Every finding on record at Shady Oaks Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 32 opportunities with two errors made, for an error rate of 6.25%, which affected two residents (Residents #41 and #53) out of 11 sampled residents. The facility census was 65. The facility did not provide a policy regarding insulin administration.Review of the Humalog/insulin lispro (a fast-acting insulin) Pen's Manufacturer Guidelines for Priming Before Each Injection and Administration, revised 02/2023, showed:- Turn the dose selector to select two units;- Hold the pen with the needle pointing up;- Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;- Keep the needle pointing upwards, press the push-button all the way in;- The dose selector returns to zero;- A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times;- Select your dose you want to give. 1. Review of Resident #41's December 2025 Physician Order Sheet (POS) showed:- An order for Humalog Kwikpen (type of insulin pen) 10 units subcutaneous (injection under the skin) with meals related to diabetes mellitus (a disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it makes, leading to high blood sugar) after the resident had eaten each meal, dated 07/17/25.Observation on 12/03/25 at 4:08 P.M. of the resident's insulin administration showed:- Certified Medication Technician (CMT) B did not prime the Humalog Kwikpen and administered Humalog 10 units to the resident;- CMT B failed to prime the Humalog insulin pen before administering the medication to the resident.During an interview on 12/03/25 at 4:10 P.M., CMT B said the insulin pen primes itself when dialing the dose to give to the resident.2. Review of Resident #53's December 2025 POS showed:- An order for insulin lispro-aabc Pen subcutaneous as per sliding scale: if blood sugar 150-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 301-350 = 9 units; 351-400 = 11 units before meals and at bedtime for diabetes mellitus, dated 07/14/25.Observation on 12/03/25 at 11:21 A.M., of the resident's insulin administration showed:- CMT A did not put a needle on the insulin pen and attempted to prime the insulin pen but the pen would not prime without the needle attached;- CMT A administered insulin lispro-aabc 7 units to the resident;- CMT A failed to prime the insulin lispro-aabc pen before administering the medication to the resident.During an interview on 12/04/25 at 1:15 P.M., CMT A said the process for priming an insulin pen was to attach a new needle to the insulin pen, dial 2 units, push the button on top of the pen for 10 seconds to prime it. Then he/she would administer the ordered dose of insulin to the resident. The process was repeated for each insulin administration.During an interview on 12/05/25 at 10:20 A.M., Registered Nurse (RN) C said the insulin pens were primed by pushing the button on top of the insulin pen without dialing up two units of insulin to waste.During an interview on 12/05/25 at 11:45 P.M., the Director of Nursing (DON) said she would expect medications to be given as ordered and for the medication error rate to be less than five percent. Insulin pen administration should be followed by using the manufacturer's box instructions.

