 9's eye condition and preference.

Based on record review, observation, and interview, the facility failed to ensure tab alarm was properly attached to one of 10 sampled residents (Resident 3). This failure had the potential to result in Resident 3 falling and risking injury. Findings: Review of Resident 3's clinical record revealed Resident 3 had a fall which resulted to left side subdural hematoma (collection of blood outside the brain) and had a neck collar brace in place. Physician order [REDACTED]. During observation and concurrent interview with Resident 3, on 10/4/17, at 9:06 a.m., Resident 3's tab alarm was attached to the pillow. Resident 3 revealed it was the staff who attached the tab alarm to the pillow. During an interview with LN 3, on 10/4/17, at 9:11 a.m, LN 3 acknowledged the tab alarm was not attached to the resident, and explains if resident got out of bed, it will not alarm staff.

Based on observation, interview, and record review, the facility failed to ensure: 1. Wound dressing was dated on one unsampled residents (Resident 12). 2. CPAP (Continuous positive airway pressure - a machine for treating inability to breath while sleeping) face mask was placed in plastic bag and filter is changed for one of 10 sampled residents (Resident 5). 3. Oxygen nasal cannula was placed in the plastic bag for one of 10 sampled residents (Resident 7). This failures had the potential to result in transmission of infection. Findings: 1. During an observation and concurrent interview with license nurse (LN 1), on 10/2/17, at 1:31 p.m., in room [ROOM NUMBER]. Resident 12 had an undated wound dressing in place. LN 1 acknowledged the wound dressing was undated, and explained it indicates wound dressing was not changed if not dated. Reviewed of facility policy and procedure titled, Dressing, dry/clean dated 9/2013, indicated, Label tape or dressing with date, time and initials. Place on clean field. 2. During an observation, on 10/4/17, at 9:30 a.m., in room [ROOM NUMBER]B, CPAP face mask was left uncovered on top of table with the Resident 7's personal items. Resident 7 indicated no instructions were provided by license nurse where to put CPAP face mask after use and when to change the CPAP filter. Resident 7 revealed CPAP filter was not changed for a month. During an interview with the license nurse (LN 2), on 10/4/17, at 9:32 a.m., LN 2 acknowledged CPAP face mask was left uncovered and filter has not been changed. 3. During an observation and concurrent interview with the administrator (ADM 1), on 10/5/17, at 10:51 a.m., an oxygen nasal cannula was not placed in the plastic bag. Adm 1 acknowledged the nasal cannula was not placed in the plastic bag and was looped around the water pitcher.

Based on record review and interview, the facility failed to ensure accurate documentation about pain medication on one of 10 sampled residents (Resident 9). This failure had the potential to result in medication overdose and possible drug adverse reaction for Resident 9. Findings: Record review of Resident 9's physician order, dated 9/26/17, indicated, [MEDICATION NAME]- [MEDICATION NAME] 10 mg- 325 mg tablet every four hours for chronic pain. Review of narcotic count sheet dated 10/1/17 revealed Resident 9 received [MEDICATION NAME] - [MEDICATION NAME] 10 mg - 325 mg tablet every two hours. On 10/2/17, Resident 9 received two tablets of [MEDICATION NAME] - [MEDICATION NAME] 10 mg - 325 mg at 4:33 a.m. During an interview with LN 3, on 10/5/17, at 12:34 p.m., LN 3 acknowledged no documentation regarding wasting medication or notifying physician to change order. Further explains, based on the narcotic count sheet, it is a medication error. During an interview with the director of nursing (DON), on 10/5/17, at 12:39 p.m., The DON acknowledged physician order [REDACTED].

Based on observation, interview, and record review, the facility's quality assessment and assurance (QAA) committee failed to: 1. Ensure clean oxygen concentrators were stored in a clean room. 2. Ensure three dented cans were separated from non dented cans and an expired food coloring bottle was disposed of. Cross reference: F 371 and F 441. Findings: 1. Six clean oxygen concentrators stored two feet away from a dusty floor fan, a compartment of uncleaned nebulizer machines, a dozen pad and wheelchair alarms, and maintenance tools. During an interview with the administrator (ADM) on [DATE], at 10:00 a.m, the ADM confirmed the QA committee had not identified and had not developed a plan. 2. Three dented cans and an expired plastic bottle of blue food coloring were stored with the dry storage items for use. During an interview with the ADM on [DATE], at 10:00 a.m, the ADM confirmed the QA committee had not identified and had not developed a plan.

