Every finding on record at Scottish Pines Rehabilitation and Nursing Center

Based on observations, record review, and staff interviews, the facility failed to discard expired food and milk available for use and to label opened food items with the date opened and expiration date in 1 of 1 walk-in refrigerator in the kitchen. These practices had the potential to affect the food served to 73 of 77 residents.The findings included:An initial observation of the kitchen was conducted with the [NAME] on 12/15/25 at 10:34 AM. Observation of the walk-in refrigerator revealed an opened plastic bag labeled diced potatoes with an expiration date of 12/11/25, 98 eight ounce containers of 2% milk in 2 racks with an expiration date of 12/14/25, a half full box of white mushrooms with gray and white fuzz growing on top of them and with black parts with a received date of 11/11/25 and an opened plastic bag labeled mozzarella cheese with no opened or expiration date. An interview with the [NAME] was completed on 12/15/25 at 10:45 AM. The [NAME] stated that the opened plastic bag of diced potatoes and the mushrooms that were black with grayish white fuzz on them should have been discarded. He reported that the milk was supposed to have a Do Not Use tag on it because it was expired. The [NAME] indicated that it was the responsibility of all the staff working in the kitchen to label and date food items correctly. He stated the opened plastic bag of mozzarella cheese should have had an opened date and expiration date on it. An interview with the Dietary Manager occurred on 12/15/25 at 11:00 AM. The Dietary Manager stated that checking the walk-in refrigerator for expired food items was usually completed first thing in the morning. The Dietary Manager indicated that because she was not there early that morning, it was not done. She further stated there was not a sign off sheet for daily or weekly checking of the walk-in refrigerator. She explained that that she had instructed one of the dietary aides to attach a Do Not Use label to the 2% milk containers the night before and place it on the bottom shelf for pick up by the milk man on Wednesday. The Dietary Manager stated she didn't know why the milk didn't have the label on it and was not placed on the bottom shelf. An interview with the Administrator was conducted on 12/18/25 at 10:52 AM. The Administrator indicated all opened foods in the walk-in cooler were to be labeled and dated.

Based on observations, record review, and staff interviews the facility failed to; 1) implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to a resident (Resident #10) with a gastrostomy tube (a feeding tube placed through the abdominal wall into the stomach and used to provide essential nutrition); 2) and failed to properly dispose of soiled linens that were observed being put on the floor and failed to remove contaminated gloves and perform hand hygiene prior to transferring and touching a resident (Resident #51) and his belongings. This occurred for 3 of 4 staff members who were observed for infection control practices (Nurse #1, Nurse Aide #1 and Nurse Aide #2). Findings included: 1.) The Infection Control Policy dated 3/26/25 revealed Enhanced Barrier Precautions referred to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. During an observation on 12/17/25 at 10:00 AM Resident #10 was observed lying in bed. An Enhanced Barrier Precaution sign was observed by the door outside of Resident #10's room. A PPE (personal protective equipment) supply cart was outside of the room with supplies including gloves and gown. Nurse #1 was observed administering medications through Resident #10's gastrostomy tube. Nurse #1 set up the supplies on the bedside table, removed the blankets covering Resident #10. Nurse #1 checked the gastrostomy tube for placement by inserting a syringe into the tip of the gastrostomy tube. Nurse #1 then administered medications and water flushes through the tube and replaced the blankets over Resident #10. Nurse #1 was wearing gloves but did not don a gown prior to providing direct care to Resident #10. During an interview on 12/17/25 at 10:15 AM Nurse #1 stated she did not see the sign outside of Resident #10's room and did not realize he was on enhanced barrier precautions. She stated she did not think to put on a gown before administering Resident #10's medications through the gastrostomy tube. Nurse #1 stated she had received infection control training recently including training on enhanced barrier precautions and this was done in error. During an interview on 12/18/25 at 9:50 AM the Infection Control Preventionist Nurse stated staff had been trained on enhanced barrier precautions. He stated they provided in-service education on infection control including enhanced barrier precautions during each staff meeting, and he conducted random audits to ensure staff were adhering to PPE guidelines. He stated Nurse #1 should have donned a gown along with gloves when administering medications through a gastrostomy tube. He stated continued education would be provided to staff. During an interview on 12/18/25 at 2:00 PM the Director of Nursing (DON) stated staff received infection control training throughout the year. She stated staff should be following the infection control guidelines and wearing PPE when providing direct care to residents on enhanced barrier precautions. 2) The Infection Prevention and Control Program policy dated 12/2010 and revised on 10/28/2020 revealed in part, for standard precautions that all staff shall assume that all residents are potentially infectious or colonized with an organism that could be transmitted during the course of providing resident care services; and soiled linens shall be collected at the bedside and placed and secured in a linen bag; and hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. An observation of incontinence care was conducted with Resident #51 on 12/15/25 at 11:50 AM with Nurse Aide #1 and Nurse Aide #2. Resident #51 was noted to be lying in bed. His shirt was wet up to his naval, his sheets and his brief were noted to be saturated with urine. Nurse Aide #2 entered the room and observed Resident #51's wet clothes, brief, and his sheets and stated she would provide his care now. Nurse Aide #1 entered the room with clean linens and towels to assist Nurse Aide #2. Nurse Aide #1 and Nurse Aide #2 were noted to apply gloves before starting resident care. There was a rolling dispenser of linen bags noted to be secured to the wall of Resident #51's room. Nurse Aide #2 removed Resident #51's soiled shirt and tossed it on the floor. The urine-soaked brief was removed by Nurse Aide #2 and placed in the trash can. Nurse Aide #1 and Nurse Aide #2 proceeded to remove the urine-soaked sheets and give Resident #51 his bed bath. Nurse Aide #2 was observed using clean linens to bathe Resident #51 and after cleansing the resident, tossed the soiled wash clothes, towels and soiled sheets onto the floor. When the bath was completed and the bed was changed, Resident #51 was assisted with getting dressed by the nurse aides without removing their contaminated gloves. Nurse Aide #2 went to the wall by the door entrance and obtained a linen bag from the rolling dispenser. She did not remove her contaminated gloves. Nurse Aide #2 proceeded to put all the soiled linens, towels and personal clothes in the linen bag and secured the bag. Nurse Aide #1 and Nurse Aide #2 were observed transferring Resident #51 after providing care. The nurse aides did not remove their gloves or wash their hands before transferring Resident #51 out of bed to his wheelchair. Once Resident #51 was in his wheelchair, Nurse Aide #2 moved Resident #51's bedside table, phone, and walker within Resident #51's reach and did not remove her contaminated gloves until she was ready to leave the room. Nurse Aide #1 and Nurse Aide #2 removed their gloves before exiting the room and used sanitizer to cleanse their hands. An interview was conducted with Nurse Aide #2 on 12/15/25 at 12:22 PM. Nurse Aide #2 stated she should not have put the soiled clothes, towels and linens on the floor. She stated she was educated to put soiled items in a plastic linen bag which were available to her in each resident's room. She stated she just was not thinking and was trying to get the bath done before lunch. Nurse Aide #2 also stated she should have removed her gloves and washed her hands after all the soiled items were secured in a bag and before touching Resident #51 and his personal belongings. Nurse Aide #2 stated she had received education on hand hygiene upon hire in April 2025. An interview was conducted with Nurse Aide #1 on 12/15/25 at 12:30 PM. Nurse Aide #1 stated she realized halfway through the bed bath that the towels and linens were being put on the floor and she should have said something when she realized it. Nurse Aide #1 stated she had received education on handling soiled linens and hand hygiene, and she should have removed her gloves and washed her hands after handling the soiled linens and she should not have assisted with transferring Resident #51 with her contaminated gloves still on. An interview was conducted with the Infection Preventionist on 12/18/25 at 10:20 AM. The Infection Preventionist stated he would have expected the nurse aides to follow the infection control procedures. He stated he provided education to all the staff regarding infection control and handling and disposing of dirty linens. He stated the plastic linen bags were placed in the rolling dispenser in every room to enable the staff to be compliant with placing the dirty/soiled linens in the bag when they were providing care. The Infection Preventionist stated he provided education to all the staff regarding infection control and hand hygiene. He stated hand hygiene should be done before staff enter the room, before staff touch a resident, after staff touch a resident, after the staff provide care, and after the staff touch surfaces in the room. He stated the moment Nurse Aide #1 and #2 were done with care and everything was placed in bags; he would have expected them to remove their contaminated gloves and perform hand hygiene before touching the resident and setting up his personal items in his room to prevent potential contamination. The Infection Preventionist stated education was provided to all new hires during orientation and if he saw a trend in infections in service education would be completed. An interview was conducted with the Administrator on 12/18/25 at 1:00 PM. The Administrator stated she expected all the staff to adhere to the infection control policy and utilize the provided linen bags to place soiled linen in. The Administrator stated the staff also needed to ensure they were removing contaminated gloves prior to touching a clean resident and their personal belongings in order to prevent contamination.