Based on observation, interview, and record review, the facility failed to provide enhanced barrier precautions (EBP) when staff failed to implement EBP for one resident (Resident #56) and failed to wear a gown during wound care for one resident (Resident #71) with a chronic wound out of five sampled residents. The facility census was 65.Review of the facility policy titled, Enhanced Barrier Precautions, dated 2024, showed:- All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions;- All staff receive training in high-risk activities and common organisms that require EBP;- The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities;- EBP will be initiated for residents with wounds, and/or indwelling/implanted medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO), and infection or colonization with a Centers for Disease Control and Prevention (CDC) targeted MDRO with contact precautions (gloves and gown are used for infectious agents that may be transmitted by direct or indirect contact with the person or the person's environment) do not otherwise apply;- Personal protective equipment (PPE) for EBP is only necessary when preforming high-contact care activities and may not need to be donned prior to entering the resident's room;- Place a yellow sticker or magnet on the name plate of the resident's door to identify the need of EBP;- High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care;- EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at a higher risk.1. Review of Resident #56's medical record showed:- An admission date of 02/25/13;- Diagnoses of rheumatoid arthritis (an ongoing condition that causes pain, swelling and irritation in the joints), morbid obesity, moisture associated skin damage (MASD- occurs when skin is repeatedly exposed to various sources of bodily fluids) to right inner thigh, and pressure ulcer (localized injuries to the skin and/or the underlying tissue) to the right inner thigh;- No documentation the resident required EBP;- An order for wound care to the right medial (inner) thigh to cleanse with Vashe (wound cleanser), apply skin prep (a treatment that creates a protective film) to the peri wound (skin and tissue immediately surrounding a wound), apply collagen powder (a type of treatment), apply calcium alginate (a type of treatment) cut to fit inside the wound edges, secure with an island dressing (an adhesive bordered gauze dressing), cleanse with Vashe, apply skin prep to peri wound, apply collagen powder (aids in healing) to wound bed, apply calcium alginate (manage wound drainage and promote healing) cut to fit inside wound edges, secure with island dressing (adhesive bordered gauze dressing for wounds) daily and as needed for soiling or displacement, dated 11/20/25;- A Provider Note, dated 11/11/25, showed the wounds would heal and then open back up for the past two years.Observation on 12/03/25 at 11:25 A.M. of the resident's incontinent care showed:- No EBP signage outside of the resident's room;- Certified Nurse Assistant (CNA) J did not put on a gown before entering the resident room and performed incontinent care for the resident.2. Review of Resident #71's medical record showed:- An admission date of 11/25/25;- Diagnoses of acquired absence of the right leg above the knee, acquired absence of the left leg above the knee, rectal abscess (a pocket of infection) , type 2 diabetes mellitus (a disorder in which the body doesn't produce enough or respond normally to insulin which causes blood sugar levels to be abnormally high), morbid obesity, stage three (full thickness tissue loss) pressure ulcer of the coccygeal (the area surrounding the tailbone) region, and chronic ulcer of the sacral (pressure that develops over the at the base of the spine above the tailbone) region;- The resident required EBP;- An order to clean the bilateral (both left and right) above the knee amputation incisions with wound cleanser, apply bacitracin (a topical antibiotic) and Xeroform (a sterile protective dressing that will not stick to the wound), apply skin prep to the peri wound, and cover with 6x6 gauze, dated 12/04/25;- An order to cleanse the sacrum (a shield-shaped bony structure that is located at the base of the spine) with Vashe (a wound cleanser), apply skin prep to the peri wound, pack the wound with wet-to-wet gauze moistened with normal saline (a mixture of water and salt), and secure with gauze, an abdominal pad (a thick gauze pad used to absorb discharges from heavily draining wounds), and paper tape daily and as needed for soiling or displacement, dated 12/03/25;- An order for the coccyx (the tailbone) and left ischium (the curved bone forming the base of each half of the pelvis) wound to apply a nickel-thick layer of Triad (paste that helps maintain a moist wound healing environment) two times a day and as needed to maintain a thick layer, dated 11/25/25.Observation on 12/04/25 at 4:04 P.M. of the resident's wound care showed:- An EBP sticker above the name plate on the resident's room;- An 8 inch (in.) by 10 (in.) EBP sign taped to the resident's door;- CNA H brought two gowns into the room;- CNA H put on one gown and lay the other gown on the bedside table;- Licensed Practical Nurse (LPN) G did not put on a gown and performed the resident's wound care to the right and left surgical incisions to the above the knee amputations;- LPN G leaned over the right side of the bed and cleaned the wound to the left leg;- LPN G leaned over the right side of the bed to dress the wound to the left leg;- LPN G leaned over the right side of the bed to clean the wound to the right leg;- LPN G leaned over the right side of the bed to dress the wound to the right leg.During an interview on 12/04/25 at 4:53 P.M., LPN G said he/she forgot to put a gown on before doing the resident's wound care.During an interview on 12/05/25 at 8:30 A.M., CNA E said he/she knew residents were on EBP by the EBP signage on the nameplate. If a resident had lines, implanted devices, and/or wounds, they would be on EBP. A gown should be worn when performing high-contact care on those residents. The linen closets on each hall had PPE supplies.During an interview on 12/05/25 at 8:32 A.M., the Minimum Data Set (MDS - a federally mandated assessment to be completed by the facility staff) Coordinator said EBP was documented on a resident's Kardex (a nursing system for quick resident information) and their care plan when they were on EBP. A magnet was placed outside the door and an EBP sign was put on the door. Residents on EBP were those with chronic wounds, indwelling catheters, or tubes. Staff were to wear a gown and gloves during hands-on care which included dressing a resident or performing personal hygiene. The Infection Preventionist (IP) implemented EBP.During an interview on 12/05/25 at 8:38 A.M., CNA F said he/she knew a resident was on EBP by the EBP signage. He/she wore a gown when doing high-contact care on residents with lines, wounds, and implanted devices. PPE supplies were in the linen room on each hall.During an interview on 12/05/25 at 8:40 A.M. the Infection Preventionist (IP) said EBP was implemented on residents with any kind of line or tube and pressure ulcers. He/she did not implement EBP on Resident #56 because the wound was classified as MASD. He/she was not aware of the wound having a secondary diagnosis of a pressure ulcer.During an interview on 12/05/25 AT 11:39 A.M., the Director of Nursing (DON) and Administrator said they would expect residents with pressure ulcers or a chronic wound to be on EBP. They would expect staff to wear a gown and gloves during high-contact care of a resident on EBP or with a chronic wound.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. This had the potential to affect all residents. The facility's census was 65.Review of the facility policy titled, Medication Labeling and Storage, revised February 2023, showed:- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;- If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;- Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices;- The medication label includes, at a minimum, the medication name (generic and/or brand), prescribed dose, strength, expiration date - when applicable, resident's name, route of administration, and appropriate instructions and precautions;- Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Review of the manufacturer's information for insulin aspart (a rapid-acting insulin) pen, Lantus (a long-acting insulin) Pen, Humalog (a fast-acting insulin) Kwikpen, Basaglar (a long-acting insulin) Kwikpen, and insulin lispro (a rapid-acting insulin) Kwikpen, updated May 2024, showed:- When opened or left at room temperature, the insulin aspart Pen, Lantus Pen, Humalog Kwikpen, Basaglar Kwikpen, and insulin lispro Kwikpen expires after 28 days.1. Observation on 12/04/25 at 10:40 A.M., of the Wing 1/Wing 2 medication storage room showed: - An opened tuberculin purified protein derivative (medication to check exposure of tuberculosis (a serious bacterial infection primarily affecting the lungs)) one milliliter (ml) multidose vial, dated 9/20/25. Observation on 12/04/25 at 10:55 A.M., of the Wing 1 medication cart showed: - One opened insulin aspart (a rapid-acting insulin) Pen, dated 8/20/25 (79 days past expiration date);- One opened Lantus Pen not dated;- One opened Humalog Kwikpen not dated;- One opened Basaglar Kwikpen not dated;- One opened insulin lispro Kwikpen labeled with a room number and not a resident name, dated 09/03/25 (65 days past expiration date);- One opened insulin glargine (a long-acting insulin) Pen not dated.During an interview on 12/04/25 at 11:05 A.M., Registered Nurse (RN) D said opened insulin pens and turberculin vials should be labeled with the resident's name and dated when opened. Insulin pens and tuberculin vials were good for 28 days after opened.During an interview on 12/05/25 at 11:39 A.M., the Director of Nursing (DON) said opened insulin medications and tuberculin vials should be discarded 28 days after opened.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care for two residents (Residents #17 and #61) out of four sampled residents and one resident (Resident #8) outside the sample. The facility also failed to use proper infection control techniques for glove use during catheter care for one resident (Resident #60) out of two sampled residents. The facility census was 64. Review of the facility's policy, Wound Care, dated October 2010, showed: - Put on gloves; - Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers; - Wear sterile gloves when physically touching the wound or holding a moist surface over the wound; Review of facility's policy titled Catheter Care, Urinary revised August 2022, showed: - Perform hand hygiene and use clean gloves; - Place resident in dorsal recumbent (on back with knees bent, feet spread out to sides) position or supine position during care; - Place bed protector under resident. 1. Review of #8's Physician Order Sheet (POS), dated July 2024, showed: - An order, dated 07/24/24, to cleanse the back of the left arm with normal saline, apply Medi honey gel (a supportive removal of necrotic tissue and aids in wound healing gel) and secure with silicone bordered gauze (absorbent silicone foam dressing consist of three layers to ensure wound healing) daily. - An order, dated 07/25/24, cleanse the back of the left upper arm and the back of the left elbow with normal saline, apply wet to dry dressing, secure with sterile bordered gauze (an absorptive dressing that consist of three layers). Observation on 07/30/24 at 3:01 P.M , showed: - Licensed Practical Nurse (LPN) J pushed the treatment cart into the resident's room; - LPN J washed his/her hands and applied a protective gown; - LPN J started to prepare for the treatment and realized he/she did not have all supplies on the cart; - LPN J pushed the treatment cart outside the resident's room into the hall wearing the protective gown; - LPN J gathered the needed supplies and re-entered the resident's room wearing the same gown; - LPN J performed the wound care, removed the protective gown, washed his/her hands and pushed the treatment cart outside the resident's room into the hall. - LPN J placed the treatment cart in the hall, without cleaning it. 2. Review of Resident #17's Physician Order Sheet (POS), dated July 2024 showed: - An order, dated 07/22/24 to cleanse right heel with normal saline, paint peri-wound with gentian violet (an antiseptic used for minor wound care to reduce infection), dermablue (a triple action antimicrobial protection), optifoam (a dressing for partial and full thickness wounds with moderate drainage), and wrap with comfort gauze (non-sterile absorbent gauze roll and stretches to conforms to the body). - An order, dated 07/22/24 to cleanse right foot, third toe with saline, paint with betadine (an antiseptic used for skin disinfection), apply Polymen AG dressing (a topical wound dressing that contains silver); - An order, dated 07/22/24 to cleanse the right and left shinbone area with normal saline, apply skin protectant, secure with bordered gauze every other day and as needed (prn) for preventative wound care. Observation on 07/31/24 at 2:51 P.M., showed: - LPN J in the resident's room with the treatment cart; - LPN J washed his/her hands and applied a protective gown; - LPN J performed the wound care, removed the protective gown, washed his/her hands and pushed the treatment cart outside the resident's room into the hall. - LPN J placed the treatment cart near the nurses' station, without cleaning it. During an interview on 08/01/24 at 10:45 A.M., LPN J said he/she should have removed the gown before exiting Resident #8's room to gather needed supplies. He/she said the cart is not always taken into the resident's room, however she had fairly new orders that were not in the computer and he/she had printed those out and need a place to lay the treatment orders. LPN J said with so many different kinds of supplies, he/she lays everything on top of the cart. During an interview on 08/01/24 at 3:40 P.M., Registered Nurse (RN) E said she would expect the staff to remove the gowns before exiting the resident's rooms and would not expect the staff to take the treatment cart into the resident's rooms. 3. Review of #61's POS showed: - An order for wound care to abdomen and right and left lower extremities to be cleaned with normal saline, pat dry and apply Medi honey; - An order for wound care to top of left foot and heel to be cleansed with normal saline, apply polymem AG, ABD (abdominal pad)(a dressing used to treat large wounds that require high absorbency) and wrap with conforming gauze; - An order to cleanse weeping blisters to right and left lower extremities with normal saline, apply ABD pad, wrap with conforming gauze; - An order to cleanse right and left inner thigh area with normal saline, polymem AG, cover with ABD pad and secure. Observation on 07/30/24 at 3:47 P.M., showed: - LPN K washed his/her hands, applied protective gown and clean gloves; - LPN K touched doorknob and bed frame with clean gloves; - LPN K did not change gloves before performing wound care; - LPN K removed dirty gloves, performed hand hygiene and applied clean gloves; - LPN K touched call light and without changing gloves applied Medi-honey to two open wounds on abdomen; - LPN K removed dirty gloves, performed hand hygiene and applied clean gloves; - LPN K touched blanket with clean gloves, then without changing gloves, performed wound care to right buttock. During an interview on 07/31/24 at 3:33 P.M., RN E said he/she would expect wound care to be performed using clean technique and for nursing staff to change gloves anytime they become contaminated. 4. Observation on 7/30/24 at 2:32 P.M., showed: - CNA (Certified nursing assistant) G washed hands, applied gloves and assisted Resident #60 in removing pants and undergarments to perform catheter care. - The CNA had the resident sit on the side of the bed; - Without changing gloves, CNA G took a wipe from CNA I and wiped down left side of resident's genitalia and laid it on the resident's bed sheet; - Continuing to wear the same gloves, CNA G took a new wipe from CNA I and wiped down the right side the resident's genitalia and laid it on resident's bed sheet; - CNA G then asked CNA I to retrieve a dry paper towel from the dispenser. CNA G took the paper towel and dabbed dry around catheter insertion area. During an interview on 8/1/2024 at 11:29 A.M., CNA I said he/she would lay a resident supine when performing catheter care. He/she said gloves should be changed after removing residents clothes and undergarments, and clean gloves applied before care. CNA I said he/she would not place dirty wipes on resident's clean linens and would provide a barrier or place in trash. During an interview on 8/1/2024 at 3:45 P.M., RN E she he/she would expect resident to be lying in supine position unless requested to sit up for catheter care. RN said he/she would expect clean gloves to be applied before performing catheter care. RN said he/she would not expect dry paper towel to be used during catheter care. 50260

