Every finding on record at Shiloh Nursing and Rehab, LLC

Based on observation, interview, and facility policy review, the facility failed to ensure food was thawed properly and in sanitary conditions, specifically thawing fish in a dirty sink at room temperature with no water. This failed practice had the potential to affect 4 of 4 residents who received the alternate meal choice from the kitchen. The findings are: On 02/24/2025 at 11:03 am, during the initial tour of the kitchen, a zipper sealed bag of frozen fish was observed in a sink with no water. The sink also contained a whisk and a knife with a yellow liquid substance covering them. On 02/24/2025 at 11:04 am, the Dietary Manager (DM) was asked what was in the zipper sealed bag. The DM said it was frozen fish. The DM stated that the fish was for the alternate meal choice. On 02/26/2025 at 9:06 am, the DM was asked to explain how frozen meats, fish, and poultry should be thawed. The DM confirmed that the proper way is to place the frozen food in a pan and run cold water over it. The DM was asked what could happen if frozen food was served to residents that had been thawed improperly. The DM confirmed the residents could get sick. On 02/27/2025 at 9:04 am, [NAME] #3 confirmed training and in-servicing on safe food handling had been completed. [NAME] #3 confirmed the proper way to thaw frozen meats, fish, and poultry is to either sit it in the refrigerator 3 days prior to serving or placing it in a pan and running cold water over it. On 02/27/2025 at 9:11 am, Dietary Aide #5 (DA) was asked to explain how to properly thaw frozen meat, fish, or poultry. DA #5 confirmed that frozen food should be placed in a deep pan and covered with cold water. DA #5 confirmed that improper thawing of meats, fish, and poultry could cause the residents to get sick if served and consumed. On 02/27/2025 at 9:41 am, the Administrator confirmed competencies and trainings were done with staff regarding safe food handling. The Administrator was asked to describe a possible negative outcome if meat, fish, or poultry were served to residents that had been improperly thawed. The Administrator said they could get sick from a foodborne illness. On 02/27/2025 at 1:22 pm, [NAME] #4 confirmed in-service training on safe food handling had been completed. [NAME] #4 also confirmed that the proper way to thaw frozen meats was to place them in a deep pan and run cold water over it. [NAME] #4 was asked what potential negative outcome could occur from serving meats that had been improperly thawed. [NAME] #4 said that it could make people sick. The Administrator provided dietary staff competencies on basic skills check-off, diets, and food textures, in-service on safe food handling, and the policy and procedure on thawing foods. The policy and procedure for thawing frozen foods indicated 4 acceptable methods of thawing: refrigeration, as part of cooking process, microwave, and in a pan with cold water. The policy also indicated that All food is purchased, stored, prepared and distributed in a clean safe sanitary manner promoting safe food handling and compliance with state and federal guidelines.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain infection control prevention for 4 (Residents #24, #59, #62, and #67) of 5 residents reviewed for infection control. The findings include: A review of a facility policy titled, Medication, Insulin Injection, revised 11/22/2016, indicated, equipment and supplies needed included clean gloves which would be put on prior to withdrawal of insulin from the vial. Gloves were to be removed after administration and disposal of needle and syringe in the sharp's container. A review of a Centers for Disease Control (CDC) undated table titled, Summary of Personal Protective Equipment (PPE) Use and Room Restriction When Caring for Residents in Nursing Homes, provided by the Administrator on 02/26/2025, as the facility's guide for PPE application indicated, standard precautions applied to all residents and PPE should be utilized for situations with any potential for exposure to blood, body fluids, mucous membranes, non-intact skin, and potentially contaminated environmental surfaces or equipment. Depending on anticipated exposure, any or all may be required: gloves, gown, face mask or eye protection. During an observation on 02/26/2025 at 7:37 AM, Licensed Practical Nurse (LPN) #1 administrated 3 units (u) of short acting insulin by subcutaneous (SQ) injection to Resident #62 in the left upper arm, without wearing gloves as a standard precaution. During an observation on 02/26/2025 at 7:41 AM, LPN #1 administrated 6u of short acting insulin by SQ injection to Resident #24 in the left lower abdominal quadrant, without wearing gloves as a standard precaution. During an observation on 02/26/2025 at 7:50 AM, LPN #1 administrated 10u of a short acting insulin by SQ injection to Resident #59 in the left lower abdominal quadrant and a second syringe with 55u of long-acting insulin in the right lower abdominal quadrant, without wearing gloves as a standard precaution. During an interview on 02/26/2025 at 7:55 AM, LPN #1 stated she did not routinely use gloves when administering medications. During an observation on 02/26/2025 at 8:46 AM, LPN #1 administrated 17u of a long-acting insulin by SQ injection to Resident #67 in the right upper abdominal quadrant, without wearing gloves as a standard precaution. During an interview on 02/26/2025 at 8:07 AM, the Infection Preventionist (IP) stated, during administration of SQ injections, gloves should definitely be used for standard precautions. During an interview on 02/26/2025 at 1:33 PM, the Director of Nursing (DON) stated, standard precautions should be utilized at all times when personal care was provided by staff, including the administration of a SQ injection. During an interview on 02/27/2025 at 10:12 AM, the Administrator stated, gloves and hand hygiene should be utilized during a medication pass. During an interview on 02/27/2025 at 1:42 PM, the Medical Director stated, he expected the staff to wear the appropriate PPE during administration of a SQ injection.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to properly label and discard a medication per the manufacture's guidelines for 1 medication cart of 3 carts reviewed for medication labeling and storage. The findings include: A review of a facility policy titled, Medication Storage in the Facility, revised in January 2018 indicated, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. When the original seal of a manufacture's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. A review of the (Brand Name) inhaler package insert indicated, 16. How Supplied/Storage and Handling: Each canister is packaged in a foil overwrap pouch with desiccant sachet and placed into a carton. The inhaler should be discarded when the labeled number of inhalations have been used or within 3 months after removal from the foil pouch. During a concurrent observation and interview on 02/26/2025 at 1:22 PM, Licensed Practical Nurse (LPN) #2 retrieved Resident #74's (Brand Name) inhaler from the Apple Blossom/Bayberry medication cart. The inhaler had a small pharmacy label with a printed date of 05/10/2024. LPN #2 stated she was unable to locate an open date or an expiration date, we barely use it, it maybe expired. No original packaging or bag was located with the full pharmacy label. LPN #2 located a second (Brand Name) inhaler in another drawer. The small pharmacy label had a printed date of 09/25/2024, no open date was located on the inhaler, and both inhalers had been used according to the inhaler meter. During an interview on 02/26/2025 at 1:33 PM, the Director of Nursing (DON) stated, open dates should be placed on inhalers when they are opened for the first time. During an interview on 02/27/2025 at 10:12 AM, the Administrator stated, open dates should be placed by the nurse on medications at the time of opening and nurses should check for expiration dates at the end of their shift.