Based on record review, staff, the Medical Director, and the Consultant Pharmacist interviews the facility failed to hold two antihypertensive medications (Amlodipine Besylate and Carvedilol) that included parameters to hold the medication if the systolic blood pressure was less than 120 mm/hg ( millimeters of mercury). This resulted in a resident receiving 5 additional doses of Amlodipine Besylate 5 milligram (mg) tablets and 4 additional doses of Carvedilol 6.25 milligram tablets. There was no outcome from receiving the medications. This occurred for 1 of 5 residents (Resident #99) reviewed for medication administration. Findings included. Resident #99 was admitted to the facility on [DATE] with diagnoses that included Hypertension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #99 had mildly impaired cognition. He received limited assistance with activities of daily living (ADLs.). He had no rejection of care. A physicians order dated 09/11/24 for Resident #99 revealed Amlodipine Besylate 5 milligram (mg) tablets. Give 1 tablet orally one time a day related to Essential hypertension. Hold for systolic blood pressure less than 120 mm/hg (millimeters of mercury). Review of the Medication Administration Record (MAR) for Resident #99 dated October 2024 revealed Amlodipine Besylate 5 milligram (mg) tablets were administered on the following dates/times: 10/02/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 118/62 (systolic/diastolic). 10/03/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 112/62. 10/04/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 103/52. 10/07/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 114/60. 10/16/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 118/62. A physicians order dated 09/11/24 for Resident #99 revealed Carvedilol 6.25 milligram tablets. Give 1 tablet by mouth two times a day related to Essential hypertension. Hold for systolic blood pressure less than 120 mm/hg (millimeters of mercury). Review of the Medication Administration Record (MAR) for Resident #99 dated October 2024 revealed Carvedilol 6.25 milligram tablets were administered on the following dates/times: 10/02/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 118/62 (systolic/diastolic). 10/03/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 112/62. 10/07/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 114/60. 10/16/24 at 9:00 AM. The recorded blood pressure at 9:00 AM was 118/62. Review of the progress notes for Resident #99 from 09/11/24 through 10/16/24 revealed no documentation that the Amlodipine Besylate 5 milligram (mg) tablets or the Carvedilol 6.25 milligram tablets were held. An interview was conducted on 10/23/24 at 3:00 PM with Medication Aide #1 who signed off on the Amlodipine Besylate 5 milligram (mg) tablets and the Carvedilol 6.25 milligram tablets on 10/02, 10/03, 10/04, 10/07, and 10/16/24. She stated if the medications were checked off on the Medication Administration Record (MAR) as administered then she did give the medications. She stated she didn't realize the Amlodipine had hold parameters but knew the Carvedilol did have hold parameters. She stated the medications were administered in error. During an interview on 10/23/24 at 03:41 PM the Medical Director stated Resident #99 was on long term antihypertensive medications. He stated if Resident #99 was administered the medications with the systolic blood pressure less than 120 mm/hg then it would have no effect on this resident due to chronic use. He indicated staff should follow the medication orders and administer medications according to the physician orders. During an interview on 10/24/24 at 3:00 PM the Consultant Pharmacist stated there would be no harm in Resident #99 receiving the antihypertensive medications due to long term use. She stated it would be more concerning if he had consistently low pulse rate, but his pulse rate consistently remained 60-80 beats per minute. She indicated staff should be following the physician orders and administering medications as ordered and holding medications according to the order. During an interview on 10/24/24 at 3:29 PM the Director of Nursing (DON) stated Medication Aide #1 should have followed the physicians order and held both antihypertensive medications according to the parameters. She stated education would be provided.

Based on record review and staff interviews, the facility failed to code Minimum Data Set (MDS) assessments accurately for 4 of 22 residents whose MDS assessments were reviewed (Resident #59, Resident #19, Resident #5, and Resident #108). Findings included: 1. Resident #59 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #59 had not received dialysis treatments. In an interview with Resident #59 he stated he went to dialysis every Monday, Wednesday, and Friday morning at 6:00 AM. In an interview with MDS Nurse #1 on 08/09/23 at 2:40 PM she stated Resident #59 had been going to dialysis every Monday, Wednesday, and Friday since his admission in 2019. She noted he was on dialysis and meant to indicate he was currently receiving dialysis on the assessment but had not. She stated she did not know why except that it was human error. In an interview with the Administrator on 08/09/23 at 3:35 PM she stated she expected the MDS assessment to be accurate. 2. Resident #19 was readmitted to the facility on [DATE] with diagnoses that included, in part: gastrostomy (percutaneous endoscopic gastrostomy feeding tube or PEG tube) and dysphagia (difficulty swallowing). Review of a Registered Dietician (RD) note written on 05/24/23 documented the following: Resident is currently NPO (nothing by mouth) receiving enteral tube feeding of Vital 1.5 at 237 ML (8 oz) bolus feeding via gravity via PEG tube for every 6 hours with 100 ML water flush before and after of each bolus feeding . Resident additionally receiving nutritional supplement of 30 ML via feeding tube twice a day .to increase protein intake and skin integrity. Review of a quarterly MDS assessment dated [DATE] documented Resident #19 received 25% or less of her nutrition and 500 ML (Milliliters) or less of fluid daily by tube feeding. In an interview with the facility RD on 08/09/23 at 2:00 PM she stated that the nutrition section of the MDS assessments were completed by the RD. She noted she was new at the facility and had not completed this assessment. She stated Resident #19 was and had been NPO. She commented the MDS assessment should have been coded to reflect that the resident received all her nutrition and hydration (51% or more of nutrition and 500 ML or more of fluids daily) by tube feeding. In an interview with the administrator on 8/9/23 at 2:10 PM she stated the facility had not had consistent RD Consultants recently. She expected the MDS assessment to be completed correctly. In an interview with MDS Nurse #1 on 2/9/23 at 2:45 PM she stated the RD fills out the nutrition section. She reviewed the MDS and commented the resident was NPO and received all her nourishment and fluids via tube feeding. She stated she would correct the nutrition section. 44890 3. Resident #5 was admitted to the facility 03/20/2019 with diagnosis to include Alzheimer's disease. The quarterly MDS assessment dated [DATE] revealed Resident #5 was coded as having a feeding tube and receiving more than 51% of her nutrition from parenteral feeding. Resident #5 was coded as being totally dependent on the assistance of 2 staff members for eating. A progress note written by the Registered Dietician dated 08/03/2023 read in part, Resident is NPO (nothing by mouth) and is receiving tube feeding of 237 milliliters (ml) bolus feeding, 4 times a day with 75 ml of free water flush before and after each bolus. An interview was conducted with MDS Nurse #1 on 08/09/2023 at 09:10 AM. MDS Nurse #1 stated that on the worksheet she used to code the MDS she had crossed out eating assistance of 2 staff members. She further stated that it was just an entry error that she had coded wrong. MDS Nurse #1 stated that she was going to correct the MDS and resubmit it. An interview was conducted with the DON on 08/09/2023 at 2:39 PM. The DON stated that MDS Nurse #1 had made a human error. She further stated that the MDS assessments should be coded accurately and submitted to the state on time. 4. Resident #108 was admitted to the facility on [DATE] with diagnoses to include hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease. He was discharged to the hospital on 07/30/2023 and readmitted on [DATE]. Resident #108's discharge MDS assessment dated [DATE] was coded as discharged to the community. An interview was conducted with MDS Nurse #1 on 08/09/2023 at 09:06 AM. MDS Nurse #1 stated that Resident #108's MDS was coded wrong. She further stated that he was not discharged to the community, he was discharged to the hospital. MDS Nurse #1 stated that she was going to correct the MDS assessment and resubmit it to the state. An interview with the DON was competed on 08/09/2023 at 2:39 PM. The DON stated that Resident #108 was still residing in the facility and had not been discharged to the community. She further stated that MDS Nurse #1 had made a human error and was going to correct it. The DON indicated that the MDS assessments should be coded accurately and submitted to the state on time.

Based on record review, observations, and staff interviews the facility failed to store medications securely when 1. a cognitively impaired resident's (Resident #65) medications were observed on her bedside table, and 2. controlled substances were not stored in a permanently affixed compartment of the refrigerator in the only refrigerator used to store controlled medications (100, 200, 300 Hall medication storage room). Findings included: 1. Resident #65 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, and vascular dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was severely cognitively impaired. An observation of a Resident #65's room was completed on 08/07/2023 at 11:59 AM. The resident was lying in bed with her eyes closed. A plastic medication cup containing crushed medications and applesauce and a plastic cup of white liquid was noted to be sitting on the bedside table. There were no staff members observed in Resident #65's room. An observation of the hallway on 08/07/2023 at 12:00 PM revealed Nurse #1 was standing at the medication cart 4 rooms down on the opposite side of the hallway. An interview was completed with Nurse #1 on 08/07/2023 at 12:01 PM. Nurse #1 stated that she left the medications on Resident #65's bedside table because she was asleep, and she needed to be pulled up in the bed, before taking the medications. Nurse #1 indicated that she went to find someone to help pull Resident #65 up in bed and she forgot to take the medications with her. Nurse #1 stated the medication cup contained Resident #65's 9:00 AM medications which included lisinopril, vitamin D3, hydrochlorothiazide, donepezil, sertraline hydrochloride, and mirtazapine, and the cup of liquid was 120ml of weight support liquid. An interview with the Director of Nursing (DON) was completed on 08/08/2023 at 11:10 AM. The DON stated that Nurse #1 should not have left the cup of medications in Resident #65's room. She stated that Nurse #1 went to find someone to help her pull Resident #65 up in bed and just forgot to pick up the cup of medications. She further stated it was just a human error. An interview was conducted with the Administrator and the Director of Operations on 08/10/2023 at 10:23 AM. The Administrator stated she thought the breakdown in the process was caused by distractions and nerves. 2. An observation of the locked 100, 200, 300 hall medication storage room was completed with the DON on 08/08/2023 at 11:09 AM. The refrigerator designed for medication storage did not have a lock on it and contained a small metal box with a key lock on it and it was not permanently affixed to the refrigerator. The metal box contained 18 foil packages of dronabinol (dronabinol is one of the psychoactive compounds present in cannabis and is abusable and controlled Schedule III under the Controlled Substance Act). The DON stated the dronabinol was for a specific resident on the 100 hall, and it had to be kept in the refrigerator. She further stated that it was probably better to be safe than sorry because someone could remove the metal box. An interview was completed with the DON on 08/08/2023 at 2:17 PM. The DON stated that the old refrigerator in the 100. 200, 300 hall medication storage room broke a few weeks ago and that no one put a lock on the new refrigerator. She stated that maintenance had put a padlock on the refrigerator door and the metal box was now secured to the refrigerator.