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 64. Review of the facility's policy titled, Sanitation, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All kitchens, kitchen areas and dining room areas are kept clean, free from garbage and debris, and protected from rodents and insects; - Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions; - Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumspters/compactors with lids (or otherwise covered). 1. Observations made on 07/29/24 at 10:37 A.M. and 07/30/24 at 08:17 A.M., of the kitchen area, showed: - The floors around the food preparation area dirty and with a greasy buildup; - Visible dirt and debris under the three-compartment sink; - Visible dirt and debris under the cook stove; - Visible dirt and debris under the steam table; - A buildup of dirt, debris, and a white hard substance on sides and top panel surfaces of dishwasher; - A buildup of dirt and debris on the top of the standing two door oven; - An oven rack laid on the floor under the two-door standing oven with a buildup of debris; - A brick wall behind the two-door standing oven and two-basin sink with a dark-colored grease-like substance running down from the top of ceiling down the wall; - A buildup of dirt and debris with miscellaneous items including outdated food items and de-[NAME] on a portable cart with a black microwave located in the dry goods and canned area; - A trashcan with exposed garbage and debris by the dish machine with no lid outside the door in hallway; - A trashcan with exposed garbage and debris by the two-basin sink with no lid; - A dried reddish sauce-like substance on the wall by the trashcan by the two-basin sink located next to the walk-in freezer; - A plastic tub contained a runny, reddish, water-like meat stock liquid on the bottom rack shelf on the back wall of the walk-in freezer. 2. Observations made on 07/29/24 at 10:53 A.M. and 07/30/24 at 08:27 A.M., of the kitchen/employee breakroom showed: - A buildup of a hard white substance on the sides, top and bottom outside surfaces of the ice machine; - A buildup of a white substance around the entire edges of the lid where ice is dispensed inside the ice machine. Review of the the food temperature log, dated 01/28/24 to 07/29/24, showed several days of no documentation of meal temperature checks. Review of the daily freezer/refrigerator temperature log, dated 02/01/24 through 07/29/24, showed several days of no documentation of daily temperature checks. Review of the daily cleaning schedule, dated 06/23/24 to 07/27/24, showed several days of no documentation of kitchen staff completing cleaning tasks. During an interview on 07/30/24 at 8:34 A.M., Kitchen Aide C said food and refrigerator temperatures should be documented. Daily cleaning should be completed and staff should sign off when completed. Evening staff usually do the kitchen cleaning. During an interview on 07/30/24 at 8:38 A.M., Kitchen [NAME] D said food temperatures should be documented and it should be done daily, but he/she forgets to log the temperatures sometimes. Daily refrigerator temperatures should be documented. Kitchen cleaning should be done daily and signed off when completed. During an interview on 07/30/24 at 10:13 A.M., the Dietary Manager (DM) said the kitchen staff could do a better job at documenting food meal temperatures and refrigerator temperatures. The DM said staff should be completing daily cleaning checklist and needs to monitor this more closely to make sure tasks are being done. The RD completes inspection rounds and makes recommendations during monthly visits and should be following up with the Administrator. During an interview on 07/30/24 at 10:32 A.M., the Maintenance Supervisor (MS) said each department is responsible for bringing any concerns to the department head meetings to be addressed. During an interview on 07/30/24 at 10:42 A.M., the Administrator said she would expect scheduled kitchen cleaning, food temperature checks and refrigerator temperature checks to be completed daily by dietary staff to ensure compliance for requirement. The Administrator does kitchen inspections randomly and will address the areas of concerns in the dietary department found during the survey inspection.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the kitchen and main dining room. This deficient practice had the potential to affect all residents. The facility census was 64. Review of the facility's policy titled, Pest Control, revised May 2008, showed: - The facility shall maintain an effective pest control program; - This facility maintains an on-going pest control program to ensure the building is kept free of insects an rodents; - Windows are screened at all times; - Garbage and trash are not permitted to accumulate and are removed from the facility daily; - Maintenance services assist, when appropriate and necessary, in providing pest control services. 1. Observations made on 07/29/24 at 8:23 A.M., 07/30/24 at 8:43 A.M. at 07/31/24 at 8:10 A.M., of the library located next to the kitchen, showed: - Several dead flies laid on the bottom ledges of the left and right-side windows; - Multiple flies buzzed around the room. 2. Observations made of the assisted feeding dining room area, showed: - On 07/29/24 at 12:24 PM, an orange fly swatter laid on the ledge of the left-side window by the door facing the picnic table outside; - On 07/29/24 at 12:38 P.M. and 07/29/24 at 12:49 P.M., Resident #34 ate his/her food while a fly crawled on his/her egg noodles and blueberry cake in plate; - On 07/29/24 at 12:44 P.M., Resident #26 ate his/her food while two flies crawled on his/her clothing protector; - On 07/29/24 at 12:46 P.M., Resident #44 ate his/her food while a fly crawled on his/her dining table; - On 07/29/24 at 12:48 P.M., Resident #48 ate his/her food while flies buzzed around and two flies crawled on his/her food in plate; - On 07/29/24 at 12:51 P.M., Resident #15 ate his/her food while flies buzzed around and two flies crawled on his/her food in plate; - On 07/29/24 at 12:53 P.M., Resident #21 ate his/her food while several flies buzzed around his/her food on plate and one fly crawled on his/her forehead. - On 07/29/24 at 12:59 P.M., 07/30/24 at 9:27 A.M. and 07/31/24 at 11:14 AM., several dead flies on the right-side window ledge facing the designated smoke area. 3. Observations made on 07/30/24 at 8:22 A.M., of the kitchen area, showed: - Two flies crawled on the steam table; - Three flies crawled on the three-compartment sink back splash; - Two flies crawled on the three-door refrigerator; - Flies buzzed in and out of a trashcan with no lid by the two-basin sink and walk-in freezer. 4. Observation made on 07/30/24 at 8:26 A.M., showed flies buzzed around and throughout the kitchen area while interviewing staff. Review of the pest control inspection reports and service comments dated, 05/08/24, 6/12/24 and 07/10/24, showed: - Kitchen area inspected and treated; - Fly glue boards replaced; - Fly bait placed in random areas of the facility. During an interview on 07/30/24 at 8:26 A.M., the Dietary Manager (DM) said flies do get bad this time of year and staff use fly swatters to kill them. DM has never brought the concern to the attention of the administrator. DM said there is no pest control devices located in the kitchen to help with the fly issue. During an interview on 07/30/24 at 9:15 A.M., the Maintenance Supervisor (MS) said it is the department head's responsibility to notify the administration of any pest control issues during department head meetings so it can be addressed. MS said a new pest control company had just started servicing and treating the facility in the last few months. During an interview on 07/30/24 at 10:32 A.M., the Administrator said she was not aware of a fly concern in the kitchen or dining room. The DM had not brought the issue to her attention while doing random inspections, but this will be addressed.