Based on observation, and interview, the facility failed to ensure dietary staff washed their hands before serving food in the kitchen to prevent potential for cross contamination. This failed practice had the potential to affect 72 residents who received a tray from the kitchen. The findings are: 1. On 1/4/24 at 12:33 pm, observed Dietary Employees (DE) #2 and #3 standing near the food line go directly to the food line and begin serving food to the residents without washing their hands before serving food. 2. On 1/4/24 at 3:29 pm, during an interview the Surveyor asked the Dietary Manager (DM) what should an employee do before they start to serve food? The DM said wash their hands. The Surveyor asked what could happen from staff not washing their hands. The DM said if they had germs or an infection, they could pass it through the food to the residents. 3. On 1/5/24 at 8:04 am, during an interview the Surveyor asked DE #2 what should an employee do before serving food on the line? DE #2 said wash my hands. The Surveyor asked what could happen if you don't wash your hands? DE #2 said it could spread infection to residents. 4. On 1/5/24 at 8:04 am, during an interview the Surveyor asked DE #3 what should an employee do before serving food on the line? DE #3 said wash your hands. The Surveyor asked what could happen if you don't wash your hands. DE #3 said it could spread infection to residents. 5. On 1/4/24 at 3:52 pm, the Administrator provided a facility policy titled, Handwashing/Hand Hygiene, which documented, The facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .

Based on observation, interview and record review, the facility failed to investigate in a timely manner a possible injury to 1 (Resident #42) of 1 sampled resident, who reported a possible knee injury to the nurse due to an improper transfer performed by a staff member. The findings are: 1. Resident #42 had a diagnosis of rheumatoid arthritis, reduced mobility, and muscle wasting atrophy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/23 documented the resident received a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and required two plus persons assistance for bed mobility and transfer. a. On 01/02/24 at 2:42 PM, Resident #42 informed the Surveyor that a few days ago when the staff was changing her, when they got ready to roll her back over, they let her leg just fall over instead of rolling her back over and she heard her right knee pop. Resident #42, then pulled back the covers for the Surveyor to observe her knee. It was swollen and much larger than her left knee and had some discolored areas to it. The Surveyor asked Resident #42, did you report this to anyone. Resident #42 said it didn't hurt until the next day, and I told my nurse on the weekend about it and she just kind of brushed me off stating it was probably just still my shingles, but I told her know it was hurting and something was going on with it. 3. On 01/03/24 at 8:20 AM, the Surveyor asked Resident #42 if she had informed anyone else about her knee, Resident #42 said yes, I told my nurse last night and the nurse this morning. I told the nurse this morning that I needed to see my provider about it that it was really hurting. 4. On 01/3/24 at 12:25 PM, the Surveyor asked the Director of Nursing (DON) for a list of Incidents and Accidents for Resident #42 in the past 30 days. The DON said, I don't have any. I am getting ready to write one because the Physician Assistant just informed me that Resident #42 had reported an injury to her right knee. 5. On 01/03/24 at 8:00 PM, the Surveyor reviewed the x-ray of the right knee, which was negative for injury. 6. On 1/3/24 at 2:24 PM, during a phone interview with Licensed Practical Nurse (LPN) #3, the Surveyor asked if she was aware of Resident #42. LPN #3 said yes, I am. The Surveyor asked do you know how many people it takes to transfer her in bed. LPN #3 said two people. The Surveyor asked has she complained of pain to you. LPN #3 said yes in her shoulders and her right knee. The Surveyor asked can you remember when she complained. LPN #3 said yes on 12/23/24. The Surveyor asked what did you do for her pain? LPN #3 said she asked me to rub some (Name Brand) Pain-Relieving Gel on her shoulders and right knee. The Surveyor asked did you notify the provider of the new pain she had informed you of in her right knee. LPN #3 said no I didn't. The Surveyor asked did you do an Incident and Accident on her new pain after she informed you of what happened. LPN #3 said no I didn't. The Surveyor asked did you report the new pain to your director of nursing? LPN #3 said no I didn't. 7. On 01/04/24 at 3:44 PM, during an interview with LPN #1 the Surveyor asked if a resident complains of pain and reports an injury from staff, what should the nurse do? LPN #1 said the nurse should assess the area that the resident is complaining about. The Surveyor asked after assessing, if the nurse confirms that there is an injury what should the nurse do? LPN #1 said I should contact the provider. 8. On 1/4/24 at 4:01 PM, during an interview, the Surveyor asked the Director of Nursing (DON) if a resident complains of pain or an injury that a staff member could have done, what should the nurse do? The DON said first assess the possible injury. Do a pain assessment and after the assessment, if there is a difference in the resident assessment the nurse should contact the provider. The Surveyor asked if the nurse doesn't investigate the resident's complaint what could happen? The DON said it could cause the resident to be in unnecessary pain, or if here was an injury it could get worse. 9. On 1/4/24 at 4:44 PM, the DON provided a facility policy titled, Incident and Accident Policy which documented, Policy Al1 incidents and accidents occurring in this Facility or its premises will be investigated and reported to the Administrator and Director of Nursing. An incident or accident is an incident or unusual occurrence where there is apparent injury, or where injury may have occurred. An incident may also be allegations or suspicions of, or actual incidents of abuse, neglect or misappropriation of property. 1. All incidents and accidents will be reported (immediately or as soon as practicable) to the Administrator and the Director of Nursing. 2. When an accident occurs, immediate assistance will be rendered to the injured person .

Based on observation, interview, and record review, the facility failed to ensure Resident #42 had a physician's order for medication that was being administered by nurses. This had the ability to affect 16 residents who resided on 600 Hall and receive medications. The findings are: 1. On 1/2/24 at 2:42 pm, Resident #42 said that the nurses were applying (Name Brand) Pain Relieving Gel to her right knee when she asked them to. 2. On 1/3/24 at 2:48 pm, during record review it was noted Resident #42 did not have a Physician's Order for the (Name Brand) Pain Relieving Gel applied by Licensed Practical Nurse (LPN) #3. 3. On 1/4/24 at 3:54 pm, during an interview the Surveyor asked LPN #1, what should a nurse do before administering a medication? LPN #1 said look at the Medication Administration Record (MAR), and order. The Surveyor asked what should a nurse do if a resident asks for a medication that they do not have an order for? LPN #1 said call the provider. 4. On 1/4/24 at 4:02 pm, during an interview the Surveyor asked the Director of Nursing (DON) what should a nurse do before administering a medication? The DON said look at the order. The Surveyor asked should a nurse administer medications without an order. The DON said no they shouldn't. 5. On 1/4/24 at 4:08 pm, The DON informed the Surveyor that the facility did not have a policy for medication administration.