Based on observations and staff interviews the facility failed to remove food items stored ready for use by the use by date in 1 of 1 reach-in cooler, 1of 1 dry goods storage area and 1 of 1 walk-in refrigerator. This practice had the potential to affect the food served to the residents. The findings included: 1. A. Initial observation of the kitchen reach in cooler on [DATE] at 11:57 AM revealed: · a 46-ounce bottle of nectar thick water with a sticker labeled use by [DATE]. · A 46-ounce bottle of honey thick water with a sticker labeled use by [DATE]. 2. Initial observation of the dry storage on [DATE] at 12:00 PM revealed: · a case of 1.5-ounce packages of raisins with an expiration date of [DATE] 3. Initial observation of the walk-in refrigerator on [DATE] at 12:03 PM revealed: · a plastic bag with an opened package of sliced turkey breast with a sticker labelled use by [DATE] · a case of gelatin cups with an expiration date of [DATE] · An opened plastic bag containing rolls with no label and no opened date Interview with the Dietary Manager (DM) on [DATE] at 12:05 PM revealed that all items in the kitchen were checked weekly by the kitchen staff and that the dates were checked as the items were used. DM further stated that the expired items should have been noted during the weekly check and discarded then and that the rolls should have been labelled with an opened date and expiration date. Interview with the Administrator on [DATE] at 3:50 PM indicated that her expectation was that the dietary department ensured that there were no expired items served and that all expired items were discarded immediately.

Based on observation and staff interview the facility failed to clean vents in the kitchen ceiling and filters above the oven/stove system, failed to discard abraded kitchenware, and failed to cover the tea canister in the presence of pests in the kitchen. Findings included: 1. During initial tour of the kitchen, beginning at 11:30 AM on 02/10/20, four vents in the kitchen ceiling had grated coverings which were coated with dust and dirt, and there were strands of dust hanging from the vents. These vents were above racks where sanitized kitchenware was stored and the three-compartment sink where kitchenware was washed, rinsed, and sanitized. During an interview with the Dietary Manager (DM) on 02/12/20 at 3:07 PM she stated the maintenance department was supposed to check the ceiling vents in the kitchen weekly to make sure they were clean. However, she reported she was unsure of the last time maintenance had actually made a visual inspection. The DM commented that dusty and dirty vents in the kitchen ceiling could contaminate sanitized kitchenware and food which was being prepared and/or served. During an interview with Dietary Aide #1 on 02/12/20 at 3:22 PM she stated the maintenance department wiped down the ceiling vents monthly. She reported it was important to keep the vents clean so dust, dirt, bacteria, mold, and germs did not get blown all over kitchenware and food. During an interview with the Maintenance Manager (MM) on 02/14/20 at 9:02 AM he stated the vents in the kitchen ceiling were currently being cleaned every three months. He reported he thought it was possible the vents with the grated coverings got overlooked the last time kitchen vents were cleaned because vents of another style in the kitchen ceiling were clean and free of any dust and dirt. However, the MM commented there had been some discussion recently that the frequency of kitchen vent cleaning needed to be adjusted due to all the steam and oils present in the kitchen. He explained that this revised cleaning schedule was in the process of being finalized. 2. During initial tour of the kitchen, beginning at 11:30 AM on 02/10/20, 4 of the 8 filters above the oven/stove system had a very heavy coating of oil and grease on them with particles of dust beginning to stick to them. During an interview with the Dietary Manager (DM) on 02/12/20 at 3:07 PM she stated the filters above the stove and ovens were supposed to be cleaned by the dietary department bi-weekly and as needed when grease and oil built up on them. She reported if the cooks observed a build-up of grease and oil on the filters it was their responsibility to make sure they were cleaned immediately. The DM commented greasy filters were a fire hazard, and because dust and dirt collected on oily surfaces, the filters were a possible source of cross contamination. She explained dust and dirt on the filters could fall into or onto the foods being prepared in this section of the kitchen. During an interview with Dietary Aide #1 on 02/12/20 at 3:22 PM she stated the filters above the stove and ovens were cleaned by the night cooks who soaked them in a sanitizing solution. She reported she was not sure if these filters were routinely cleaned at a specific time interval, but thought that the expectation was just to clean them when they were observed to have a build-up of grease and oil on them. She commented greasy, oily surfaces attracted dust and dirt which could contaminate the foods being prepared on the stove or foods placed in and on top of the ovens. During an interview with the Maintenance Manager (MM) on 02/14/20 at 9:02 AM he stated the filters above the stove and ovens were cleaned professionally every six months when the entire hood system was serviced. He reported in between this professional service the dietary department was responsible for visual inspections to prevent the build-up of grease and oil which could pose a fire hazard. 3. During an inspection of kitchenware on 02/12/20 at 10:21 AM a rack containing twelve plastic soup and cereal bowls was inspected. This rack contained kitchenware that was observed being used by residents at the breakfast meal, and observed being run through the dish machine afterwards. 8 of 12 plastic bowls had heavy abrasions inside of them which were rough to the touch. During an interview with the Dietary Manager (DM) on 02/12/20 at 3:07 PM she stated the dietary staff was taught to dispose of pieces of kitchenware compromised by cracks, chips, and abraded surfaces as they found them. She reported food and bacteria could build up in the abraded surfaces with the potential of making residents sick. The DM commented she had cases of new bowls in storage, but apparently the dietary staff had not had a chance to sort out compromised bowls that needed to be replaced. During an interview with Dietary Aide #1 on 02/12/20 at 3:22 PM she stated dietary staff were supposed to pull pieces of kitchenware damaged by chips, cracks, and abrasions as they found them. She reported the process was to present the compromised kitchenware to the DM so she could verify the damage and make sure replacement kitchenware was on order. She commented she was unable to explain why so many soup and cereal bowls were still being used with abraded interior surfaces. According to Dietary Aide #1, pieces of plastic could slough off the bowls and get into resident food with the potential of residents swallowing the plastic. She also stated the abrasions could harbor germs and bacteria which could make residents sick. 4. During initial tour of the kitchen, beginning at 11:30 AM on 02/10/20 and concluding at 11:58 AM on 02/10/20, a canister containing tea was not covered. The canister was not warm to the touch. During a follow-up inspection of the kitchen, beginning at 9:33 AM on 02/12/20 and concluding at 10:36 AM on 02/12/20, a canister containing tea was not covered. The canister was not warm to the touch. At 10:16 AM on 02/12/20 multiple gnats were observed in the kitchen. During a 02/12/20 observation of the kitchen, beginning at 11:30 AM and concluding at 11:48 AM, a canister containing tea was not covered. The canister was not warm to the touch. At 11:43 AM on 02/12/20 a fly was observed in the kitchen. During an interview with the Dietary Manager (DM) on 02/12/20 at 3:07 PM she stated the facility had a top for the tea canister which was supposed to be covering the tea to prevent dust/dirt and pests from contaminating the tea. She reported she thought the top was being cleaned during part of the kitchen survey, but was unsure why it would have taken so long to put it back into use. During an interview with Dietary Aide #1 on 02/12/20 at 3:22 PM she stated there was supposed to be a lid on the tea canister at all times. She reported this was important to keep flies, gnats, dust/dirt, and bacteria out of the tea which all posed risks to the health of the residents.

Based on observations, record review and staff and resident interviews the facility failed to accurately code bladder and bowel appliances, falls history, and nutritional approaches on the Minimum Data Sets (MDS) of 3 of 30 sampled residents (Resident #57, Resident #81, and Resident #34) whose MDS assessments were reviewed. Findings included: 1. Resident #57 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Urinary Catheter Order Clarification dated 07/11/19 revealed that Resident #57 was readmitted to the facility with an indwelling catheter in place. The (MONTH) 2019 Medication Administration Record [REDACTED]. The quarterly MDS dated [DATE] specified that Resident #57 was always incontinent of bladder during the seven day look back period. Further review of this MDS revealed this section was completed by MDS Coordinator #1. In an interview on 02/15/20 at 11:55 AM MDS Coordinator #1 stated that she reviewed physician orders [REDACTED]. She verified that Resident #57 had an indwelling catheter at the time of the 12/12/19 quarterly MDS assessment and stated that she had incorrectly coded Resident #57 as being incontinent of bladder. She indicated that she had marked the wrong box on the assessment by mistake. In an interview on 02/15/20 at 12:06 PM the Director of Nursing Services (DNS) stated that an indwelling urinary catheter should always be coded on the MDS. She indicated that the MDS should accurately reflect what was going on with the resident. 2. Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall report for Resident #81 dated 12/12/19 indicated she was found on the floor of her room. The most current Minimum Data Set (MDS) assessment dated [DATE] for Resident #81 indicated she was severely impaired for daily decision making, required the limited assistance of one person for bed mobility and transfers, had impaired lower extremity range of motion on both sides, was not steady but was able to stabilize without human assistance, received an anti-psychotic medication routinely seven (7) out of seven (7) days and had no falls during the assessment period. On 02/15/20 at 11:33 AM an interview with MDS coordinator #1 indicated she completed the falls section of Resident #81's MDS dated [DATE]. She further stated she was aware Resident #81 had a fall during the assessment period and should have noted the resident's 12/12/19 fall on the 01/06/20 MDS assessment, but just missed it. MDS coordinator #1 stated it was important for resident's MDS to accurately reflect their condition and Resident #81's did not. On 02/15/20 at 11:35 AM an interview with the Director of Nursing and the facility Administrator indicated Resident #81's MDS assessment dated [DATE] should have reflected the fall she had on 12/12/19 but it did not. They stated it was important for resident's MDS to be accurate and Resident #81's was not. 3. Resident #34 was admitted to the facility on ,[DATE]. The resident's [DIAGNOSES REDACTED]. A 10/30/19 physician's orders [REDACTED]. Resident #34's 11/15/19 quarterly minimum data set (MDS) documented the resident's cognition was severely impaired, she experienced an unplanned significant weight loss, and she was on a therapeutic diet. The MDS assessment did not indicate that the resident received a mechanically altered diet. During an observation on 02/11/20 at 12:33 PM Resident #34 received chopped smoked sausage, and her tray slip documented she was on a heart healthy diet with chopped meats. During an observation on 02/12/20 at 8:30 AM Resident #34 received chopped breakfast sausage on her meal tray, and her tray slip documented she was on a heart healthy diet with chopped meats. During an interview with Nursing Assistant (NA) #1 on 02/12/20 at 8:45 AM she stated Resident #34 had not had any chewing and swallowing problems since the kitchen had started chopping her meats. During an interview with Nurse #1 on 02/12/20 at 11:08 AM she stated Resident #34 could eat regular texture vegetables and starchy foods, but needed her meats chopped because they were tougher and more difficult to swallow. During an interview with Resident #34 on 02/12/20 at 12:35 PM she stated it was easier for her to swallow her meats now that they were being chopped. During an interview with MDS Nurse #1 on 02/15/20 at 9:56 AM she stated section K (Swallowing/Nutritional Status) of MDS assessments was completed by the facility's Registered Dietitian (RD). She reported she reviewed the MDS assessments to make sure they were complete before she signed off on them, but the accuracy of the assessments was the responsibility of the staff members who completed each section of the assessments. During an interview with the facility's RD on 02/15/20 at 10:47 AM she stated when she completed the Nutritional Approaches portion of Section K on MDS assessments she referred to the resident diet orders, and talked with the direct care staff. After reviewing Resident #34's 10/30/19 diet order, she stated she should have coded the resident as receiving a mechanically altered diet since she was receiving chopped meats, and did not do so. She commented that she must not have seen the last part of the diet order before documenting only the therapeutic element in Resident #34's diet. According to the RD, it was her responsibility to code responses in Section K of MDS assessments correctly, and not coding that Resident #34 received a mechanically altered diet was an error.