Based on observation, interview and record record review the facility failed to employ a qualified director of food and nutrition services. The facility did not have a Dietary Manager (DM) with a background or required years of experience in food preparation, food service and/or food storage. This deficient practice had the potential to affect all residents in the facility. The facility census was 64. Review of the facility's policy titled, Organizational Plan and Roles of Key Staff, dated 2016, showed: - The organizational plan shall be used to communicate clearly the functions of the Dining Services Department and the appropriate chain of command. The organization plan and department organization Chart will be shared with all staff and employees; - The Administrator directly supervises the Dining Services Manager, providing support and assistance and guidelines from the Registered Dietician (RD) on a monthly basis; - The Dining Services Manager directs the food preparation and dining services activities of all other employees in the Dining Service Department at department head meeting, care plan meetings, high risk meeting and other interdisciplinary meetings in the community; - The Dining Services Managers credentials will be determined by state regulations which include a Sanitation Certification, a 90-hour approved Dietary Manager's Course, or a two or four year degree in nutrition or food service as approved by the state; - The RD will make monthly or weekly visits to identify ding service needs; plan, implement and monitor dining service programs; oversee food preparation, service and storage, access and monitor the nutritional status of residents and train community staff. Review of the facility's current employee list, dated 07/29/24, showed DM's hire date as 12/01/22. Observations made on 07/29/24 at 10:37 A.M. and 07/30/24 at 8:17 A.M., of the food service department, showed: - Staff did not maintain the cleanliness of the kitchen; - Staff did not document food temperatures; - Staff did not document cleaning schedule log; - Staff did not control pests in the kitchen. During an interview on 07/29/24 at 10:13 A.M., the DM said upon hire in December 2022, he/she was told by the Administrator and previous Administrator he/she would be enrolled in courses to become a certified dietary manager (CDM) within a year of his/her hire date. A couple of months into his/her position, DM asked about the required courses and was informed by the Administrator and previous Administrator he/she did not have to be certified after all and would not be enrolled to complete the training. Instead, DM was enrolled and completed a one-hour course called Food Safety and Principles - Food Handler Training dated 02/12/23 to meet the job requirement. DM said he/she had no previous long-term care experience as a dietary manager prior to accepting the DM position at the nursing facility. During an interview on 07/30/24 at 10:32 A.M., the Administrator said she was informed from her corporate office that a course in Food Safety and Principles - Food Handler Training was the only requirement to be completed for the dietary manager position at the time the employee was hired. She was not aware that the employee needed to have two or more years of experience in the position of the director of food and nutrition services in a long-term care nursing home setting prior to employment.

Based on interview and record review the facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for five residents (Residents #15, #18, #38, #56) out of 16 sampled residents and one resident (Resident #42) outside the sample. The facility census was 64. The facility did not provide a policy. 1. Review of Resident #15's medical record showed: - An admitted [DATE]; - Diagnoses of vascular dementia with agitation (changes in memory, thinking, and behavior) and major depressive disorder (persistent depressed mood or loss in interest); - An order for Seroquel (antipsychotic used to treat schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations) 100 milligram (mg)1 tablet two times daily (BID); - No documentation of an appropriate diagnosis for the Seroquel. 2. Review of Resident #18's medical record showed: - An admitted [DATE]; - Diagnoses of major depressive disorder (persistent depressed mood or loss on interest), senile dementia (mental deterioration or cognitive decline associated with aging), hypertension (high blood pressure), coronary artery disease (damage or disease in the heart's major blood vessels; - An order for Seroquel 100 mg, one tablet by mouth two times daily for major depressive disorder; - No documentation of an appropriate diagnosis for the Seroquel. 3. Review of Resident #38's medical record showed: - An admitted [DATE]; - Diagnoses of hemiplegia affecting non-dominant side (paralysis of the left side of the body caused by neurological injury), hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body), hypertension, major depressive disorder, (persistent depressed mood or loss on interest), anxiety (intense, excessive, and persistent worry and fear about everyday situations); - An order for risperidone (antipsychotic used to treat mental/mood/behavior disorders)1.5 mg by mouth twice daily for a diagnosis of major depressive disorder dated 05/24/24; - No documentation of an appropriate diagnosis for the Risperidone. 4. Review of Resident #42's medical record showed: - An admitted [DATE]; - Diagnoses include congestive heart failure (CHF, an inability of the heart to pump sufficient blood flow to meet the body's needs), dementia, hypothyroidism (a decreased level of thyroid hormone), gastro-esophageal reflux disease (GERD, stomach acid being forced back into the throat region), pacemaker (a device used to control an irregular heart rhythm), and bradycardia (slow heart rate); - An order for Seroquel 50 mg oral tablet daily dated 09/28/23; - An order for Seroquel 100 mg three times a day (TID) dated 7/31/24; - No documentation of an appropriate diagnosis for the Seroquel. 5. Review of Resident #56's medical record showed: - An admitted [DATE]; - Diagnoses of sacral wound, stage 4 (a pressure ulcer that appears in the sacral region), type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar), major depressive disorder (persistent depressed mood or loss on interest), anxiety (intense, excessive, and persistent worry and fear about everyday situations), chronic kidney disorder (gradual loss of kidney function over time), tremors (involuntary shaking or movement); - An order for quetiapine (Seroquel) 100 mg by mouth at bedtime for major depressive disorder dated, 07/22/24; -No documentation of an appropriate diagnosis for the quetiapine. During an interview on 08/1/24 at 10:21 A.M., the Administrator said he/she goes by pharmacy recommendations and that determines what medications residents remain on. Administrator said he/she feels residents need to remain on anti-psychotic medications if they are stable on them. During an interview on 08/06/24 at 11:55 A.M., the Director of Nursing (DON) said most of the residents that have dementia also have behaviors and the medications seem to control the behaviors. The DON said she thought it would be detrimental to the residents to discontinue the medications just because the residents do not have an appropriate diagnosis and there should be GDR's on the medications. 45872 48532 50260