Based on observation, record review and interview, the facility failed to ensure the residents was free of potential accident and hazards, as evidenced by failure to ensure that all the clips were in place on the mechanical lift when lifting 1 (Resident #63) of 1 sampled resident. This failed practice had the potential to affect 5 (Residents #24, #42, #63, #71 and #72) sampled residents who resided on the 600 Hall and were dependent on a mechanical lift for transfers. The findings are: 1. On 1/4/24 at 10:14 am observed, Certified Nursing Assistants (CNA) #2 and #5 use a mechanical lift to transfer Resident #63 from the geri-chair to the bed. The mechanical lift was missing a clip in the middle on the left side. 2. On 1/4/24 at 10:34 am, during an interview the Surveyor asked the Lead Certified Nursing Assistant (CNA) #1 if she could look at the lift and tell the Surveyor what it was missing. CNA #1 said it is missing a clip on the left side. The Surveyor asked should this lift be used when it has a missing clip. CNA #1 said no ma'am, it shouldn't. The Surveyor asked what could happen if it is being used with a missing clip. CNA #1 said, well nothing because we don't use that middle clip. The Surveyor asked then why do you have a clip on the other side? CNA #1 said well because it is the manufactures guidelines that they should be on there. 3. On 1/4/24 at 10:40 am, during an interview the Surveyor asked the Director of Nursing (DON) if she could tell the Surveyor what was wrong with the lift. The DON said it is missing a clip on the left side. The Surveyor asked should this mechanical lift continue to be used. The DON said no it shouldn't. The Surveyor asked what could happen if it is used without the clip. The DON said it could cause harm to a resident. 4. On 1/4/24 at 3:52 pm, the Manufactures Guidelines for the mechanical lift was provided by the Administrator. The guidelines documented on Page 41, . the Hanger Bar check the bolt/hooks for wear or damage. Check sling hooks for wear or deflection .

Based on observation, record review and interview, the facility failed to ensure infection control practices were maintained during the administration of medications to decrease the risk of contamination for 1 (Resident #58) of 1 sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube; staff performed hand hygiene while delivering trays to residents during the lunch meal service on the 600 Hall, and failed to ensure staff performed hand hygiene in between feeding residents who required assistance with meals during the lunch meal service. The findings are: 1. Resident #58 had diagnoses of gastro-esophageal reflux disease (GERD) with esophagitis, without bleeding, dysphagia following cerebral infarction and gastrostomy status. a. the Resident #58's Physicians Order Summary documented all oral medications to be given through the resident's PEG tube. b. A Care Plan revised 11/28/23 documented Resident #58 required tube feeding related to a swallowing problem. c. On 01/04/24 at 9:07 AM, Licensed Practical Nurse (LPN) #2 was administering Resident #58's medications through the PEG tube by gravity while wearing gloves. She noticed the medications stopped flowing through the tube. After unsuccessful attempts to get the medications flowing again, LPN #2 called for another staff member to bring her a cup and she poured the remaining medications in the cup and reconnected the end of the administration set to the end of the Resident's PEG tube. While wearing the same gloves, she took the cup with the medications in it to the bathroom, turned on the faucet and added more water from the faucet into the cup and then placed the cup on the bedside table. When she disconnected the end of the administration set from Resident #58's PEG tube, she held the end of the administration set in her left gloved hand, reconnected the tip of the syringe to the end of Resident #58's PEG tube and attempted to administer Resident #58's medications by gravity but the medications were not flowing through the tube. d. On 01/04/24 at 9:17 AM, LPN #1 again poured the medications into the clear plastic cup and reconnected the end of the administration set to Resident #58's PEG tube and began touching Resident #58's PEG tube with both gloved hands. At 9:18 AM, the Director of Nursing (DON) entered the room to assist LPN #1. e. On 01/04/24 at 9:21 AM, LPN #1 disconnected the administration set from Resident #58's PEG tube, held the end of the tubing in her left hand while wearing the same gloves and unsuccessfully attempted to administer Resident #58's medications. At 9:22 AM, the DON instructed LPN #1 to clamp Resident #58's PEG tube, and she left the room. f. On 01/04/24 at 9:26 AM, the DON returned to the room with a declogger. She donned a clean pair of gloves without sanitizing or washing her hands, disconnected part of Resident #58's PEG tube and took it and the declogger to the bathroom. The DON inserted the declogger in the part of the PEG tube and after a few minutes she was able to get the water from the faucet in the bathroom to flow through the PEG tube piece. g. On 01/04/24 at 9:30 AM, the DON changed gloves without sanitizing or washing her hands and reconnected the piece of tubing back to Resident #58's PEG tube. h. On 01/05/24 at 10:02 AM, during an interview LPN #2 confirmed hand hygiene should be performed before performing anything with a resident's PEG tube or if you touch something not involved with the PEG tube. i. On 01/05/24 at 10:18 AM, during an interview the DON confirmed hand hygiene should be performed before putting on or changing gloves. 49071 2. On 01/02/24 at 1:05 PM, observed Certified Nursing Assistants (CNA) #2, #3, and #4, passing out trays to the residents on the 600 Hall without sanitizing their hands in between residents. After passing out the last tray CNA #3, without sanitizing her hands, sat down and began to feed Resident #63. a. On 01/02/24 at 1:13 PM, CNA #4 went into a resident's room and removed a chair from the room to sit on in the open area where the feeders were. CNA #4 began to feed Resident #63 without sanitizing her hands. b. On 01/02/2024 at 1:21 pm, during an interview the Surveyor asked CNA #4 when passing trays what should you do before you pass out a tray? CNA #4 said sanitize your hands. The Surveyor asked what should you do in between passing trays from one resident to another? CNA #4 said sanitize your hands. c. On 01/02/24 at 1:28 PM, the Surveyor asked CNA #2 what should happen between passing out a tray and before passing out another tray. CNA #2 said wash/sanitize your hands. d. On 01/02/2024 at 1:33 pm, the Surveyor asked CNA #3 what should happen between passing out a tray and before passing out another tray? CNA #3 said wash your hands. The Surveyor asked what should happen after passing out trays and before starting to feed a resident. CNA #3 said wash your hands. e. On 1/4/24 at 3:52 pm, the Administrator provided a facility policy titled, Handwashing/Hand Hygiene, which documented, The facility considers hand hygiene the primary means to prevent the spread of infections .