Based on observation and staff interviews the facility failed to keep a medication secured by leaving it on a beside table in a resident's room for 1 of 4 rooms observed during resident wound treatments. Findings included: During a treatment observation on 02/13/20 at 10:42 AM a syringe sealed in a transparent plastic wrapper was seen on the bedside table in room [ROOM NUMBER]. The syringe was partially obscured by a pillow. On examination, the labeling of the syringe revealed it contained 500 units in 5 milliliters (ml) of [MEDICATION NAME] lock flush. The Treatment Nurse verified that the syringe contained [MEDICATION NAME] 500 units. On 02/13/20 at 11:22 AM following the treatment, the syringe was carried out of the room by Nurse #3 and handed to Nurse #4. Nurse #4 verified that the sealed package contained a syringe of 500 units of [MEDICATION NAME]. She stated that she had not left the syringe on the bedside table but knew that it had not been there the day before when she worked. Nurse #4 stated that medications should never be left unsecured at the bedside because residents could get them and take them. In an interview on 02/13/20 at 2:27 PM the Registered Pharmacist stated that [MEDICATION NAME] was a blood thinner and if it was ingested it could be a potential problem. She stated that medications should not be left on bedside tables in resident rooms and that they should always be secured. In an interview on 02/14/20 at 9:35 AM Nurse #5 stated that on the evening of 02/12/20 she had gone into room [ROOM NUMBER] with a syringe of [MEDICATION NAME] to flush the PICC (peripherally inserted central catheter) line of one of the resident's but that the infusion had not finished. She indicated that the other resident in the room was trying to get out of bed, so she placed the syringe on the bedside table and went to assist the resident. Nurse #5 indicated that after helping the resident, she forgot that she had left the syringe on the bedside table and did not remove it from the room. She stated that medications should always be kept locked on the medication cart for safety because if left out residents could take the medications and harm themselves. In an interview on 02/14/20 at 3:50 PM the Director of Nursing Services (DNS) stated that she expected medications to be secured in the medication carts and not left at the bedside. She indicated that the facility had residents that wandered and that leaving medications at the bedside could be harmful if a resident got ahold of them.

Based on staff interview and record review the facility failed to accurately code the reason why wound treatments did not get completed for 1 of 4 sampled residents (Resident #64) who was reviewed for pressure ulcers. Findings included: Record review revealed Resident #64 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's care plan identified Resident is at risk for skin impairment d/t (due to) decreased mobility/incontinence/advanced age with fragile skin, fluctuating appetite, altered sensation, [MEDICAL CONDITION], and overall compromised health status as a problem on 12/11/19. Interventions to this problem included skin assessments and treatments per facility protocol. The resident's 12/17/19 admission minimum data set (MDS) documented the resident's cognition was severely impaired, and she had two stage II pressure ulcers. Review of Resident #64's (MONTH) 2019 Treatment Administration Record (TAR) revealed on 12/19/19, 12/25/19, and 12/27/19 treatments to the resident's sacral pressure ulcer and the abrasion/pressure ulcer to the mid lower back were not provided. Treatment Aide #1 documented the reason the treatments were not completed was that the resident was not available. Review of progress notes and the sign out notebook at the front desk in the lobby revealed Resident #64 was present in the facility all day on 12/19/19, 12/25/19, and 12/27/19. During an interview with the facility's Treatment Nurse on 02/13/20 at 5:10 PM she stated she was informed by her Treatment Aides that Resident #64 periodically refused to have her wound treatments done even though they reapproached her multiple times, and this had been communicated to the resident's primary physician. During a telephone interview with Treatment Aide #1 on 02/14/20 at 11:57 AM she stated Resident #64 was refusing wound treatments on an average of twice a month, but she could not remember for sure what transpired with the resident on 12/19/19, 12/25/19, and 12/27/19 in regard to her wound treatments. She reported Resident #64 did not leave the facility because of her debilitated state, and she always reapproached residents if they were not in their rooms the first time she entered to provide wound treatments. According to Treatment Aide #1, she could not recall any time that she was unable to provide a wound treatment unless the resident refused to allow her to perform the task. She commented therefore it seemed likely that Resident #64 refused wound treatments on 12/19/19, 12/25/19, and 12/27/19. During an interview with the facility's Treatment Nurse and Administrator on 02/15/20 at 9:16 AM they stated upon reviewing documentation made by Treatment Aide #1 they realized she was coding the reason for not administering wound treatments to all residents, many of whom had a history of [REDACTED]. They reported this was incorrect, and many of those missed treatments, including Resident #64's 12/19/19, 12/25/19, and 12/27/19 treatments, should have been coded as R for refused. They also commented there was a third code which could be entered to justify wound treatments not being completed which was H for held.