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 64. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment with personalized furniture and room arrangements. 1. Observations made on 07/29/24 at 8:23 A.M., 07/30/24 at 8:43 A.M. and at 07/31/24 at 8:10 A.M., of the library located next to the kitchen, showed two soiled blankets with dirt, debris and several dead flies laid on the bottom ledges of the left and right-side windows. 2. Observations made on 07/29/24 at 12:59 P.M., 07/30/24 at 9:27 A.M. and 07/31/24 at 11:14 A.M., of the assisted feeding dining room area, showed: - A buildup of dirt, debris and several dead flies on the right-side window ledge facing designated smoke area; - A buildup of cob webs and dirt on the left and right-side windows facing the outside designated smoking area; - A buildup of dirt on the left and right-side windows of the door leading outside to the picnic table. During an interview 08/01/24 at 9:59 A.M., Housekeeper A said window ledges and windows are cleaned on a regular basis. Anything on the outside of the facility is done by someone else and not housekeeping. During an interview 08/01/24 at 10:03 A.M., Housekeeper B said window ledges and windows are cleaned on a weekly basis. Outside cleaning of the facility, such as cleaning windows is done by maintenance. He/she gets together with maintenance in the Spring and assists with outside cleaning to help out. During an interview 08/01/24 at 2:52 P.M., the Maintenance Supervisor (MS) said the facility's outside window cleaning is the responsibility of the maintenance department. MS checks the outside windows weekly. Housekeeping department helps with outside window cleaning as well. During an interview on 08/01/24 at 2:58 P.M., the Administrator said he/she would expect windows to be free of dirt buildup and cobwebs. Window cleaning should be the responsibility of housekeeping department for the inside of facility and the maintenance department for the outside of facility. Maintenance and housekeeping departments get together twice a year and cleans the outside facility windows. 3. Observations made on 07/30/24 at 2:07 P.M., of the secured unit shower room, showed: - A buildup of black grime approximately 16 inches up the wall and in the corners where the walls meet and four cracked 4 x 4 tiles; - A buildup of black grime approximately one foot (ft) up the wall on the left and right side of the shower walls; - A red rubber hose extending from the shower arm with a metal clamp attached near the sprayer end; - A buildup of dust and debris on the 12 x 12 exhaust fan over the toilet; - A large area of a brown dried substance under the sink area. During an interview on 7/30/24 at 9:55 A.M., Housekeeper (HS) A said the housekeeping department is contracted and not an employee of the facility. He/She said whoever works the hall is responsible for cleaning the shower rooms/and stalls. HS A said there is mold and mildew in the shower rooms because their company doesn't use the right chemicals. During an interview on 8/1/24 at 9:00 A.M., the Administrator said she would expect the shower stall to be cleaner and did not realize there were cracked tiles. She said the reason the red rubber hose is used because the standard shower head and extension breaks easily, and the rubber hose can be extended without the chance of it breaking. 45872

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 54. Record review of the facility's Maintenance Service policy, revised December 2009, showed: - Maintenance service shall be provided to all areas of the building, grounds, and equipment; - The Maintenance Department shall be responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Maintenance personnel will maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines; - Maintenance personnel will maintain the building in good repair and free from hazards; - Maintenance personnel will provide routinely scheduled maintenance service to all areas; - The Maintenance Director will be responsible for maintaining the inspection of the building records and work order requests. 1. Observations on 1/23/23 at 7:45 A.M., showed: - Resident #1 sat at the dining room table in a wheelchair with a two inch (in.) split area on the top center of the chair's left side arm pad, and a one in. split area on the top back area of the chair's right arm pad that could injure the resident's skin; - Resident #7 sat in the dining room in a chair with the right arm pad cracked and peeled in multiple spots that could injure the resident's skin; - Resident #42 sat at the dining room table in a wheelchair with arm pads cracked and peeled away around all sides of both the left and right chair arm rests that could injure the resident's skin. 2. Observation on 1/23/23 at 8:23 A.M., showed: - room [ROOM NUMBER]'s sink with a pipe underneath dripped water onto two loose floor tiles, surrounded by a black-colored substance. 3. Observation on 1/23/23 at 3:30 P.M., on Unit 2 near room [ROOM NUMBER], showed: - Two, 1 foot (ft) by 2 ft ceiling tiles with small brown circular stains; - A 6 in. by 1 ft ceiling tile with a small brown circle. 4. Observation on 1/24/23 at 10:50 A.M., on Unit 1 showed: - Near room [ROOM NUMBER], a 1 in. by 4 ft ceiling tile with a small brown circle on the west side of the light panel; - Near room [ROOM NUMBER], near the air vent, a 1 ft by 1 1/2 ft ceiling tile with a 1 ft by 3 in linear brown marking; - Near room [ROOM NUMBER], a 1 ft by 2 ft ceiling tile with two small brown discolored circles. 5. Observation on 1/24/23 at 11:00 A.M., on Unit 3 showed: - Near room [ROOM NUMBER], a 2 ft by 2 ft ceiling tile with two small brown circles; - In the dining room near the nurses' station, a 2 ft by 3 ft ceiling tile with small brown circles; - On the west side of the dining room, a 2 ft by 4 ft ceiling tile with nine small yellow/orange circles; - On the east side of the dining room, a 5 in by 2 ft ceiling tile with a large area of discolored brown markings. During an interview on 1/24/23 at 8:25 A.M., the Maintenance Assistant said at times staff will tell the maintenance department when something needs repaired, but most of the time staff fills out a work order which should be placed in the maintenance log book at the nurse's station and the maintenance department checks the log book on a daily basis. The work order should be signed and dated when completed. During an interview on 1/24/23 at 12:35 P.M., Certified Nurse Aide (CNA) C said if he/she saw equipment that needed repaired, he/she would put a repair request in the maintenance request log at the nurse's station, and it would get taken care of. During an interview on 1/24/23 at 12:40 P.M., the Administrator said she would expect if a staff member saw something in the facility that needed to be fixed, such as wheelchair arm pads, ceiling tiles, and floor tiles, they would fill out a maintenance request form in the log book at the nurse's station so it could be repaired. During an interview on 1/24/23 at 1:30 P.M., CNA A said staff usually told maintenance if they saw anything and maintenance took care of it. He/she had never put a work order in the book. 39201 47678

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff for three residents (Resident #10, #11 and #48) out of 14 sampled residents. The facility census was 54. Record review of the facility's Resident Assessment policy, revised March 2022, showed all personnel who complete any portion of the MDS, must sign attesting to the accuracy of such information. 1. Record review of Resident #10's admission MDS, dated [DATE], showed: - Resident received an anticoagulant (a blood thinner) medication daily. Record review of the resident's physician order sheet (POS), dated November 2022, showed: - No order for an anticoagulant. During an interview on 1/22/33 at 4:00 P.M., the Director of Nursing (DON) said Resident #10 was not on an anticoagulant and would expect it not to be coded on his/her MDS. During an interview on 1/24/23 10:20 A.M., the MDS Coordinator said he/she should code anticoagulant medications on a resident's MDS only if they were actually receiving it. 2. Record review of Resident #11's annual MDS, dated [DATE], showed: - Resident with no wound Stage 1 (a reddened, painful area on the skin that doesn't turn white when pressed) or higher. Record review of the resident's Weekly Skin Assessments, dated 11/1/22, 11/8/22, 11/15/22, and 11/22/22, showed: - Resident with a stage 2 (partial thickness loss of the dermis which presents as a shallow open ulcer with a red or pink wound bed) pressure ulcer on his/her left buttock. Observation of Resident #11's wound care on 1/24/23 at 10:30 A.M., showed: - Resident with a wound to his/her left buttock. During an interview on 1/24/23 at 11:55 A.M., the MDS Coordinator said he/she would expect a pressure ulcer to be indicated on the most recent MDS. 3. Record review of Resident #48's admission MDS, dated [DATE], showed: - Diagnoses of anxiety (intense, excessive worry and fear about everyday situations) and depression (a mood disorder causing persistent feelings of sadness and loss of interest); - Not coded for a diagnosis of Alzheimer's (a progressive disease that destroys memory and other mental functions). Record review of the resident's POS, dated 11/30/22, showed: - admitted [DATE]; - A diagnosis of Alzheimer's disease; - An order for Donepezil (an Alzheimer's medication) 10 milligram (mg) by mouth at bedtime, dated 11/30/22. During an interview on 1/24/23 at 8:58 A.M., the Administrator said she would expect the MDS to be coded correctly with the resident's diagnosis. During an interview on 1/24/23 at 9:05 A.M., the DON said the MDS should be coded with an Alzheimer's diagnosis. During an interview on 1/24/23 at 2:01 P.M., the MDS Coordinator said the MDS should be completed accurately to reflect the resident's condition. 47447 47678