Based on observation, record review and interview, the facility failed to ensure gastric contents were aspirated prior to administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube to decrease the potential for complications and enteral feeding bags were labeled with the date, time, and initials for 1 (Resident #58) of 1 sampled resident with a PEG tube as documented on a list provided by the Administrator on 01/04/24 at 3:52 PM. The findings are: 1. Resident #58 had diagnoses of gastro-esophageal reflux disease (GERD) with esophagitis, without bleeding, dysphagia following cerebral infarction and gastrostomy status. a. Resident #58's Physicians Order Summary, active 01/03/24, documented the Resident #58's diet was nothing by mouth (NPO). Check placement of peg tube prior to meds medications and feedings every shift. Order date 12/26/23. b. A Care Plan revised on 11/28/23 documented the Resident required tube feeding related to a swallowing problem. c. On 01/02/24 at 11:43 AM, the Resident was resting quietly in bed with a nutritional supplement infusing at 55 ml/hr (milliliters per hour) and the flush was set at 150 ml every 4 hours on the feeding pump. Neither bag had a date, time, or staff initials in place indicating when the bags were hung, or which staff member performed the task. d. On 01/03/23 at 8:35 AM, the Resident was lying in bed awake with the head of the bed (hob) elevated. A nutritional supplement was infusing by way of a feeding pump. Both bags were labeled with the date and time, but there were no staff initials on either bag. e. On 01/03/24 at 4:05 PM, Resident #58 was resting quietly while up in a geriatric chair. The were no staff initials on the enteral feeding bags at this time. f. On 01/04/24 at 08:41 AM, Licensed Practical Nurse (LPN) #2 washed her hands, placed Resident 58's feeding pump on hold, disconnected the administration set from the PEG tube, obtained stethoscope and a 60 cubic centimeter (cc) syringe, and added a 10cc air bolus in the syringe. She inserted the tip of the syringe in the end of the PEG tube, placed a stethoscope on the resident's upper abdomen, pushed the air bolus through the syringe, but did not pull back on the plunger to aspirate gastric contents. She removed the syringe and clamped the end of the PEG tube. g. On 01/04/24 at 4:07 PM, the Administrator provided a facility policy titled, Enteral Feedings, Administration via Gastrostomy which documented, .Procedure . 8. Assess placement of tube . A. Gastrostomy Tube . 3. Aspirate gastric contents . 9. Initiated Feeding: A. Gastrostomy Tube . 4. Continuous Feeding . b.Label bag with date, time and initials . h. On 01/05/24 at 10:18 AM, during an interview the DON confirmed a PEG tube should be aspirated for gastric contents to ensure placement. i. On 01/05/24 at 10:57 AM, during an interview the DON confirmed that the date, time when it was hung, and nurse initials should be on the enteral feeding bags so staff will know what's in it and when it was hung.

Based on observation, record review and interview, the facility failed to ensure cautionary signage was placed outside the room of a resident who had oxygen (O2) in use for 1 (Resident #2) of 3 (Residents #2, #4 and #127) sampled residents who had physician orders for oxygen as documented on a list provided by the Administrator on 01/04/24 at 3:52 PM. The findings are: 1. Resident #2 had diagnoses of solitary pulmonary nodule, hypoxemia, and acute respiratory failure unspecified whether with hypoxia or hypercapnia. a. The Physicians Order Summary documented, .O2 at 1L [liter] -10L L/M [liters per minute] via [by way of] Titrate O2 To Keep Sats [saturations] 90% [percent] or Greater every shift and as needed for keep 02 sat > [greater than] 90 . start date 10/12/23 . b. A Care Plan completed 10/12/23 documented, .The resident has oxygen therapy r/t [related to] SOB [shortness of breath] .OXYGEN SETTINGS: O2 @ 1L-10L/M . c. On 01/02/24 at 12:08 PM, Resident #2 was lying in bed, awake. There was an O2 concentrator on the floor that was off at this time. There was no cautionary signage posted on the outside of the Resident's room alerting staff/visitors that oxygen was in use in the room. d. On 01/03/24 at 9:04 AM, the Resident was not in her room, the O2 concentrator was on and it was set at 3.5 L/M. There was no cautionary signage posted on the outside of the Resident's room alerting staff/visitors that oxygen was in use in the room. e. On 01/04/24 at 10:25 AM, there was no cautionary signage posted on the outside of the resident's room alerting staff/visitors that oxygen was in use in the room. f. An Oxygen Safety policy, provided by the Administrator on 01/04/24 at 3:52 PM documented, .The facility will properly handle oxygen and other flammable gases . 10. Prior to administering oxygen, Oxygen in Use sign must be posted on the outside of the room entrance door . g. On 01/05/24 at 10:14 AM, during an interview the Minimum Data Set (MDS) Coordinator confirmed an oxygen in use sign should be on the door frame before entering the room of a resident who uses it. h. On 01/05/24 at 10:22 AM, the Director of Nursing (DON) confirmed residents with oxygen in the room should have cautionary signs in place to make everyone aware that oxygen is in use.

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 69 residents who received meals from the Kitchen (Total Census: 69), according to the list provided by the Dietary Supervisor on 9/07/22 at 1:18 PM The findings are: 1. The following observations were made during noon and supper meal preparations: a. On 9/06/22 at 12:23 PM Dietary Employee #1 picked up the water hose with her bare hand, used it to spray off leftover food items from the dishes contaminating her hands, placed dishes in the dirty racks and pushed them into the dish washing machine to wash and after the dishes stopped washing. Dietary Employee #1, moved to the clean side in dishwasher area and without washing her hands picked up a clean blade and attached it to the base of the blender to be used to puree food items to be served to the residents for the supper meal. The Surveyor asked Dietary Employee #1 what should you have done after touching and before handling clean equipment? She stated, I should have washed my hands. 2. On 9/06/22 at 12:42 PM, Dietary Employee #3 was on the tray line assisting with the lunch meal. She picked cartons of supplements and placed them on the trays. Without washing her hands, she picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents for lunch. 3. On 9/06/22 at 4:05 PM, Dietary Employee #1 took out a pan of breaded fried cod fish from the oven and place it on the counter. Without washing her hands, she picked up a blade and attached it to the base of the blender to be used to puree food items for the residents who required pureed diets. 4. On 9/06/22 at 4:32 PM, Dietary Employee #1 picked up deep fryer baskets that contained tater tots and placed them on the hook attached to the deep fryer to drain. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used to puree food items to be served to the residents on pureed diets. 5. On 9/06/22 At 4:46 PM, Dietary Employee #1 Pushed a cart that contained a box of lettuce and a box of tomatoes from the walk-in refrigerator towards the food preparation counter. She removed a bulk of lettuce and placed it inside a pan. She picked up a cutting board and placed it on the counter. She turned on the food preparation faucet and rinsed the lettuce and tomatoes. She used a rag that she had used to wipe off spilled food on the counter to dry the cutting board. She removed a jar of pickles, a zip lock bag of shredded cheese, a jar of olives and placed them on the counter. She removed lettuce from the pan and placed it on the cutting board. She picked up gloves and placed them on her hands contaminating the gloves in the process. She cut the lettuce and tomatoes and placed them on the plates. She unzipped the bag that contained the shredded cheese and used her contaminated gloved hands to remove shredded cheese and placed the cheese on top of the lettuce and tomatoes. She used a tong to remove pickles and olives form the jar and placed the pickles and olives on the salad to be served to the residents who requested a salad with their supper meal. She covered both salad plates with saran wrap and placed them on a shelf in the refrigerator. The Surveyor asked her immediately what should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I shouldn't have used the rag to dry the cutting board. I should have removed the gloves and washed my hands. 