Based on observation, interview, and record review, the facility failed to ensure; 1. Personal belongings were not placed inside the dry storage room. 2. The can opener was clean. 3. Maintenance and cleanliness of refrigerator air vent. 4. 20 expired [MEDICATION NAME] (plastic tube used to suction bodily fluids) were disposed of. 5. Clean oxygen concentrators were stored in a clean room. These deficient practices placed residents at risk for contamination and acquired infections. Findings: During an observation on [DATE] at 12:52 p.m, in the dry food storage area, a gray colored sweater was noted with the sleeves of the sweater touching the disposable plastic utensils. A personal cellphone and a black plastic bag were being stored in the food compartment area. During an interview with the cook supervisor (CS), on [DATE] at 12:54 p.m., the CS agreed personal belongings inside the storage room could cause cross contamination to the food. The facility policy and procedure entitled Dry storage areas dated 2014, indicated, materials (including personal) should be stored outside of the storage area. During an observation in the kitchen, on [DATE] at 2:30 p.m., an installed electric can opener had a golden yellow substance on the surface. During an interview with the CS, on [DATE] at 2:34 p.m, the CS described and agreed the golden yellow substance appeared to be rust and it could cause food contamination. A review of the record entitled Dietary Department Daily and Weekly Cleaning Schedule on [DATE], dated from [DATE] to [DATE], indicated, on the date of [DATE], the can opener was cleaned and the initials were marked as the CS's initials. During an observation and concurrent interview with the clinical dietitian (CD) on [DATE], at 9:25 a.m., the refrigerator vent was covered with a dark slimy substance and two of 15 margarine patties were unwrapped and exposed. The CD confirmed the observation and stated It is a potential for foodborne infection and can lead to foodborne illness. The facility policy and procedure entitled Cleaning instructions: Refrigerators dated 2014, indicated, refrigerators will be washed thoroughly inside and outside at least once every month or as needed. Spills and leaks will be cleaned as they are noticed. During an observation and concurrent interview with the director of nursing (DON) on [DATE], at 9:50 a.m., in the utility room, 20 expired [MEDICATION NAME], dated [DATE], were mixed in with the intravenous and oxygen tubing. During an observation and concurrent interview with the administrator (ADM) on [DATE], at 10:21 a.m., six clean oxygen concentrators were stored in a dirty room, two feet away from a dusty floor fan, uncleaned nebulizer machines, a dozen pad and wheelchair alarms, and maintenance tools. The ADM confirmed the equipment would no longer be considered clean and has the potential for contamination. The policy and procedure entitled Policies and practices - Infection control dated ,[DATE], indicated, the facility will maintain a safe and sanitary environment to help prevent and manage transmission of disease.

Based on observation, interview and record review, the facility failed to ensure sanitary conditions in their dry storage area when; 1. One food can was found on the floor. 2. Three dented cans were not segregated from the non dented cans. 3. One bottle of expired food coloring was not disposed of. These deficiencies had the potential to result in foodborne illness. Findings: During an observation on 10/3/16, at 12:42 p.m., of the dry storage room, a can of Sliced Apple Harvest was observed being used as a door [MEDICATION NAME]. During an interview with the cook supervisor (CS), on 10/3/16, at 12:43, the CS stated I don't know who placed it there. The facility policy and procedure entitled Dry Storage Areas dated 2014, indicated, all items must be stored at least six inches off the floor. During an observation on 10/3/16, at 1:00 p.m., of the dry storage area, three dented Sliced Apple Harvest cans were mixed in with the non - dented compartment cans for use. An expired plastic bottle of blue food color was available for use. During an interview with the CS, on 10/3/16 at 1:08 p.m, the CS also observed the three cans were dented and one bottle of food coloring was expired. The facility policy and procedure entitled Dry Storage Areas dated 2014, indicated, dented cans and expired foods should be disposed of promptly to prevent contamination.