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility census was 54. Record review of the facility's Administering Medications policy, dated, April 2019, showed: - Insulin pens will be clearly labeled with the resident's name or other identifying information; - Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen will be used for that resident; - The expiration/beyond use date on the medication label will be checked prior to administering; - When opening a multi-dose container, the date opened will be recorded on the container. Record review of the manufacturer's directions for Lantus (a type of insulin) insulin pen dated 2022, showed: - Lantus insulin pens should be discarded 28 days after first use, regardless of refrigeration. Record review of the manufacturer's directions for Novolog (a type of insulin) flexpen prefilled syringe, dated 6/2021, showed: - Novolog prefilled syringes should be thrown away after 28 days once opened. Record review of the package insert for Tuberculin Purified Protein Derivative (TB) (a sterile aqueous solution used in the testing for tuberculosis) solution, dated 3/2016 showed: - Vials in use more than 30 days should be discarded . Observation on 1/24/23 at 12:37 P.M., of the medication room on Unit 1 showed: - One opened Lantus Solostar Solution Pen-injector labeled with an opened date of 12/15/2022; - One opened Novolog Flexpen Solution Pen-injector not labeled with the date opened, the resident's name, and/or the expiration date; - Three bottles of TB opened and not labeled with the date opened. During an interview on 1/24/23 at 12:45 P.M., Licensed Practical Nurse (LPN) B said the TB vials should be dated when opened and the insulins should have a resident's name and date when it arrives to the facility and a date when opened. During an interview on 1/24/23 at 1:00 P.M. the Director of Nursing (DON) said the TB bottles should be dated when opened and the insulin should have a name and dated as well. She said she was not sure how long the insulin was good for, she would need to check and see. During an interview on 1/24/23 at 1:03 P.M. the Administrator said the bottles of TB should be dated when opened and the insulin should have a name and date on them. She said she was not sure, but would check with pharmacy on how long they were good for after opening.

Based on observation, interview, and record review, the facility failed to follow physician's order for the use of supplemental oxygen therapy for one resident (Resident #12) out of two sampled residents and one resident (Resident #14) outside the sample. The facility census was 54. Record review of the facility's policy for Oxygen Administration, dated October 2010, showed: - Provide the guidelines for safe oxygen administration; - Verify the physician's order for this procedure; - Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident. 1. Record review of Resident #12's Physician Order Sheet (POS), dated January 2023, showed: - Diagnosis of chronic obstructive pulmonary disease (COPD) (a lung disease that blocks airflow); - An order for oxygen at 2 liters per minute (L/min) per nasal cannula (N/C) (supplemental oxygen administered through tubing into the nostrils) as needed (PRN) for shortness of breath, dated 6/6/20. Record review of the resident's care plan, dated 1/13/23, showed: - The resident required supplemental oxygen therapy as needed; - Administer oxygen 2 L/min by N/C. Observation of Resident #12 on 1/22/23 at 3:39 P.M., showed: - The resident reclined in his/her recliner with oxygen on at 5 L/min per N/C. During an interview on 1/22/23 at 4:22 P.M., Licensed Practical Nurse (LPN) D said he/she would have to review the resident's order to confirm the oxygen order. After reviewing the resident's oxygen order, LPN D said the resident's oxygen should be on 2 L/min per N/C PRN. Observation of Resident #12 on 1/22/23 at 4:25 P.M., LPN D decreased the oxygen rate to 2 L/min per NC. During an interview on 1/24/23 11:52 A.M., Certified Nurse Assistant (CNA) E said he/she had never seen the resident adjust the oxygen and thought he/she was unable to do so. 2. Record review/ of Resident #14's POS, dated January 2023, showed: - An order for oxygen 2 L/min by N/C PRN, dated 8/22/22. Record review of the resident's care plan, dated 11/16/22, showed: - The resident required oxygen therapy; - Administer oxygen as ordered. Observations of the resident showed: - On 1/22/23 at 11:15 A.M., the resident lay in bed with oxygen on at 0.5 L/min per N/C; - On 1/23/23 at 9:30 A.M., and 2:45 P.M., the resident lay in bed with oxygen on at 0.5 L/min per N/C. During an interview on 1/23/23 at 2:50 P.M., CNA F said the resident never adjusts the knob on the concentrator, had never seen him/her touch the concentrator at all. He/she said the resident will ask for the oxygen at times when staff put him/her to bed. During an interview on 1/23/23 at 2:53 P.M., CNA G said he/she had never seen the resident touch the concentrator. During an interview on 1/24/23 at 2:30 P.M., the Director of Nursing (DON) said she would expect a resident who received oxygen to be on the ordered L/min unless the resident had adjusted it themselves.

Based on observation, interview, and record review, the facility failed to ensure a proper [DIAGNOSES REDACTED].#46) out of five sampled residents. The facility census was 64. 1. Record review of Resident #46's Physician order [REDACTED]. - an order for [REDACTED]. Record review of the resident's medical record showed: - [DIAGNOSES REDACTED]. - No documentation of specific, targeted behaviors; - No attempt by the physician for an appropriate [DIAGNOSES REDACTED]. Record review of the pharmacist's monthly Medication Regimen Review (MMR) log, 1[DATE] - [DATE], showed no pharmacist's recommendations for an appropriate [DIAGNOSES REDACTED]. Record review of the resident's care plan, reviewed on 1/16/20, showed: - No antipsychotic medication use with interventions; - No identification of specific, targeted behaviors with interventions. Record review of Mosby's 2019 Nursing Drug Reference for [MEDICATION NAME] showed: - Contraindications for geriatric patients; - Black box warning of increased mortality in elderly patients with dementia (a brain disease which may cause a decrease in thinking ability)-related [MEDICAL CONDITION] (some loss of contact with reality); - Possible serious reactions in geriatric patients of fatal (death) pneumonia (lung inflammation caused by bacterial or [MEDICAL CONDITION] infection), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), sudden death, and dementia. Observations of the resident showed: - On [DATE] at 3:34 P.M., the resident lay in bed quietly with his/her eyes closed; - On 2/20/20 at 8:21 A.M., 1:01 P.M., and 4:16 P.M., the resident lay in bed quietly with his/her eyes closed; - On [DATE] at 8:06 A.M., the resident lay in bed quietly with his/her eyes closed. During an interview on [DATE] at 11:20 A.M., the Director of Nursing (DON) said she would expect the physician to document an appropriate [DIAGNOSES REDACTED]. She would expect the facility staff to identify specific, targeted behaviors for the resident that receives an antipsychotic medication and to document them in the medical record. Record review of the facility's Antipsychotic Medication Use policy, revised on 12/2016, showed: - Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms identified and addressed; - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - [DIAGNOSES REDACTED]. - The staff will observe, document, and report to the attending physician information in regards to the effectiveness of any interventions which include antipsychotic medications.