Based on record review, and staff and Physician interviews, the facility failed to follow the protocol regarding standing orders for [DIAGNOSES REDACTED] (low blood sugar) and failed to follow the physician order [REDACTED].# 1). Resident #1 experienced prolonged [DIAGNOSES REDACTED] which resulted in the resident having a [MEDICAL CONDITION]. Findings Included: Resident # 1 was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident #1 was cognitively intact. She required set up assistance with eating. She received [MEDICAL TREATMENT] treatments three times weekly and had a [DIAGNOSES REDACTED]. A review of the care plan revised on [DATE] revealed a plan of care was in place for, at risk of [DIAGNOSES REDACTED] with goals to include reducing the risk of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (elevated blood sugar) and associated complications. Interventions included; identifying signs of [DIAGNOSES REDACTED] such as change in mental status, confusion, lethargy, and diaphoresis (sweating), providing diet, accuchecks, and medications per order, and reporting abnormal values to the physician promptly. The physician's orders [REDACTED]. A review of the facility's investigation dated [DATE] documented Nurse #1 worked 3:00 - 11:00 PM on [DATE]. At 8:45 PM, per her documentation, she performed a finger stick blood sugar on Resident #1 and it was noted to be 31. Nurse #1 gave the resident a container of juice with added sugar and fruit. She left the resident and went to break. Later in the evening at 10:20 PM she was told by a nurse aide that resident #1 was diaphoretic. Nurse #1 rechecked the residents blood sugar and it was 35. The on-call facility physician was notified, and verbal orders were given to administer [MEDICATION NAME] 1 mg (milligram) IM (intramuscular injection) and recheck the blood sugar. The nurse did not recheck the blood sugar and administered instant glucose (a rapidly absorbed gel to increase blood sugar levels) a second time. The physician gave orders to send her to the Emergency Department. Resident #1 coded in the facility after 911 was notified and the facility nurse-initiated CPR (cardiopulmonary resuscitation). The facility investigation documented that Nurse #1 left the resident unattended with a blood sugar of 31, she failed to recheck the blood sugar per facility protocol, she failed to ensure the resident recovered from the hypoglycemic episode, she failed to recheck the resident for an hour and twenty minutes and failed to carry out physician orders. A review of the interview conducted by the facility with Nurse #1 on [DATE] documented Nurse #1 stated in response to the residents' low blood sugar, that she gave two tubes of instant glucose, rechecked her blood sugar and it was 36, and stated she gave what was available. During the interview she was asked why it took her an hour and twenty-five minutes before checking on the resident again, and why she didn't follow the hypoglycemic protocol. Nurse #1 replied that the resident had low blood sugars before and they would just have her eat and replied that she didn't know there was a hypoglycemic protocol, and she didn' t know what the standing orders were. A review of the physician standing orders for signs and symptoms of [DIAGNOSES REDACTED] included; for blood sugar below 50, immediately recheck and document. If the resident can safely take oral treatment, offer sweetened drink, sugar candy, or other foods that resident was known to respond to. If the resident was unable to safely take oral treatment give [MEDICATION NAME] 1mg IM as needed. Recheck blood sugar and if it remains low offer oral treatment or [MEDICATION NAME] 1mg IM. After second treatment if blood sugar remains below 50, notify the physician. If, at any time, the residents' condition declines or becomes non-responsive, notify the physician immediately. A review of the nursing note dated as a late entry on [DATE] at 12:42 AM signed by Nurse #1 documented, resident refused to eat dinner and snacks. Blood sugar at 4:40 PM was 159. Residents blood sugar at 8:45 PM was 38, orange juice and crackers were given, and she began to eat them. At 10:10 PM staff notified nurse that the resident was very warm and wet with sweat. The nurse checked blood sugar and it was 31. The facility physician was called, and he gave orders to give two Instant Glucose (gel) which were administered, and blood sugar was 36. The physician was notified and gave orders to send the resident to the hospital. EMS (emergency medical services) was called around 11:00 PM. At 11:20 PM the nurse got the crash cart and started CPR because resident was unresponsive and a full code. CPR was continued until EMS arrived and took over around 11:40 PM. A review of the physician interview conducted by the facility on [DATE] documented the physician was called at 10:37 PM on [DATE], per his phone records, by Nurse #1 regarding the residents' low blood sugar. The nurse informed him that she had given glucose gel and then resident began to refuse the glucose gel and her blood sugar did not improve. Nurse #1 stated the resident was awake and alert. He ordered her to give [MEDICATION NAME] IM now, recheck blood sugar and call him back afterwards. No return call was received. He called the nurse back at 10:48 PM to ask what the blood sugar was and if the [MEDICATION NAME] was given and the nurse stated yes, she had given [MEDICATION NAME]. He told the nurse to call 911 and give a second [MEDICATION NAME] in five minutes. He was not called again until 11:28 PM and informed that the resident was coding, and EMS had just arrived. The physician documented that he was concerned that a lot of time had passed from his last call until the time EMS arrived. He documented that the nurse stated EMS was called an hour before they arrived. A review of the Emergency Services record documented on [DATE] the 911 call was received at 11:05 PM, and EMS arrived on scene at 11:17 PM. Upon arrival staff were giving compressions. According to the staff the resident became unresponsive five minutes prior to arrival. She was taken to the ambulance placed on a cardiac monitor and a tube was placed to assist with ventilation. She was transported to the Emergency Department. The hospital progress note dated [DATE] documented Resident #1 was alert but not improved. The family decided the resident would enter hospice care and stop [MEDICAL TREATMENT]. An interview was conducted on [DATE] at 1:25 PM with the facility physician who was on call [DATE]. He stated he instructed the nurse to give [MEDICATION NAME] IM for the resident's low blood sugar and call him back after she did so. He stated eight minutes passed with no return phone call. He called the nurse back and she stated she had given [MEDICATION NAME], he then instructed her to call EMS. He stated he expected the nurse to administer the [MEDICATION NAME] per his order and to call him back, and to call EMS at the time he instructed her to do so which was 10:48 PM. He stated that low blood sugars can cause cardiac arrythmias and the two-hour delay in treatment by the nurse and not administering the [MEDICATION NAME] per his orders did lead to the resident going into [MEDICAL CONDITION]. He stated since that time they have gone through remediation with staff regarding managing low blood sugars and its dangers. The physician reported [MEDICATION NAME] was now placed in more locations and instructions have been reviewed on how to administer [MEDICATION NAME] IM safely. He stated he in serviced staff on [DATE] which included classifications of [DIAGNOSES REDACTED], what to do, how to give [MEDICATION NAME], and what to do immediately after administration. A phone interview was conducted on [DATE] at 5:14 PM with Nurse #1. She stated she had been informed by the off going nurse that the resident had episodes of low blood sugars at times and the residents blood sugar was okay before dinner, but the resident did not eat dinner that night. Nurse #1 reported at around 8:30 PM her blood sugar was 38 and she gave orange juice with sugar and she still had her meal tray, so she offered fruit and crackers. She stated she felt confident the resident would eat so she went on break and came back around 9:30 PM and resident was alert and eating. The nurse stated she went back to check her blood sugar while the aides were changing her around 10:00 PM and it was at that time when she was lethargic, she gave instant glucose then called the doctor and the residents daughter. She stated she told the doctor that she had given instant glucose. She stated she told the nurse on the 700 halls to call EMS. She stated she made the decision to call EMS then she called the doctor. She stated Nurse #2 came in and notified her that the resident coded. She stated [MEDICATION NAME] was administered in the mouth and stated the resident was alert and oriented and drinking OJ and had one bite of crackers when she left the residents room after the 8:45 PM blood sugar. She stated on the second blood sugar around 10:00 PM her blood sugar was 31 and the resident was not speaking, she was turning her head, fighting and pushing away. Nurse #1 stated she told the doctor that all she had was a tube of instant glucose and he told her to give it and call him back, and she did not have a chance to call him back. He then called her back and at that time she was busy with the resident. She stated the doctor told her to give another dose of [MEDICATION NAME]. She stated she received no formal training upon hire as far as protocols or standing orders, and that she knew from experience as to what to do for low blood sugars. She stated a normal blood sugar was ,[DATE]. She stated the doctor did not tell her to give an injection. An interview was conducted on [DATE] at 10:58 AM with Nurse #2 who was on duty the night of [DATE]. She stated the resident looked as if something was wrong, and Nurse #1 informed her that her blood sugar was low. Nurse #1 asked Nurse #2 to recheck the residents blood sugar and it was 39 and her color had not changed at the time and stated she could not recall the time that occurred. Nurse #2 stated while she was near the residents room watching for EMS to arrive, the residents color changed so she ran and grabbed the crash cart across from the nurses station. Nurse #2 stated she looked like she was coding so she grabbed the crash cart, and back board, and started CPR until EMS arrived. She stated EMS arrived quickly maybe within ,[DATE] minutes. A phone interview was conducted on [DATE] at 7:30 PM with the Emergency Medical Services lead medic who responded to the call. She stated compressions were given by the facility staff and EMS took over compressions upon arrival and stated the blood sugar was up to 118 at the time of transport the hospital. She stated the EMS low blood sugar protocol was not initiated due to blood sugar of 118. A review of the hospital progress note dated [DATE] documented that Resident #1's [MEDICAL CONDITION] was suspected to be due to prolonged [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 1:15 PM. She stated Nurse #1 was terminated on [DATE]. She stated nursing staff were oriented to facility protocols and standing orders at the time of hire and were instructed on how to access the standing orders located in the electronic charting system. The DON stated it was her expectation that the nurses administered medications as ordered by the physicians and followed facility protocols in the provision of care. She stated the [MEDICATION NAME] injections were available on [DATE] and were kept in the facility Omnicell (medication dispensing system), and on the crash carts which are located on each hall. The corrective action for noncompliance dated [DATE] was as follows: 1.A thorough investigation was initiated on [DATE] to determine the root cause regarding failure to follow the physicians order to administer [MEDICATION NAME] injections and failure to follow the facility policy regarding standing orders for [DIAGNOSES REDACTED]. The facility documented that on [DATE] resident #1 was experiencing symptoms of [DIAGNOSES REDACTED]. Nurse #1 noted her blood sugar to be 38 at 8:45 PM and crackers, juice and snacks were provided at that time. Her blood sugar at 10:10 PM was 31. The physician was notified, and orders were given to administer [MEDICATION NAME] and glucose was administered by the nurse. A code was initiated, and the resident was sent to the hospital for evaluation. Her primary [DIAGNOSES REDACTED]. She has a history of noncompliance with [MEDICAL TREATMENT] and medications. The responsible party and the physician were made aware. The Director of Nursing (DON) provided statements from staff that were working on [DATE]. The DON completed in services and provided education to the nursing staff regarding standing orders for [DIAGNOSES REDACTED], how to access standing orders in electronic charting, and the facility policy on nursing care of residents with diabetes. The facility medication carts were audited on [DATE] and additional [MEDICATION NAME] and glucose were purchased for all carts. The corrective actions for the affected resident included: The physician was notified on [DATE] and orders given to send to the hospital. The resident's responsible party was notified on [DATE]. The nurse was reported to the Health Care Personnel Registry and the North [NAME]ina Board of Nursing on [DATE] and was terminated. The corrective action for residents with the potential to be affected included; all licensed nurses were in serviced prior to their next scheduled shift on standing orders for [DIAGNOSES REDACTED], and how to access standing orders, and care of diabetic residents on [DATE]. The facility Medical Director provided in-service training to licensed nurses on care of residents with diabetes on [DATE]. On [DATE] nurse aides were in serviced regarding reporting abnormal signs and symptoms to the nurses. 2.Measures implemented to assure the deficient practice would not reoccur include; all medication carts were audited on [DATE], and [MEDICATION NAME] purchased for all carts on [DATE]. New hires would be educated on how to access standing orders and return demonstration with nurse instructor to ensure understanding. The facility standing orders were laminated and placed in the physician phone order notebook for nursing reference on [DATE]. 3.Outcomes of compliance with the plan of action will be monitored by discussion in the morning administrative meeting by the Director of Nursing, or appropriate designee, five times a week for four weeks, followed by weekly for four weeks, and as needed beginning on [DATE] and continuing as outlined in the plan. The DON will bring outcomes of compliance with designated plan to the facility monthly meeting Quality Assurance (QA) meeting for three months beginning [DATE], then quarterly for one year. The facility Quality Assurance Performance Improvement (QAPI) committee will review during morning administrative meetings, as well as monthly and quarterly meetings. Noncompliance with the corrective action plan will be discussed and the plan revised as needed. As part of the validation process on [DATE] the plan of correction was reviewed which included dates and content of the in-services that were conducted, laminated copies of the facility protocol, supplying the med carts with [MEDICATION NAME], and interviews with the nurses and nurse aides to ensure their understanding and knowledge of [DIAGNOSES REDACTED] and reporting abnormal signs and symptoms. During the investigation twelve direct care staff were interviewed regarding training that was conducted and knowledge of diabetic care to include recognizing symptoms of [DIAGNOSES REDACTED]. Multiple observations were conducted of the medication carts, the crash cart, and locations of where [MEDICATION NAME] was stored. All nurses interviewed were able to demonstrate where the facility standing orders were located, and where to find [MEDICATION NAME] IM injections, and where the crash carts were located. The facility alleges full compliance with this plan of correction effective date [DATE].