Based on record review and interview, the facility failed to ensure a care plan was developed to meet the needs for one of ten sampled residents (Resident 1), who lost twelve pound in two weeks. This failure left Resident 1 at risk for dietary needs not being met and possible loss of more weight. Findings: Review of Resident 1's record indicated the resident was admitted with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 1, the Weight Progress Record indicated the resident's admission weight upon admission was 251 lbs (pounds). Seven days later, on 7/19/16 Resident 1 was weighed and his weight was 226 lbs. On 8/8/16 (five days later) Resident 1's weight was recorded as 213 pounds, a weight loss in 14 days of 38 pounds (15. % weight loss). The facility was unable to provide documentation to indicate a care plan was put in place to address the weight loss. During a concurrent interview on 08/18/16 at 5:45 pm with the Clinical Consultant (CC) and the MDS Clinical Nurse Consultant confirmed a care plan has not been initiated to address Resident 1's weight loss.

Based on interviews and records review, the facility failed to ensure the resident's weight loss was conveyed to Resident 1's family. This deficient practice placed the resident at risk for further unplanned weight loss. Findings: During a review of the clinical record for Resident 1, the Weight Progress Record indicated the resident's admission weight upon admission was 251 lbs (pounds). Seven days later, on 7/19/16 Resident 1 was weighed and his weight was 226 lbs. On 8/8/16 (five days later) Resident 1's weight was recorded as 213 pounds, a weight loss in 14 days of 38 pounds (15. % weight loss). A further review of Resident 1's clinical record revealed only the physician was notified of the significant weight loss of 25 lbs in 7 days. The resident's family were not notified of the weight loss. During a concurrent interview with the Administrator, Activity Director (AD), and the Clinical Consultant on 8/18/16 at 5:40 p.m., the Clinical Consultant acknowledged the record did not have proof of documentation to indicate the family was notified of Resident 1's unplanned 38 lbs weight loss in 14 days. The AD also confirmed the resident's family was actively involved with resident's care. The facility policy and procedure titled Notification Of Changes revised 8/26/2012, indicated Compass Health, Inc. facilities will inform the resident and the resident's physician when changes occur If known, Compass health, Inc. facilities shall also notify the resident's legal representative . · A significant change in the resident's physical, mental or psychosocial status, such as deterioration in health, mental or psychosocial status, life threatening conditions or clinical complication;

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of infection which could affect all residents in the facility. 1. For Resident 2 a tube of nasal gel was handled in an unsanitary manner and placed back in the medication drawer used by all residents. 2. For Residents 2, 11, and 12 medications were transported in the nurses pocket. 3. For Resident 12, an oxygen cannula was left lying uncovered in a plastic bin covered with items. These failures potentially placed residents at the risk for the spread of disease and infections. Findings: 1. During observation of the medication pass on 10/13/14 at 9 p.m. LN 1 handed a container of nasal gel to Resident 2. Resident 2 proceeded to put a small amount of gel on Resident 2's finger. Resident 2 put her finger containing the gel inside her left nostril then proceeded the same with the other nostril. LN 1 stated, "Don't pick the scabs" and at the same time the right nostril began to bleed a stream of blood over Resident 2's upper lip and hands. LN 1, without gloves took the gel container which had been handled by Resident 2 during the nosebleed and putting her fingers in her nose, and handed Resident 2 a tissue. LN 1 then put on gloves and assisted Resident 2 with the bleeding nose. Without sanitizing the gel container LN 1 placed it on top of the medication cart, containing medications for half of the residents in the facility, unlocked the cart, and placed the gel back in it's box in the medication drawer. 2. During observation of medication pass on 10/13/14 at 8 p.m. a licensed nurse (LN 1) after administering eye drops to Resident 11, placed the eye drops in his pants pocket and transported them back to the med cart. After administering one container of eye drops to Resident 12, LN 1 placed the two containers eye drops in his upper pocket of his shirt. After administering eye drops to Resident 2, LN 1 placed the eye drops in his pants pocket. When asked, LN 1 indicated he had keys in his pants pockets with the eye drops. 3. During a tour of the facility, accompanied by the director of nurses (DON), on 10/12/14 at 7:22 p.m. an oxygen nose cannula was observed covered by a baseball cap, deodorant, electric razor, toothpaste, and toothbrush in a plastic container at Resident 12's bedside. The oxygen cannula was not individually covered. Review of the facility's policy revised 5/24/13 "Oxygen Procedure. The equipment will be maintained in a manner to ensure the best possible outcome for the patient."