Based on interview and record review, the facility failed to implement care plans with specific interventions tailored to meet individual needs for two residents (Resident #46 and #50) out of 16 sampled residents. The facility census was 64. 1. Record review of Resident #46's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/3/20, showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. - Moderately impaired cognitive status; - Received antipsychotic medication; - Received antidepressant medication. Record review of the resident's Physician order [REDACTED]. - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, reviewed on 1/16/20, showed: - No antipsychotic medication use with interventions; - No identification of specific, targeted behaviors with interventions; - No individualized interventions for the [MEDICAL CONDITION] care; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors 2. Record review of Resident #50's medical record showed: - [DIAGNOSES REDACTED]. - A nurses' note showed the resident moved to the secured unit after he/she threatened and attempted to leave the facility, dated 1/15/20. Record review of the resident's care plan, last updated 1/24/20, showed: - No focus area for elopement; - No focus area in relation to moved to the secured unit. During an interview on [DATE] at 11:04 A.M., the MDS Coordinator said the reason for the antipsychotic medication use, especially for behaviors, should be documented on the resident's care plan. If a resident attempts to elope and/or wanders and is moved to the secured unit, it should be addressed on the resident's care plan. During an interview on [DATE] at 11:20 A.M., the Director of Nursing (DON) said she would expect a resident's care plan to address why a resident is receiving an antipsychotic medication and specific, targeted behaviors if the resident has them. She would also expect a resident's care plan to address a resident's attempts to elope or wander and is moved back to the secured unit. Record review of the facility's Comprehensive Person-Centered Care Plan policy, dated 12/2016, showed: - Will include measurable objectives and timeframe's; - Describe the services to be furnished; - Describe services not provided due to the resident exercises his/her rights; - Incorporate identified problem areas; - Incorporate risk factors associated with identified problems; - Build on resident's strengths; - Reflect resident's wishes; - Aid in prevention or reduction of a decline in the resident's functional status and/or functional levels; - Enhance the optimal function of the resident with a focus on a rehabilitative program; - Reflect current recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure proper transfer technique for one resident (Resident #65) out of three sampled residents. The facility census was 64. Record review of the facility's Gait Belt (a device to aide in the safe transfer of a resident) Transfer Procedure policy, undated, showed: - Place the gait belt around the resident's waist, below the ribs and over the resident's clothing; - A gait belt should always be with you; - The nurse assistant should not transfer or ambulate residents by grasping their upper arms or under their arms. 1. Observation on 2/20/20 at 10:00 A.M., of Resident #65, showed: - The resident sat in his/her wheelchair: - Certified Nursing Assistant (CNA) B placed a gait belt around the resident's waist; - CNA B grabbed the resident under his/her right arm, Licensed Practical Nurse (LPN) A grabbed the resident under his/her left arm, stood the resident up, pivoted the resident to sit on the bed; - The resident's feet drug across the floor; - The resident did not bear weight or help during the transfer. During an interview on [DATE] at 9:13 A.M., LPN A said when a resident is transferred by a gait belt, both hands should be on the gait belt. You are not supposed to grab the resident under the arms. During an interview on [DATE] at 11:15 A.M., the Director of Nursing (DON) said she would expect to properly transfer residents with a gait belt. Staff should not grab a resident under the arms; both hands should be on the gait belt.

Based on interview and record review, the facility failed to ensure residents diagnosed with [REDACTED]. level of functioning and psychosocial needs for three residents (Resident #23, #45, and #46) out of three sampled residents. The facility census was 64. 1. Record review of Resident #23's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 12/9/19, showed: - An admission date of [DATE]; - A [DIAGNOSES REDACTED].>- Moderately impaired cognitive status; - Received an antipsychotic (a major tranquilizer) medication; - Received an antidepressant medication. Record review of the resident's Physician order [REDACTED]. - A [DIAGNOSES REDACTED]. - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, last updated on 12/24/19, showed: - No individualized interventions for the [DIAGNOSES REDACTED].>- No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors. 2. Record review of Resident #45's annual MDS, dated [DATE], showed: - An admission date of [DATE]; - Severely impaired cognitive state; - A [DIAGNOSES REDACTED].>- Received an antipsychotic medication; - Received an antidepressant medication. Record review of the resident's POS, dated February 2020, showed: - [DIAGNOSES REDACTED]. - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, last updated 1/14/2020, showed: - No individualized interventions for the [DIAGNOSES REDACTED].>- No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors. 3. Record review of Resident #46's significant change MDS, dated [DATE], showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. - Moderately impaired cognitive status; - Received antipsychotic medication; - Received antidepressant medication. Record review of the resident's POS, dated February 2020, showed: - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, reviewed on 1/16/20, showed: - No antipsychotic medication use with interventions; - No identification of specific, targeted behaviors with interventions; - No individualized interventions for the [MEDICAL CONDITION] care; - No non-pharmacological interventions to help improve his/her mood and to help control some of his/her thoughts and behaviors During an interview on 2/20/20 at 4:00 P.M., the MDS/Care Plan Coordinator and the Director of Nursing (DON) said if a resident had a [DIAGNOSES REDACTED]. plan. The DON said she had not realized dementia care with a resident's targeted behaviors should be care planned and not just behaviors in general. The DON and the MDS Coordinator said they did not realize the behaviors should be related to the resident's dementia.

Based on observation and interview, the facility failed to ensure the handrails on Wing Three were properly attached to the wall and without sharp edges. The facility census was 64. 1. Observation on 2/20/20 at 9:06 A.M., of the handrails on Wing Three, showed: - Handrail on the left side of room [ROOM NUMBER], two of three supports broken through the drywall on the wall and the handrail not secure; - Handrail on the right side of the nurses' area door, two of three supports broken through the drywall on the wall and the handrail not secure; - Handrail on the left side of the door of room [ROOM NUMBER], no end cap on the rail and the plastic rough; - Handrail on the left side of the door of room [ROOM NUMBER], no end cap on the rail and the plastic rough; - Handrail on the left side of the door to the soiled utility room, no end cap on the rail and the plastic rough; - Handrail on both sides of the door to the dining room, no end cap on the rail and the plastic rough; - Handrail on both sides of the door to the nurses' room, no end cap on the rail and the plastic rough. During an interview on 2/20/20 at 2:30 P.M., the Administrator said the handrails should be secured to the wall and the end caps should be on the handrails to prevent injury. The Administrator said she had been unaware of these issues and they would be fixed immediately.

Based on observation, interview, and record review the facility failed to thaw food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 64. Observation on 2/20/20 at 12:00 P.M., of the kitchen showed: - Two, 10 pound (lb) rolls of pork loin lay in a container in the sink; - The upper corner of the roll of pork loin not covered by water; - No water running continuously over the pork loin. During an interview on 2/20/20 at 1:40 P.M., Cook C said the pork loin is needed for the menu tomorrow. They usually thaw meat on the bottom shelf of the refrigerator, but had forgot to start to thaw the meat. It was decided to thaw it under running water, but the water had been turned off and not all the meat had been covered by water. During an interview on 2/20/20 at 4:00 P.M., the Dietary Manager (DM), said the meat should have been completely submerged in the water and under running water. The DM said it should have been caught by someone in the kitchen the meat was not thawing properly. Record review of the facility's Thawing Frozen Food policy, dated 4/2019, showed; - To thaw in the refrigerator in a drip proof container; - To completely submerge the item in cold running water 70 degrees Fahrenheit or below with water running fast enough to agitate and remove loose ice particles.