Based on observations and staff interviews the facility failed to: 1) air dry 7 trays of clean 8 oz. beverage glasses and 1 tray of clean serving bowls before stacking them on top of one another in storage and failed to remove dried food debris from 2 of 12 serving bowls; 2) failed to dispose of 4 expired hamburger rolls and one expired 4 oz. chocolate milk carton, and 3) failed to label and date two open bags of dried cereal. Findings included: 1. During the initial tour of the kitchen beginning on [DATE] at 11:45 AM, 7 trays of clean wet 8 oz. beverage glasses were observed to be stacked on top of one another with moisture trapped inside them and a tray of wet individual serving bowls were observed to be stacked under one tray of dry bowls with noted moisture trapped inside them. A follow up tour of the kitchen on [DATE] at 11:25 AM, revealed there were 12 wet individual serving bowls observed to be stacked under one tray of dry bowls with noted moisture trapped inside them. Two of the 12 bowls were noted to have dry food debris inside the bowls. An interview was conducted with the Food Service Director (FSD) on [DATE] at 11:30 AM. The FSD stated her expectation was that dietary staff ensure piece of kitchenware were clean and air dried before stacking them on top of one another to prevent moisture from being trapped which could cause bacteria to grow. The FSD stated the dietary staff were all new and were recently in serviced and trained during orientation on how to properly store kitchenware to prevent food borne illnesses. An interview was conducted with the Cook Manager (CM) on [DATE] at 1:55 PM. The CM reported the dietary staff were responsible for washing, drying and storing the dishes. The CM stated the dietary staff had been in serviced and were oriented on how to wash, dry and store dishes. The CM stated his expectation was that the staff ensure that wet dishes were not stacked on top of one another and should be spread out so they can dry completely. 2. During the initial tour of the kitchen beginning on [DATE] at 11:45 AM, 1 package of hamburger rolls was noted to be expired. The expiration date was [DATE]. During a tour of the walk in refrigerator, 1 carton out of 12 4 oz. chocolate milk was expired on [DATE]. A follow up tour of the kitchen on [DATE] at 11:25 AM revealed there were 3 packages of hamburger rolls that expired on [DATE]. An interview was conducted with the FSD on [DATE] at 11:25 AM. The FSD reported the expired items should have been discarded on the day they expired. The FSD stated the dietary staff were all new and were recently in serviced and trained during orientation to ensure all packages were within the recommended use date and to monitor and dispose of any expired items daily. 3. During the initial tour of the kitchen beginning on [DATE] at 11:45 AM, 2 packages of opened dried cereal were observed in the dry storage room with no label or date. An interview was conducted with FSD on [DATE] at 11:50 AM. The FSD reported the dried packages of food looked like they were granola and stated they should have been labeled and dated. The FSD stated it looked as though there had been a date on the package but it was illegible. An interview was conducted with the CM on [DATE] at 2:00 PM. The CM stated a dietary aide (DA #1) was responsible for checking the dried storage room, the walk in refrigerator and the walk in freezer for any expired products and to ensure the packages were labeled and dated when opened. The CM reported DA #1 was responsible for putting the deliveries away each Tuesday and he was in serviced to make sure all products were labeled, dated and expired products were disposed of. DA #1 was unavailable for an interview on [DATE] at 2:00 PM.

Based on staff interviews and review of the facility ' s abuse policies and procedures the facility failed to include procedures in the abuse policies related to not providing personal care to an alleged sexual abuse victim for 1 of 1 residents reviewed for alleged sexual assault (Resident #2). The findings included: The facility ' s Abuse Policy titled Abuse Prevention Program, dated (MONTH) 2006 did not include instructions for staff related to not providing personal care to an alleged sexual abuse victim. Resident #2 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had severe cognitive impairment. The MDS noted the resident required extensive to total assistance with all activities of daily living, was non-ambulatory and incontinent of bowel and bladder. A nursing progress note dated 3/28/18 at 9:46 PM revealed the following: NA (Nursing Assistant) reported a male resident was in resident ' s room standing over her. He was immediately removed from the room and taken back to his room. Resident had no marks and brief was still intact. Resident is now resting in bed with safety measures in place. Family and DON (Director of Nursing) notified. An interview was conducted on 4/4/16 at 5:28 PM with NA #1 who was assigned to Resident #2 on the 3 PM to 11 PM shift on 3/28/18. The NA stated she was coming down the hall and saw a walker in the doorway of Resident #2 ' s room. The NA stated when she got to the room she observed a male resident standing at the bedside leaning over Resident #2. The NA further stated the sheet was pulled down and she could see the resident ' s incontinent brief but could not see the male resident ' s hands. The NA further stated the male resident was fully clothed and she did not notice anything unusual about his clothes but did not notice if his pants were unzipped. The NA stated she ran to the nurse ' s station and got the nurse and they both went back to the room where they saw the male resident standing by the bed facing the door and the nurse told him to get out and he got his walker and left the room. The NA stated she escorted him back to his room and asked him what he was doing in Resident #2 ' s room and he stated he needed sex. The NA stated she returned to the room of Resident #2 and she checked the resident to see if the male resident had done anything to her. The NA further stated the resident had a brownish discharge that had some light pink material in it and the resident had been incontinent of urine and she cleaned her up and disposed of the brief in the trash. The NA stated a family member came in and wanted to check the resident and when the brief was removed there were 2 spots of bright red blood in the brief and when the family member wiped her with pre-moistened wipes there were streaks of blood on the wipes. The NA stated at that point the family member wanted Resident #2 to go to the hospital to be checked and EMS and the police were called and the resident sent to the Emergency Department (ED). On 4/4/18 at 12:45 PM a Family Member stated on the night of the incident the family received a call from the facility that a male resident had been caught with Resident #2 and someone would call her in the morning. The Family Member stated she went to the facility and she was told the NA (Nursing Assistant) caught a male resident in Resident #2 ' s room with her gown pulled up and the male resident stated he needed sex and the NA made him leave the room. The Family Member further stated the staff had not checked the resident ' s brief and she checked the resident and when she pulled back her brief there was a small amount of blood on the brief and she asked the staff if the resident was on her cycle and was told the resident had no bleeding up to this point. The Family Member stated she requested the resident be sent to the hospital and EMS (Emergency Medical Services) was called and they came and transported the resident along with the sheets on the bed and she took the brief with her to the hospital. The Family Member further stated the police came to the hospital and asked for the sheets and the brief for evidence. An interview was conducted on 4/4/16 at 4:40 PM with Nurse #1 who was assigned to Resident #2 on the 3 PM to 11 PM shift on 3/28/18. The interview revealed the following: The NA notified her that a male resident was in Resident #2 ' s room and they both went to the room and observed the male resident standing over Resident #2. The male resident was escorted back to his room by the NA and told him to stay in his room. The gown of resident #2 was pulled up and her incontinent brief exposed but was intact. The Nurse stated the resident had been incontinent and the NA changed the resident and provided peri-care. The family and the DON were notified. The Nurse further stated a family member came in about 20 minutes later and wanted to check the resident and when the brief was removed there were 2 small spots of bright red blood in the brief. The family member used pre-moistened wipes to wipe the resident and noted streaks of blood on the wipe. The police and EMS (Emergency Medical Services) were called and the resident was transported to the Emergency Department (ED) for evaluation. The family member took the brief with her to the ED. On 4/5/18 at 4:50 PM an interview was conducted with the Administrator and the Facility Consultant. The Consultant stated their abuse policies and procedures did not include procedures related to not providing personal care to an alleged sexual abuse victim.