6. On 9/07/22 at 9:48 AM, the Surveyor asked Dietary Employee #3, what should you have done after you touched dirty dishes and before you handled clean objects. She stated, Washed my hands. 7. The facility's policy on hand washing provided by the Dietary Supervisor on 9/07/22 documented, After engaging in other activities that contaminate the hands.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 9/7/22. The findings are: 1. On 9/6/22, the menu for the lunch meal documented residents who received pureed diets were to receive #8 scoop (1/2 cup) of pureed taco meat, pureed refried beans, pureed Mexican rice, and tortilla bread. On 9/6/22 at 12:39 PM, the following observations were made during the lunch meal: a. Dietary Employee #1 used a #16 scoop (blue scoop) which is equivalent 1/4 cup (4 ounces) to serve a single portion of pureed refried beans, pureed taco meat and pureed plain rice to residents who required pureed diets, instead of #8 scoop as specified on the menu. b. There was no Mexican rice served to the residents on pureed diets. Residents on pureed diets were served pureed plain rice, instead of pureed Mexican rice as specified on the menu. On 9/7/22 at 9:55 AM The Surveyor asked Dietary Employee #2 the reason plain rice was served to the residents. She stated, It should have been pureed Mexican rice. The Surveyor asked what scoop size did you to serve pureed food item? She stated, We used the blue scoop. 2. On 9/6/22, the menu for the supper meal documented residents who received pureed diets were to receive 2 #8 scoops (1 cup) of pureed fish sandwich. a. On 9/6/22 at 5:53 PM. Dietary Employee #4 used a #10 scoop which is equivalent to 3 to 4 oz (ounces) to serve a single portion of pureed fish sandwich to the residents on pureed diets, instead of 2 #8 scoops of pureed taco meat as specified on the written menu. On 9/6/22 at 6:46 PM, the Surveyor asked Dietary Employee #1 the reason residents on pureed diets did not receive 2 servings of pureed taco meat and the reason #10 scoop was used, instead of #8 scoop. She stated, We used the wrong scoop.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Food Service Supervisor on 9/07/22. The findings are: 1. On 9/06/22 at 12:06 PM, Dietary Employee #1 used a 6 0z spoon to place 3 servings of plain rice into a blender, added milk and pureed. On 09/06/22 at 12:07 PM, She poured the pureed rice into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed rice was lumpy, not smooth. Pieces of rice remained in the mixture. 2. On 9/06/22 at 12:34 PM, The following items were on the steam table: a. Pureed refried beans were on the steam table. The consistency of the pureed refried beans were runny. b. A pan of pureed taco meat. The consistency of the pureed meat was gritty, not smooth. c. A pan of pureed bread was on the steam table. The consistency was lumpy, not formed, not smooth. There were pieces of breadcrumbs visible in the mixture. 3. On 9/06/22 at 3:54 PM, Dietary Employee #1 placed 4 breaded fried cods into a blender, added 4 slices of cheese and 4 hamburger buns and whole milk. She pureed the mixture into a pan. At 3:56 PM, she poured the pureed fish sandwich into a pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed fish sandwich was lumpy, not smooth. There were pieces of fish and bread in the mixture. 4. On 9/06/22 at 4:36 PM, Dietary Employee #1 used a tong to place 5 servings of tater tots into a blender, added 2 cups of chicken broth and pureed. At 4:38 PM, she poured the pureed tater tots into a pan, covered it with foil and placed it in the oven. The consistency of the pureed tarter tots was lumpy, not smooth. 5. On 9/06/22 at 6:42 PM, The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, It could have been pureed a little more. 6. On 9/06/22 at 6:45 PM, the Surveyor asked Dietary Employee #4 to describe the consistency of the pureed food items prepared and served to the residents on pureed diets. She stated, Pureed sandwich and pureed tater tots were clumpy. 7. On 9/07/22 at 8:03 AM, the items were on the steam table: a. Pan of pureed bread was on the steam table. The consistency of the pureed bread was lumpy and was not smooth. b. A pan of pureed egg was on the steam table. The consistency of the pureed eggs was not formed. It was lumpy, not smooth. c. A pan of pureed sausage was on the steam table. The consistency of the pureed sausage was not formed. It was gritty, smooth. d. The Surveyor asked Dietary Employees #5 and, #6 to describe the consistency of the pureed food items served to the residents on pureed diets. They both stated, Pureed bread, pureed eggs and pureed sausage were lumpy and not pudding consistency.

Based on record review and interview the facility failed to ensure a comprehensive plan of care was developed for a resident who had a [CONDITION(S)], to assure that the resident's individual needs were met and maintained for 1 (Resident #36) of 1 (Resident #36) who had a [CONDITION(S)]. The findings are: 1.Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 07/10/22 documented the resident scored 3 (severely impaired) on the Staff Assessment for Mental Status (SAMS) and required extensive assist of two persons for bed mobility, dressing, extensive assist of one for toileting, personal hygiene, limited assist of one person for eating, and totally dependent for bathing. a. On 09/07/22 at 11:59 AM, current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .CHANGE OSTOMY APPLIANCE/BAG WEEKLY ON WEDNESDAY every day shift every Wed . b. On 09/07/22, a review of R#36's Care Plan was completed, and [CONDITION(S)] care was not found on the care plan. c. On 09/07/22 at 10:08 AM, the Treatment Nurse changed the [CONDITION(S)] wafer and bag to left lower quadrant of R#36's abdomen. d. On 09/07/22 at 02:19 PM, the Surveyor asked the MDS Coordinator, Who is responsible for completing the Resident's Care Plans? She stated, I am. The Surveyor asked, Does [R36] have a [CONDITION(S)]? She stated, Yes. The Surveyor asked, What [CONDITION(S)] interventions do you have in place on her care plan? The MDS Coordinator looked at her computer and she was asked, Do you have [CONDITION(S)] interventions on her Care Plan? She looked at her computer screen again and stated, No. The Surveyor asked the MDS Coordinator, What are the potential negative outcomes of not having [CONDITION(S)] interventions documented on her care plan? She stated, Improper care of her [CONDITION(S)] . It's not there. I will get them in there now. e. On 09/08/22 at 12:47 PM, a document provided by the Administrator titled Section H: Bladder and Bowel documented, .Planning for Care-Care planning should include interventions that are consistent with the resident's goals and minimize complications associated with appliance use .should be based on an assessment and evaluation of the resident's history, physical examination, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation and interview, the facility failed to ensure dietary equipment was maintained in clean condition and beverage glasses were allowed to air dry before being stored to prevent potential contamination that could result in food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: 1. On 11/01/21 at 11:47 AM during the initial tour of the kitchen, the following observations were made: a. Immediately to the right of the entrance door to the kitchen, there was a shelf with clean glasses stored on it. Three glasses were stacked on top of each other with water droplets visible inside them. The Surveyor asked the Dietary Manager to describe what she saw in the glasses. She stated, They are wet. When asked how clean glasses should be stored, the Dietary Manager stated, They should be kept over there to air dry. b. On the wall above the clean glasses, there was a black fan that was covered with fuzzy greyish specks that was blowing toward the clean glasses. c. Near the coffee machine, there was a small cart with splotches of dry black stained substances on the bottom shelf. d. In the dish room, there was a black oscillating fan blowing toward the clean dishes as they came out of the dish machine. The fan was covered with fuzzy greyish debris. 2. On 11/3/21 at 3:41 PM, a storage cabinet across from the coffee machines had four clean glasses that had been stacked and stored while wet and still contained water droplets. 3. On 11/4/21 at 8:49 AM, the Dietary Manager was asked how often the oscillating fans in the kitchen were cleaned. She stated, The standing ones, I clean weekly. The ones that are hanging are cleaned once a month. The Dietary Manager was asked when the fans were last cleaned and stated, The standings one was cleaned last week, and then the black one in the dish room, I cleaned Monday after you saw it.