Based on interview and record review, the facility failed to ensure the pharmacy consultant identified an appropriate [DIAGNOSES REDACTED].#46) out of five sampled residents. The facility census was 64. 1. Record review of Resident #46's Physician order [REDACTED]. - an order for [REDACTED]. Record review of the resident's medical record showed: - [DIAGNOSES REDACTED]. Record review of the pharmacist's monthly MMR log, 1[DATE] - [DATE], showed no pharmacist's recommendations for an appropriate [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:28 A.M., the Pharmacist said the medical director has been the main prescriber for the [MEDICAL CONDITION] (any medication that affects the mind, emotions, and behaviors) medications. He/she knows the medical director doesn't like to be questioned about the ordering and the use of the [MEDICAL CONDITION] medications so the Pharmacist doesn't address the diagnosis/use for these medications with the medical director. He/she will look at the [DIAGNOSES REDACTED]. If there isn't a psychiatric diagnosis, then he/she reviews the nurses' notes and the care plan to look for behaviors and such and then he/she documents that reason for the [MEDICAL CONDITION] medication use. During an interview on [DATE] at 11:20 A.M., the Director of Nursing (DON) said she would expect the pharmacist to report the need of an appropriate [DIAGNOSES REDACTED]. She would expect the physician to document an appropriate [DIAGNOSES REDACTED]. Record review of the facility's Pharmacy Services Overview policy, revised on 4/2019, showed: - Pharmaceutical services consist of the provision of medication-related information to health care professionals and residents; - Specific procedures governing pharmacy services will be developed by the consultant pharmacist in collaboration with the medical director and the DON services.

Based on observation, interview and record review the facility failed to initiate a timely investigation into the bruises of unknown origin for one resident (Resident #1). This failure to report and investigate allowed an inappropriate practice to continue causing bruising the resident. The facility census was 70. Record review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 3/09/10 showed: - No short or long term memory problems; - Make self understood; - Understands others; - Vision highly impaired; - Requires limited assistance with bed mobility and transfers; - Totally dependent on staff for locomotion off the unit; - Not able to attempt the test for balance while standing without physical help; - Shin desensitized to pain or pressure. Record review of the physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - Aspirin 81 milligram (mg) one tablet by mouth at bedtime (start date 9/23/09 and discontinued 12/23/10). Record review of the Nurses Notes showed: - On 12/13/10 11:00 P.M., "yellow/blue bruising noted to chest and under right arm. Will cont. to monitor." - On 12/16/10 at 10:00 P.M., "Right backside with bruising. Denies pain or discomfort." - On 12/22/10 at 10:00 A.M., Noted large hematoma from under resident right axillary to right hip, swollen, resident has not had any falls per herself in a long time, resident is not on any blood thinner such as [MEDICATION NAME] or aspirin. - On 12/22/10 (no time given) Send to hospital ER for evaluation of hematoma to right lateral ribs. - On 12/22/10 at 12:25 P.M., Ambulance called for transport. - On 12/23/10 at 1:20 P.M., Discontinue aspirin and have Physical Therapy evaluate for Hoyer lift due to right side bruising. Record review of the Weekly Skin Assessment form, dated December 2010 showed: - On 12/14/10 large bruise to right side of back. Resident unable to state what happened. - On 12/22/10 large bruise to right side of back (mid shoulder to lower back). Record review of the Skin Monitoring: Comprehensive CNA Shower Review form dated 12/18/10 showed the resident with bruising to his/her chest wall and right back side. Record review of the Hospital records sent back to the facility with the resident, dated 12/22/10 at 6:10 P.M., showed [DIAGNOSES REDACTED]. Record review of the facility Resident Abuse/Neglect Investigation report showed: - Date of occurrence: Found on 12/13/10; - Report to the Director of Nursing and Administrator on 12/22/10 at 10:00 A.M.; - Unknown bruising; - Resident injured: Hematoma to right side; - The resident sent to the hospital for evaluation; - Bruises noted by staff to right side and right axilla with hematoma; - Bruises noted on 12/13/10; - Conclusions from investigation: No neglect/abuse occurred, CNA/Licensed Practical Nurse's concerned with staff use of gait belt. During an interview on 12/23/10 at 12:18 P.M., the Administrator said the bruise on the resident was reported on 12/22/10. She had talked to the DON and was told the resident would be sent to the hospital. She did not know how the bruises happened. During an interview on 12/23/10 at 12:30 P.M., the DON said she had started her investigation on 12/22/10 after she was informed about the bruises. She had talked to the resident and he/she had said no one had hurt her. The staff thought the bruising could be from the use of the gait belt. During an interview on 12/23/10 at 12:35 P.M., the DON said she was not aware that the nurses notes contain documentation of bruising to the resident on 12/13/10,12/16/10, or that the shower sheet had showed that the resident had bruising. She normally would start an investigation when the incident occurred but this resident bruises had not been report until 12/22/10. If it had been reported to her on the 12/13/10 she would have investigated it at that time and could have stopped the aspirin and the use of the gait belt. She said the staff should report anything abnormal to her and the Administrator. During an interview on 12/23/10 at 12:52 P.M., CNA D said he/she had seen the bruises on the resident on 12/21/10 on the day shift and reported it to the supervisor. Observation on 12/23/10 at 1:00 P.M., showed Resident #1 sitting in his/her wheel chair. CNA A and CNA B applied a gait belt by placing the gait belt around the upper part of the resident's chest wall. The resident said "Oh" as the CNA A buckled the gait belt. Both CNA's grabbed the resident under his/her arms and grabbed the gait belt from the back and transferred the resident to the bed. The resident could not bear full weight. Observation on 12/23/10 at 1:05 P.M., showed the resident's upper chest wall yellow in color (fresh bruises on the skin are usually red or purple while older bruises turn green and then yellow or brown). Under the resident's right arm down to his/her hip (approximate 12 inch by 8 inch) showed a dark purple and red bruise area. During an interview on 12/23/10 at 1:15 P.M., CNA A said he/she had placed the gait belt on the resident's upper chest wall because of the bruises to the resident's right side. He/she said the resident did not have the bruises on Monday. During an interview on 12/23/10 at 2:35 P.M., the Administrator said the gait belt should never be placed on the resident's chest area. The CNA's are instructed on the proper use of the gait belt in CNA classes. During an interview on 12/23/10 at 2:23 P.M., CNA E said he/she had seen the bruises on the resident. He/she could not remember the date but it was a few week ago, it was reported to the nurse. The shower aide had also written it down. During an interview on 12/23/10 at 2:55 P.M., the Administrator said she did not know how the resident had got the bruises but the investigation should have started when it was first found. Record review of the facility Abuse Prevention Program showed: - Indicators of potential abuse as in finding unwitnessed injuries such as skin tears, bruising, swelling should be reported. - An employee, volunteer, visitor, or anyone with knowledge of the incident, or possible incident should report the incident. - The report can be made verbally or in writing to the charge nurse who will complete a resident abuse/neglect report. - The charge nurse will forward the resident abuse/neglect report to the Director of Nursing Services, or designee, who will report to the Administrator. - The report is to be made as soon as the incident, or potential incident, is made known. - The resident abuse/neglect report is to be completed by the charge nurse by the end of the assigned work period. - The DON, or designee, is to be informed prior to the end of the work period and as soon as is practicable. - The Administrator, or acting Administrator, is to be informed as soon as is practicable, and in no more than 24 hours. - Every employee must report witnessed abuse, any remarks or reports made which might indicate abuse has occurred, and any unexplained sign of injury, like bruising or skin tears, immediately to the charge nurse.