Based on record review and staff interviews the facility failed to use the assigned mechanical lift to transfer a resident from the bed to a wheelchair, resulting in a left femur fracture which required surgery for [REDACTED].#98). Findings included: Review of Resident #98's annual Minimum Data Set ((MDS) dated [DATE] revealed a readmission date of [DATE] and [DIAGNOSES REDACTED]. Resident #98 was severely cognitively impaired. Resident #98 required the extensive assistance of two persons for transfers and had no impairment in the functional range of motion in the upper and lower extremities. Resident #98 did not reject care. Review of Resident #98's Care Plan revised 01/19/18 revealed the resident was at risk for falls due to increased weakness and that extensive assistance for activities of daily living (ADLs) was required. Goals included a reduction in the risk for falls and the improvement to limited assistance for ADLs. Interventions included the use of a mechanical lift. Included in the Care Plan was the Kardex which direct care staff utilized to provide care to residents. The Kardex revealed Resident #98 was a transfer by mechanical lift only. Review of the General Nursing Notes dated 02/11/18 at 6:12 PM written by Nurse #2, revealed that approximately one hour prior to shift change Resident #98 was lowered to the ground by Nursing Assistant (NA) #4 who was transferring the resident to a wheelchair from the bed. Resident #98 was picked up off the floor by Nurse #2 and NA #4 and placed into the wheelchair. Nurse #2 assessed Resident #98 at that time and no complaints were noted. As the day progressed Resident #98 complained of left leg pain and an order for [REDACTED]. Review of the Radiology impression dated 02/11/18 revealed Resident #98 had a fracture to her left leg. Review of a Late Entry General Nursing Note dated 02/12/18 revealed Physician #1 had been notified of Resident #98's fracture at approximately 8:20 PM on 02/11/12. A new order was received to send Resident #98 to the emergency room (ER). Review of the Hospital Discharge Summary dated 02/14/18 revealed Resident #98 underwent a surgical repair of the left leg fracture. Review of the undated and unsigned Summary of Investigation revealed the facility determined the incident was related to the employee's failure to follow Resident #98's plan of care as indicated on the Kardex. Review of the facility Investigation initiated 02/12/18 revealed NA #4 failed to transfer Resident #98 per the plan of care utilizing the mechanical lift. NA #4 attempted to transfer Resident #98 without assistance which resulted in a guided fall to the floor. Later in the day Resident #98 complained of pain and was transferred to the hospital. X-rays revealed an acute impacted [MEDICAL CONDITION] femur. Review of the typed witness statement in the Occurrence Report dated 02/11/18 revealed Nurse #2 indicated Resident #98 was being dressed and transferred into a wheelchair and was lowered to the ground. In a telephone interview on 03/15/18 at 2:29 PM Nurse #2 indicated NA #4 came to her and informed her that Resident #98 had been lowered to the ground after becoming weak during a transfer. Nurse #2 stated that she and Charge Nurse #1 physically lifted Resident #98 off the floor into the wheelchair. She stated she assessed Resident #98 who had no complaints of pain at that time. She indicated that later that day Resident #98 began to complain of pain and an x-ray was ordered. Nurse #2 stated that NA #4 had not asked her how to transfer Resident #98. She indicated that if an aide did not know how a resident was transferred, the aide should ask the nurse or look it up. She stated if there was any doubt then a mechanical lift should be used. Review of NA #4's undated handwritten witness statement revealed she had asked Nurse #2 how residents were transferred and had not been told that Resident #98 required a mechanical lift. During the physical transfer of Resident #98 to the wheelchair, Resident #98's knees became weak and NA #4 placed Resident #98 on the floor. NA #4 notified Nurse #2 who came to the room and attempted to physically lift Resident #98 off the floor. The attempt was unsuccessful and the assistance of Charge Nurse #1 was requested. Nurse #2 and Charge Nurse #1 physically lifted Resident #98 into the wheelchair from the floor. Resident #98 had no complaints for the remainder of the shift. In a telephone interview on 03/15/18 at 10:02 AM NA #4 stated she had been employed by the facility for three weeks at the time of the incident and was not that familiar with Resident #98. NA #4 stated she asked Nurse #2 how residents got up and was not told that Resident #98 needed a mechanical lift for transfers. She indicated she knew she should look at Resident #98's care plan but since she was not familiar with the resident she asked the nurse. NA #4 stated she sat Resident #98 on the side of the bed, wrapped her arms around her, and lifted the resident off the bed. She indicated Resident #98's knees became weak and she lowered the resident to the floor. NA #4 stated she went to get Nurse #2 and they attempted to lift Resident #98 off the floor. When they were unable to lift Resident #98, Charge Nurse #1's assistance was requested. Charge Nurse #1 and Nurse #2 physically lifted Resident #98 off the floor and into the wheelchair. NA #4 indicated Resident #98 did not complain of pain to her. Review of a Witness Interview Form dated 03/15/18 and signed by the Director of Nursing Services (DNS) revealed a hand written interview with Charge Nurse #1. In the interview, Charge Nurse #1 revealed Nurse #2 requested assistance with transferring Resident #98. When Charge Nurse #1 arrived at the room, Resident #98 was sitting on the floor and had no complaints. Resident #98 was physically lifted into the wheelchair and then began to complain of left leg pain. In a telephone interview on 03/15/18 at 1:27 PM Charge Nurse #1 stated NA #4 indicated Resident #98 had been eased to the floor. Charge Nurse #1 and Nurse #2 physically lifted Resident #98 to the wheelchair and did not use a mechanical lift for the transfer. Charge Nurse #1 stated Resident #98 did not complain of pain at that time but started to complain of pain about an hour or two after the incident. Charge Nurse #1 stated resident transfer information was listed on the Kardex and that aides should check there to see what type of transfers residents needed. In an interview on 03/15/18 at 3:30 PM the Director of Nursing Services (DNS) stated she expected the aides to check the Kardex in the computer kiosk for resident transfer requirements. She indicated that if an aide did not know how a resident was transferred they could always call her, the Administrator, or a therapist for the information. The DNS indicated if there was any doubt then a mechanical lift should be used. Review of the facility Plan of Action dated 02/12/18 revealed: 1. Corrective action for the resident affected. An in-house x-ray was ordered and an order to send the resident to the ER for an evaluation was received. An interview with the aide was conducted to determine the root cause analysis of the incident. It was determined the aide did not utilize the computer kiosk to determine the correct transfer method for Resident #98. Disciplinary action took place. 2. Corrective action for residents with the potential to be affected. All mechanical lifts were inspected by the Maintenance Director. Resident Kardexes and care plans were reviewed to make sure they matched and were the safest transfer method. The safest transfer methods for new admissions were to be determined by a therapist and placed in Kardex. The resident census was updated and lift transfers highlighted and placed in NA notebook and in the narcotic book on each resident hall. 3. What measures/systems will be put into place to ensure the deficient practice does not occur again? All NA's were in-serviced on facility policy to properly transfer residents, how to determine proper transfer method on the Kardex and how to safely remove residents from the floor post fall. During new hire orientation NAs will be trained on the proper use of mechanical lifts and where to find the transfer information in the Kardex. Safe Resident Handling Power Point presentation will be reviewed with all new hires. Mechanical lifts will continue to be inspected weekly and repaired as needed. Safe Resident Handling and the facility Buddy Program will be reviewed annually. Transfer audits will be conducted randomly for four weeks. Any non-compliance will be addressed as it occurs and discussed in morning clinical meetings. Transfer audits will be reviewed and discussed by the safety committee monthly. The Orientation Checklist was updated to include a return demonstration of locating the Kardex on the facility kiosk. 4. How will performance be monitored and how often? The results of the compliance with the plan will be discussed and the minutes recorded for four months during the facility's monthly QAPI meeting with adjustments to the plan made as needed. The results of the audits and compliance with the plan will be discussed and minutes recorded quarterly for three quarters during the quarterly QAPI committee meeting. Should revisions be necessary appropriate staff would be re-in-serviced by the Administrator, DNS, or appropriate designee. The Action Plan showed in-servicing of NAs had been completed by 02/13/18. Mechanical Lift Transfer lists were seen in the NA notebook and in the narcotic books on each hall. The mechanical lifts had been inspected by the Maintenance Director. Audits were ongoing. In an interview on 03/15/18 at 11:35 AM NA #5 stated if she needed to find out how a resident needed to be transferred she would look in the computer kiosk. NA #5 proceeded to bring the lift information up on the kiosk screen. She indicated the information was also kept in the NA book at the nursing station. In an interview on 03/15/18 at 1:45 PM NA #1 indicated if she did not know how to transfer a resident she would look in the computer for the information.

Based on observation, staff interviews, and policy review the facility failed to prevent cross contamination by not removing contaminated gloves prior to handling clean surfaces in the resident's room for 1 of 3 sampled residents (Resident #234) reviewed for wound care. The findings included: The facility's policy on general infection control practices titled Standard Precautions - Gloves., revised December, 2009, (e.) - Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). (g.) - Remove gloves promptly after use, before touching non-contaminated items and environmental services, and before going to another resident and wash hands immediately to avoid transfer of micro-organisms to other residents or environments. Resident #234 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Nurse #1 was observed performing a dressing change for Resident #234 on 04/5/17 at 9:45 AM. Nurse #1 washed hands in Resident #234's bathroom and donned gloves before beginning to physically palpate Resident #234 ' s perineal fungal/rash area, and before re-dressing the sacral pressure ulcer. Nurse #1 started the dressing change by touching all fungal rash areas around the sacral dressing and perineal area, which was partially covered with [MEDICATION NAME] cream. Nurse #1 realized she needed wipes to remove the [MEDICATION NAME] cream before the sacral wound dressing could be removed. While wearing contaminated gloves, Nurse #1 opened all 4 of Resident #234's cabinet drawers before finding wipes. Nurse #1 then used the wipes to remove the [MEDICATION NAME] cream around the sacral dressing. Nurse #1 then removed contaminated gloves, put on clean gloves and resumed re-dressing the sacral dressing. Nurse #1 did not remove gloves after touching Resident #234's fungal rash on her sacral and perineum area, and touched clean environmental surfaces with contaminated gloves, and before donning clean gloves. An interview was conducted with Nurse #1 and Nurse #2 on 04/5/17 at 10:00 AM immediately after the observation regarding policy and procedure for hand hygiene and gloving. Nurse #2 stated, Yes, Nurse #1 should have removed her contaminated gloves before she touched cabinet knobs. Nurse #1 stated, Yes, I should have removed my contaminated gloves before I opened the 4 cabinet drawers looking for wipes. I was nervous, and forgot to remove my gloves. An interview was conducted with the Director of Nursing (DON) on 04/5/17 at 10:45 AM. She stated, It was her expectation that Nurse #1 should have first removed her contaminated gloves, washed hands, found the wipes, re-washed hands, re-gloved, and resumed the dressing change, and did not.