Based on record review and interview, the facility failed to ensure the comprehensive plan of care accurately reflected a resident's functional abilities and the level of assistance needed, and addressed actual weight loss, to ensure the resident received the necessary assistance and nutritional interventions to attain or maintain the highest practicable level of wellbeing for 1 (Resident #17) of 4 (Residents #8, #17, #39 and #50) sampled residents who had a significant change in condition since 8/1/21; and failed to ensure the plan of care addressed pain management for 1 (Resident #8), wound care for 1 (Resident #39), anticoagulant use for 1 (Resident #49), and oxygen therapy for 1 (Resident #50) of 20 (Residents #3, #45, #18, #20, #17, #15, #48, #50, #42, #49, #2, #41, #67, #8, #39, #124, #46, #12, #22, and #69) sampled residents whose care plans were reviewed. The findings are: 1. Resident (R) #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/21 documented the resident required supervision with set-up for locomotion off the unit; was independent with set-up for eating; required extensive assistance of 1 person for bathing; and had not experienced a weight loss of 5% or more in the past month or 10% or more in the past 6 months. a. The Significant Change in Condition (SCIC) MDS with an ARD 8/11/21 documented the resident required extensive assistance of 1 person for locomotion off of the unit and eating; was totally dependent on 1 person for bathing; had experienced a weight loss of 5% or more in the past month or 10% or more in the past 6 months; and was not on a prescribed weight loss regimen. b. The Plan of Care dated as revised 4/27/21 documented, .Focus: The Resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Embolism & [and] [CONDITION(S)] of Arteries of the Lower Extremities and Dementia . Interventions: Bathing/showering: The resident is extensive assist x 1; eating: Resident is able to feed self with staff set up help with supervision only; locomotion off unit: not addressed . Focus: The Resident has a potential nutritional problem r/t [related to] Therapeutic Diet . Interventions: 4/19/2021 Provide, serve diet as ordered. Monitor intake and record q meal. Enhanced foods; DCD [discontinued] ensure BID [twice daily], added mighty shake at L&D [lunch and dinner] tray, ice cream at snacks TID [three times daily]; RD [Registered Dietitian] to evaluate and make diet change recommendations PRN [as needed]; Provide and serve diet as ordered; OT [Occupational Therapy] or ST [Speech Therapy] to screen and provide adaptive equipment for feeding as needed; Monitor / record / report to MD [Medical Doctor] PRN s/sx [signs/symptoms] of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: equal to or above 5% in 1 month, equal to or above 7.5% in 3 months, equal to or above 10% in 6 months . The Care Plan did not address the actual weight loss identified by the SCIC MDS with an ARD of 8/11/21 or accurately reflect the level of assistance the resident required with bathing and eating. c. On 11/03/21 at 2:40 PM, the MDS Coordinator was asked, Why did [R #17] have a SCIS completed on 8/11/21? She stated, I believe she had recently lost some weight and she had functional declines in several care areas. 2. Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medicare 5-Day MDS with an ARD of 10/18/21 documented the resident scored 5 (0-7 indicates severe impairment) on a brief interview for mental status (BIMS), received scheduled pain medications, was offered or received as-needed (PRN) pain medications, had occasional pain in the last 5 days, limited her day-to-day activities because of pain in the last 5 days, rated her worst pain in the last 5 days at 5 on a scale of 0-10 with zero being no pain and ten being the worst pain imaginable, and received an opioid medication on 5 of the last 7 days. a. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 2 tablets by mouth three times a day for pain . [MEDICATION(S)]-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth two times a day related to pain . [MEDICATION(S)] [[MEDICATION(S)]] Tablet 5 MG. Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. b. The Comprehensive Care Plan dated as revised 10/8/21 did not address pain management or the use of scheduled and PRN pain medications. 3. Resident #39 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Weekly Wound Note dated 10/15/21 documented, .Right Ischium . unstageable . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Comprehensive Care Plan dated as revised 10/1/21 addressed pressure ulcers to the left buttock and left gluteal fold but, did not address wounds to the resident's right ischium or under the right buttock. 4. Resident #49 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 9/13/21 documented the resident scored 11 (8-12 indicates moderate impairment) on a BIMS and received an anticoagulant medication on 7 of the past 7 days. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth two times a day related to unspecified [CONDITION(S)]. This was documented an an active order on the Order Summary Report dated 11/3/21. b. The Comprehensive Care Plan dated as revised 10/1/21 did not address the care and monitoring required related to the use of anticoagulant medication. 5. Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 9/14/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and received oxygen therapy while a resident. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was documented as an active order on the Order Summary Report dated 11/3/21. b. The Comprehensive Plan of Care dated as revised 10/28/21 did not address oxygen therapy. c. On 11/04/21 at 8:35 AM, Licensed Practical Nurse (LPN) #1 was asked what the resident's oxygen flow rate was. She stated, Looks like it's 3.5 liters. She was asked, What is the rate on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, It says 2 liters. She was asked, What could happen if oxygen is not delivered at the prescribed rate? She stated, It could make her sick. She has [CONDITION(S)], so she could retain. She was asked, Should the use of oxygen be documented on the care plan? She stated, Yes. 6. On 11/04/21 at 12:34 PM, the MDS Coordinator was asked, Does [Resident #50] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes, it is 2-4 liters PRN. She was asked, Is the use of oxygen documented on her care plan? She stated, It's not. She was asked, Should the use of oxygen be documented on the care plan? She stated, Yes. She was asked, Does [Resident #49] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes, [MEDICATION(S)] [[MEDICATION(S)]]. She was asked, Is the use of an anticoagulant documented on the care plan? She stated, I don't see it. She was asked, Should the use of anticoagulants be documented on the care plan? She stated, Yes. She was asked, Does [Resident #8] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes, she has scheduled [MEDICATION(S)] and PRN oxycodone. She was asked, Is pain or the use of pain medication documented on the care plan? She stated, It is not. She was asked, Should pain or the use of pain medication be documented on the care plan? She stated, Yes, I am behind on some care plans. If I fix them now, would that help? She was asked, Does [Resident #39] have a wound? She stated, Yes, on the lower right buttock. She was asked, Is that wound documented on the care plan? She stated, Oh my gosh, this says 'left'. She was asked, Should the care plan contain accurate information? She stated, It should. 7. On 11/04/21 at 1:42 PM, the Director of Nursing (DON) was asked, What is a care plan? She stated, It's a plan of a resident's care that we give - all of the departments - it's what we do for the person and the issues that they have. She was asked, Should the use of oxygen be documented on the care plan? She stated, Yes. She was asked, Should the care plan contain accurate information? She stated, Yes. She was asked, Should the use of anticoagulants be documented on the care plan? She stated, Yes. She was asked, Should pain management be documented on the care plan? She stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the prescribed flow rate to prevent potential complications for 1 (Resident #50) of 5 (Residents #45, #3, #2, #50 and #124) initial pool residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an assessment reference date of 9/14/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS; required extensive assistance of 1 person for bed mobility, transfer and locomotion; and received oxygen therapy while a resident. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was documented as an active order on the Order Summary Report dated 11/3/21. b. On 11/01/21 at 1:29 PM, Resident #50 was sitting in a recliner in her room and receiving oxygen via nasal cannula. The flow meter on the resident's oxygen concentrator was set to deliver oxygen at 1 liter per minute, instead of 2 liters per minute as ordered by the physician. c. On 11/02/21 at 10:20 AM, Resident #50 was sitting in a recliner in her room receiving oxygen via nasal cannula. The flow meter on the oxygen concentrator was set at 4 liters per minute. She was asked, What is your oxygen supposed to be on? She stated, Two. d. On 11/04/21 at 8:30 AM, Resident #50 was lying in bed with her head elevated, receiving oxygen via nasal cannula. The oxygen concentrator flow meter was set at 3.5 liters. She stated, I'm sick today. e. On 11/04/21 at 8:35 AM, Licensed Practical Nurse (LPN) #1 was asked, What is [Resident #50's] oxygen rate? She checked the flow meter and stated, Looks like it's 3.5 liters. She was asked, What is the rate on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, It says 2 liters. She was asked, What could happen if oxygen is not delivered at the prescribed rate? She stated, It could make her sick. She has [CONDITION(S)], so she could retain [[MEDICATION(S)]]. f. On 11/04/21 at 12:34 PM, the MDS Coordinator was asked, Does [Resident #50] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes, it is 2-4 liters PRN. She was asked, What was the order prior to today? She stated, It was 2 liters, and that order was discontinued this morning.

Based on observation and interview, the facility failed to ensure dented cans were removed from stock and discarded; food items were properly sealed prior to storage; staff wore hair nets when entering the kitchen, and staff washed hands and donned gloves appropriately between clean and dirty tasks while preparing food to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect all 66 residents who receive meals from the kitchen per the Resident Listing Report provided by Administrator on 8/31/2020. The findings are: 1. On 08/31/2020 at 11:40 AM, there was a box of rice in the dry storage room with the plastic torn and not sealed. The Dietary Manager was asked, Is that rice supposed to be sealed? She said, I don't why it's not tied up. 2. On 08/31/2020 at 11:45 AM, there was a bag of pepperoni in the freezer that was torn with approximately 3 inches at the seam. The bag was open to the air in the freezer and had ice crystals on the pepperoni. Dietary Employee (DE) #2 entered the kitchen where the food was stored without a hair net. DE #2 was asked, Are you supposed to have a hair net on? She stated, Yes. I'm getting one. There was a can of pizza sauce with a dent in the seam. The Dietary Manager was asked, Tell me what you feel on that can? She stated, It has a dent in it. There was a can of black beans that had a dent in the side of the can. 3. On 08/31/2020 at 11:54 AM, DE #3 entered the kitchen where the food was stored without a hair net. She was asked if she was supposed to be wearing a hair net and she said, Yes. 4. On 09/01/2020 at 11:20 AM, the Dietary aide, place large paper on prep table, brought back container of peanut butter, loaf of bread, and 6 single serve packet of jelly and placed on prep table. She washed her hands, donned gloves, opened twist tie on bread, reached inside bread bag and removed 6 slices of bread. She placed the bread slices on the paper, closed bread loaf with twist tie, opened container of peanut butter, used plastic spoon to remove peanut butter and place on one slice of bread. She then picked up the slice of bread with her left hand while still wearing the contaminated gloves and spread the peanut butter on the bread, she repeated this same technique while the same contaminated gloves. The Dietary Consultant approached the dietary aide and spoke softly, the dietary aide stopped, removed her gloves, and washed her hands. She removed 4 gloves from a box and placed two of the gloves inside her right pants pocket that were hanging out partially, and donned the second pair of gloves. She returned to the prep table opened 1 single serve packet of jelly and used a plastic spoon placed the jelly contents on a slice of bread. She opened a second packet of jelly and placed contents on the same slice of bread, picked up repeating this procedure 2 more times with 2 more slices of bread. Wearing the same contaminated gloves she picked up one jelly slice of bread and covering one peanut butter slice of bread, repeated 2 more times, making a total of 3 peanut butter and jelly sandwiches.