Based on staff interviews and record review the facility failed to accurately complete the Restorative Therapy section of the Minimum Data Sheet (MDS) assessment for 1 of 19 residents (#139). Findings included: In an interview conducted with Nurse #5 on 04/06/17 at 1:56 PM she stated that the MDS department was not responsible for completing the therapy section of the MDS assessment. She said that the Therapy department was responsible for recording the information on the MDS assessment. In an interview conducted with the Director of Therapy on 04/06/17 at 2:02 PM she revealed that Restorative Therapy minutes were recorded in the American Health Tech application which therapy does not access. She stated that the MDS department was responsible for recording Restorative Therapy minutes in the MDS assessment. In an interview with the MDS Coordinator on 04/06/17 at 3:30 PM she revealed that she had called the facility corporate headquarters for clarification as to which department was to record Restorative Therapy minutes on MDS assessments. She stated that the MDS department was to record the Restorative Therapy minutes on the MDS assessments. Record review revealed that resident #139 had [DIAGNOSES REDACTED]. Review of Restorative Therapy orders during the assessment period included: passive range of motion to left hand of flexion and extension prior to apply splint, hand washing/drying of left hand if hygiene is needed, skin check of left hand prior to application and document condition, passive range of hand and digits prior to application, hand hygiene if needed, apply left resting hand splint with straps secure but not too tight, apply left arm sling after splint is in place, and 10 hour wearing schedule. Orders were dated 09/20/16 for a duration of 12 weeks, 6 to 7 days per week. Review of the Annual MDS dated [DATE] for Restorative Therapy showed the number of days resident #139 received passive range of motion as zero, and the number of days resident #139 received splint application as zero. Review of the Restorative Care per Day Roster revealed that resident #139 had received five days of passive range of motion and five days of splinting on October 7, 10, 11, 12, and 13, 2016, during the assessment look back period.

Based on observation, staff interviews and record review the facility failed to provide range of motion and splinting for 1 of 3 residents (# 139). Findings included: Record review revealed that resident #139 had [DIAGNOSES REDACTED]. Review of the most recent annual comprehensive Minimum Data Set (MDS) assessment revealed that resident #139 had intact cognition. It showed that she needed extensive assistance with bed mobility, transfers, and toilet use. The MDS also showed that she was dependent for dressing and personal hygiene. The [DIAGNOSES REDACTED]. No therapy days were recorded for restorative therapy. Review of the most recent care plan stated that the resident required assistance with many activities of daily living related to left sided [MEDICAL CONDITION] including mobility, toileting, dressing, and personal hygiene. Resident #139 was originally admitted to the facility on [DATE]. In August of 2016 she was reassessed by therapy and started Occupational Therapy with goals to be able to independently apply and remove her left resting hand splint and monitor her skin condition for effective contracture prevention and joint integrity. The second goal was to need minimal assistance with basic self-care in order to return home with family assistance safely or to remain in long term care at this facility. Therapy began on 08/04/16 and ended on 09/16/16 at which time Restorative Therapy was trained on the application of the left resting hand splint and range of motion. The number of missed treatments documented was zero. Review of the Restorative Therapy orders that started on 09/20/16 and were discontinued by the restorative aide on 12/01/16 included: passive range of motion to left hand of flexion and extension prior to apply splint, hand washing/drying of left hand if hygiene is needed, skin check of left hand prior to application and document condition, passive range of hand and digits prior to application, hand hygiene if needed, apply left resting hand splint with straps secure but not too tight, apply left arm sling after splint is in place, and 10 hour wearing schedule. Orders were dated 09/20/16 for a duration of 12 weeks, 6 to 7 days per week. In an interview conducted with CNA #2 on 04/06/17 at 10:30 AM she revealed that she discontinued the therapy for resident #139 on 12/01/16. She stated that because resident #139 had refused therapy on occasion she decided not to train the staff on the unit to continue the range of motion or splinting for this resident. She said that normally when restorative therapy was finished she would fill out a form to teach the CNA's on the unit to continue the therapy but that she had not followed through this time. She revealed that she had not informed therapy that she had stopped the treatment therefore no follow up assessment was conducted by therapy. In an interview with Nurse #3 on 04/06/17 at 12:05 PM he stated that the CNA's should have been trained by Restorative Therapy to continue with the range of motion and splinting for resident #139 when Restorative Therapy ended. He said that the range of motion and splinting should have been discontinued by a licensed staff member if it was to be stopped not by the Restorative Aide. In an interview conducted with resident #139 on 04/06/17 at 12:10 PM she stated that she wanted the therapy to continue and have the splint applied to her hand. She said that she had asked several times for the splint to be put on but that the staff had told her they didn't know how to do it. On 04/06/17 at 12:10 PM an observation was made of Nurse #3 assessing the left hand of resident #139. The hand was contracted and swollen. There was no skin breakdown observed. The resident was also observed on 04/03/16, 04/04/16, 04/05/16 and 04/06/16 not to be wearing a splint on her left hand. In an interview with the Director of Nursing on 04/06/17 at 12:16 PM she stated that when Restorative Therapy ended the CNA's on the units were to be trained to apply splints and do range of motion exercises for the residents. She stated that the CNA's should have been trained to apply the splint for this resident and do the range of motion exercises. In an interview conducted with the Director of Therapy on 04/06/17 at 1:05 PM she revealed that it was the expectation that when Restorative Therapy ended the direct care staff on the units be trained to carry on the range of motion and splinting for residents. The Administrator was present in the interview and agreed that this was the expectation. In an interview conducted with Nurse #6 on 04/06/17 at 2:19 PM she revealed that she had not been trained to continue range of motion or splinting for resident #139. She stated that normally she was trained to continue therapy once Restorative Therapy ended. She said that she had been working on the unit for the last four years and that resident #139 had been living there for the past two years. In an interview conducted with CNA #1 on 04/06/17 at 2:28 PM she stated that she had been working on the unit with resident #139 for about a year. She revealed that she had not been trained to do range of motion exercises or apply a splint for this resident. In an interview with Nurse #3 on 04/06/17 at 12:05 PM he stated that the CNA's should have been trained by Restorative Therapy to continue with the range of motion and splinting for resident #139 when Restorative Therapy ended.

Based on observations and staff interviews the facility failed to lock 1 of 7 medication carts located in the facility when the cart was left unattended on the Aberdeen Hall directly outside room [ROOM NUMBER] and failed to secure medications for 1 (Resident #1) of 122 residents when 2 of Resident #1's medications were left on top of the unattended cart. The findings included: Facility's Cart Management policy for medications states All carts will be locked when not in direct eyesight of the nurse supervising the cart and all medications will be observed by the nurse until administered. Continuous observation of the medication cart identified as the Aberdeen Hall cart on 4/07/2016 from 6:40 AM until 6:50 AM revealed the medication cart was unlocked and unattended by Nurse #1 who was not present on the Aberdeen Hall. Nurse #1 was not in direct view of the cart during this time. The lock in the center of the cart was in the unlocked position and drawers could be opened. There were no residents in the hallway at the time. Interview with Nurse #1 on 4/07/2016 at 6:55 AM revealed she was responsible for the Aberdeen Hall medication cart and that she had left 2 of Resident #1's medication on top of the unattended cart. Nurse #1 stated I left my cart and went to another hallway to attend to a resident. Nurse #1 stated she was aware that the medication cart was to be locked when she wa not in direct eyesight of the cart and that resident medications were not to be removed from the cart and left unattended. The nurse stated she could not see the cart from where she was on the other hallway. Nurse #1 stated I should not have left the cart unlocked or the medications unattended where other residents could get them. Nurse #1 identified the eyedrops as Prednisolone Suspention 1% (an antiinflamatory steroid eye drop) and the blue pill in the medication cup as Vimpat (a therapeutic anticonvulsant, schedule V). The nurse stated she would discard the unattended pill and replace the unattended eye drops. An interview on 4/07/2016 at 9:15 AM with the facility administrator revealed the it was her expectation that staff follow facility policy to lock medication carts when not in direct view and not to leave resident medications unattended at any time once removed from the cart. The administrator stated nurses were trained to follow this policy.

Based on observations and staff interviews the facility failed to ensure that the doors of two of two dumpster were kept closed and failed to make sure the area around the dumpsters were kept clean and free of debris. The findings included: The dumpster area was observed during the initial tour on 8/4/15 at 10:54 AM. Four disposable gloves were observed on the ground behind the left dumpster and 2 disposable gloves were on the ground between the 2 dumpsters. On 8/5/15 at 8:27 AM the dumpster area was observed. Outside the enclosed dumpster area on the cement pad 6 disposable gloves, straw paper and 5 cardboard food boxes were observed on the ground. On 8/6/15 at 8:09 AM the dumpster area was observed. The left dumpster, left side door was observed opened and one disposable glove was on the ground behind the right dumpster. Outside the enclosed dumpster area on the cement pad 3 disposable gloves and more cardboard pieces were observed on the ground. Directly behind the cement pad, 10 feet out 4 disposable gloves were observed on the grass. On 8/7/15 at 8:23 AM the dumpster area was observed. Both dumpster doors on the left side of each dumpster was observed open and 2 disposable gloves were on the ground between the 2 dumpsters. During an interview with the Chef Manager on 8/7/15 at 10:06 AM he stated that his staff knew to close the dumpster doors. The Chef Manager indicated he would contact environment services to clean up the area immediately. During an interview with the Environmental Management Services (EMS) Manager on 8/7/15 at 10:19 AM he stated that he expected when staff take out the trash they should remove their disposable gloves put them into the dumpster and close the doors.

Based on record review and staff interviews the facility failed to provide PRN (as needed) pain medication to 1 of 3 residents (Resident #1) who requested pain medication. The findings included: Resident # 1 was admitted to the facility 6/4/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident as cogitatively intact, having no behaviors, with frequent pain at a level of 6 out of 10. Review of Resident # 1 ' s November Medication Administration Record [REDACTED]. A follow up notation at 7:28 AM documented the medication was effective. A notation at 11:56 AM indicated that 2 PRN pain medicines were administered to the resident. There was no follow up notation. A follow up note documented at 6:19 PM the resident had received 2 PRN pain medications and that the medication was effective. In an interview with the Director of Nursing on 12/17/14 at 9:17 AM she stated that the resident ' s nurse had signed out for the medication and then discovered the medication was not available. She stated that the nurse probably never gave the resident his pain medication as documented and that he did not receive anything until 4:25 PM. The DON indicated that the nurse who signed the MAR indicated [REDACTED]. In an interview on 12/17/14 at 9:45 AM the nurse aide who worked with Resident # 1, she stated that the resident took his pain medications every 4 hours and would not want to miss any of his pain medications.