Based on observation and interview, the facility failed to ensure 2 of 2 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services for 1 of 1 laundry room. This failed practice had the potential to affect all 66 residents due to the potential for the interruption of laundry services due to the proximity of the laundry room, according to the Resident Census and Conditions of Residents form dated 8/31/2020. The facility failed to ensure an oxygen concentrator was stored on a flat surface to prevent a potential fire hazard in 1 (Resident (R) #5) of 1 resident rooms. This failed practice had the potential to affect 10 residents that required oxygen according to a list provided by the Director of Nursing (DON) on 9/2/2020 at 2:55PM. The facility to ensure a damaged and or torn Geri chairs were free of potential accident hazards as possible, for 1 of 1 (Resident #8) sample resident who used a geri chair. This failed practice had the potential to affect 4 residents who required the use of a Geri chair as documented on a list provided by the Director of Nurses on 9/3/2020 at 1:05 p.m. The findings are: 1. Resident #18 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/2020 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status (BIMS); required extensive assistance of two people for bed mobility, toileting and dressing; and totally dependent for transfers. a. The most recent Care Plan documented, .Resident has had an Actual Fall: 6/8/19, 7/14/19, 7/24/29, 11/16/19, 11/18/19, 4/28/2020, 5/31/2020 . The resident will not sustain serious injury through the review date . b. On 08/31/2020 at 12:17 PM, there was a Geri chair with a torn section on the Geri chair. The torn material on the bar that supports the chair was ripped and measured approximately 6 to 8 inches. A photograph was taken at this time. c. On 08/31/2020 at 03:20 PM, the resident was sitting in the Geri chair at the end of the 100 Hall. The material was torn at the top of the chair that supported the backrest cushion. d. On 09/01/2020 at 9:53 AM, there was a Geri chair with a torn section on the Geri chair. The torn material on the bar that supports the chair was ripped and measured approximately 6 to 8 inches. e. On 09/01/2020 at 01:20 PM, the resident was sitting in the Geri chair at the end of the 100 Hall. The material was torn at the top of the chair that supported the backrest cushion. f. On 09/03/2020 at 08:37 AM, the DON provided a copy of the resident's Incident and accident report that documented, . 4/28/2020 resident with an unwitnessed fall .no injury neuro checks started . intervention: winged mattress . g. On 09/03/2020 at 12:37 PM, Certified Nursing Assistant (CNA) #5 was asked, Can you tell me what you see you see is wrong that material on (R# 18's) Geri chair? She stated, It's torn. CNA #5 was asked, What can happen with it torn? She stated, A fall. h. On 09/03/2020 at 12:41 PM, the DON was asked, What is wrong with his chair? She stated, It's ripped. The DON was asked, What could happen? She stated, It could rip more and come off. The DON was asked, What would happen if it came off? She stated, It could cause him to fall and fall out of the chair. i. On 09/03/20 at 01:11 PM, the DON provided a copy of the manufacture's guidelines for the Geri chair that documented, .Warning .12. Immediately remove from service; Any recliner with broken recline mechanisms, torn upholstery, or other mechanical or visible damage . 2. On 9/2/2020 at 2:07 PM, during the Infection Control tour of the Laundry Department with the Housekeeping Supervisor and the Maintenance Supervisor, the following observations were made: a. On 9/2/2020 at 2:07 PM, on the clean side of the laundry room there were two dryers that were in the process of drying. The surveyor requested that Housekeeper #1 to fully remove the lint drawers on both dryers. Dryer #1 had lint in the back of the dryer floor. Dryer #2 had lint in the back and on the dryer floor. A photograph of dryer #1 and dryer #2 with lint on the floor was taken. b. On 9/2/2020 at 2:11 PM, Housekeeper #1 was asked, What could happen with the lint being in there? Housekeeper #1 stated, It could cause a fire. Housekeeper #1 provided the monthly lint logs that documented when lint was removed from the dryer. There was no documentation for lint removal for the month of September (2020). c. On 9/2/2020 at 2:23 PM, the surveyor showed the Administrator dryer #3's lint picture and asked, Can you tell me what you see in the floor of the dryer? The Administrator stated, Lint. The Administrator was asked, Should it be in there? The Administrator stated, No. The Administrator was asked, What could happen? The Administrator stated, It's a fire hazard. d. On 9/2/2020 at 2:45 PM, Housekeeper #1 provided the manufacture guidelines for the dryers. It states, .periodic inspection, cleaning and removal of lint form various areas of the dryer as well as throughout the ductwork system .Lint from most fabrics is highly combustible. The accumulation of lint can create a potential fire hazard . Housekeeper #1 stated, We do not have a policy on lint removal. 3. Resident #5 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/2020 documented resident scored 12 (8-12 indicates moderately impaired) on Brief Interview for Mental Status (BIMS); required supervision with eating; extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing; was totally dependence for transfers. a. On 08/31/2020 at 12:54 PM, Resident #5 was setting up in bed, and had a nonproductive cough. Resident #5 was receiving O2 (oxygen) via (by way of) nasal cannula at 2.5L (liters). The updraft machine was on the bedside table. The O2 concentrator was sitting on the fall matt on the floor beside the bed. A photograph of the O2 concentrator was taken at this time. b. On 9/1/2020 at 9:20 AM, Resident #5 was resting in bed with her eyes closed. She was receiving O2 via nasal cannula at 2.5L. The O2 concentrator on the fall mat on the floor beside the bed. c. Physician orders [REDACTED].@ 2-3 L/M (liters per minute) VIA NC (nasal canula) every 24 hours as needed for sob/wheezing-O2 sat (saturation) > (less than) 90% (percent) on RA. d. Physician orders [REDACTED]. e. There was no documentation of oxygen therapy on the resident's care plan. f. On 09/02/20 at 12:26 PM, Resident #5 was setting in her recliner with O2 via nasal cannula at 2.5L. She had heel protectors on her feet bilaterally. The fall mat was folded and placed by the resident's wardrobe. The O2 concentrator was sitting on the floor. g. On 09/02/2020 at 2:18 PM, Maintenance #1 was asked, Should the oxygen concentrator be setting on the fall mat? Maintenance #1 stated, No. It shouldn't be. Maintenance #1 was asked, What could happen? Maintenance #1 stated, It could cause the concentrator to overheat and catch fire. f. On 09/02/20 2:21 PM, the DON was asked, Should the oxygen concentrator be setting on a fall mat? DON stated, No. The DON was asked, What could happen? DON stated, The censor light could go off and it not work correctly g. On 09/02/20 02:232 PM, the Administrator was asked, Should the oxygen concentrator be setting on a fall mat? The Administrator stated, No ma'am. The Administrator was asked, What could happen? The Administrator stated, If a resident fell it could cause injury or they could trip and injure themselves. The Administrator was asked, Could it potentially cause a fire? The Administrator stated, Yes. h. On 09/03/20 08:28 PM, The manufacturer's guidelines for oxygen concentrator, .Position your unit at least 6 inches from walls, draperies, or any other objects that might prevent the proper flow of air in and out of your concentrator. The oxygen concentrator should be located so as to avoid pollutants or fumes .

Based on observation, interview and record review, the facility failed to ensure that an antipsychotic medication was not given without an approved [DIAGNOSES REDACTED].#58 and #25) of 5 (Resident #25, #34, #58, #64, and #218) sampled residents. This failed practice had the potential to affect 7 residents who received antipsychotic medication based on a list provided by the Director of Nurses (DON) on 9/03/20 at 10:20 am. The findings are: 1. Resident #25 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with Assessment Reference Date of 7/01/20 documented the resident scored 05 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. The September 2020 physician's orders [REDACTED]. ADJUSTMENT DISORDER WITH ANXIETY .[MEDICATION NAME] Tablet 25 MG (QUEtiapine [MEDICATION NAME]) Give 12.5 mg by mouth at bedtime related to ADJUSTMENT DISORDER WITH ANXIETY . 2. Resident #58 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 7/01/20 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the BIMS. The September 2020 physician's orders [REDACTED]. with a start date of 8/12/20. 3. On 9/03/20 at 10:00 am, the DON was asked what were the approved [DIAGNOSES REDACTED]. She was asked if anxiety was an acceptable [DIAGNOSES REDACTED].