Every finding on record at Signature Healthcare of Cleveland

Based on facility policy, observations, and interviews, the facility failed to label, and date opened food items and maintain kitchen equipment in a sanitary condition in 1 of 1 kitchen and failed to discard expired cold food items in 1 of 1 nourishment rooms which had the potential to affect 93 of 95 residents residing in the facility. The findings include: Review of the facility's policy titled, Equipment, revised 9/2017, revealed All foodservice equipment will be clean, sanitary, and in proper working order .all equipment will be routinely cleaned and maintained .all non food contact equipment will be clean and free of debris . Review of the facility's policy titled, Receiving, revised 2/2023, revealed .All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . Review of the facility's policy titled, Foods Brought by Family/Visitors, revised 9/15/2023, revealed Staff will discard foods .past due package expiration dates . During an observation on 2/17/2026 at 10:02 AM, in the kitchen's walk-in cooler with the Certified dietary Manager (CDM) revealed: (1) 1 gallon of Whole Milk and (2) 1 gallon of Butter Milk opened, undated, and available for resident use. During an interview on 2/17/2026 at 10:04 AM, the Certified Dietary Manager (CDM) confirmed (1) gallon of Whole Milk and (2) 1 gallon Butter Milk were open, unlabeled, and available for use. Review of the facility's cleaning log dated 2/8/2026 - 2/14/2026 posted in the kitchen on 2/17/2026 at 10:15 AM, revealed the ovens were to be cleaned daily and the convection and deep fryer were to be cleaned weekly. Continued review revealed no documentation the oven being cleaned daily from 2/8/2026 -2/14/2026. Further review revealed no documentation that the convection oven was cleaned between 2/8/2026 - 2/14/2026. Continued review revealed the deep fryer was last cleaned on 2/9/2026. There was no cleaning log available after 2/14/2026. During an observation on 2/17/2026 at 10:18 AM, in the kitchen line prep cooking area with the CDM revealed: 1 oven not in use with baked food particles on the inside oven door and brown splattered substance on the oven floor. 1 convection oven with a black and brown splattered substance on the entire inside of both oven doors. The convection oven had a sticky brown substance streaked down the front of the legs. Beneath the convection oven to the right of the fryer revealed a greasy black substance on the floor. 1 fryer not in use had food particles in the metal reservoir and grease splatters on the side of the convection oven. During an interview on 2/17/2026 at 10:30 AM, the CDM confirmed the ovens had not been cleaned and the fryer was last cleaned on 2/9/2026. During an observation on 2/17/2026 at 10:32 AM, in the nourishment room with the CDM revealed: 11 black cherry and mixed berry low fat yogurt 5.3 ounces in the nourishment room refrigerator with an expiration date of 2/9/2026 available for resident use. 5 Whole Milk 12-ounce bottles in the nourishment room refrigerator with an expiration date of 2/7/2026 available resident for use. During an interview on 2/17/2026 at 10:37 AM, the CDM confirmed 11 black cherry and mixed berry low fat yogurt 5.3 ounces had an expiration date of 2/7/2026 and was available for resident use.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure resident personal refrigerators were maintained in a clean and sanitary manner, failed to ensure temperature logs were maintained and temperatures were within facility policy recommendations, and failed to ensure expired foods were not available for resident use for 6 residents (Residents #114, #71, #11, #31, #18, and #9) of 11 resident personal refrigerators observed.The findings include:Review of the facility's policy titled, Food Brought in by Family/Visitors, dated 9/2023, revealed .to ensure proper handling, serving, and storage of food items brought into our facilities by families .the staff will both ensure and utilize proper safe food handling practices .if a resident has a refrigerator in their room a thermometer be used to ensure appropriate temperatures are maintained .these daily temperature checks should be recorded .perishable foods .containers will be labeled with resident's name, and the date brought in, so staff are aware of the by use-by date (3 days) .staff will discard perishable items prior to the use by date .Medical record review revealed Resident #114 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Rheumatoid Arthritis, and Atrial Fibrillation. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #114 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a personal refrigerator temperature log for Resident #114 dated 2/2026, revealed .temperature should be at 32-41 degrees . The log had temperatures recorded of 42 degrees, above the specified range, on 4 days (2/6/2026, 2/7/2026, 2/8/2026, and 2/9/2026), and had no temperatures recorded on 8 days (2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026). During an observation on 2/18/2026 at 9:30 AM, Resident #114's personal refrigerator revealed a tray in the freezer compartment, with the bottom covered with a yellow substance, with multiple small gray fuzzy-appearing splotches. The refrigerator contained a cinnamon roll in an undated ziplock bag, and a sandwich in an undated ziplock bag.Medical record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Lumbar Vertebrae Compression Fracture, Osteoporosis, and Lung Disease. Review of an annual MDS assessment dated [DATE], revealed Resident #71 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a personal refrigerator temperature log for Resident #71 dated 2/2026, revealed .temperature should be at 32-41 degrees . The log had no temperatures recorded on 8 days (2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/16/2026, 2/17/2026, and 2/18/2026). During an observation on 2/18/2026 at 9:35 AM, revealed Resident #71's personal refrigerator had a thermometer inside which read 44 degrees Fahrenheit, above the specified range of 32-41 degrees. The refrigerator contained a cinnamon roll in an undated ziplock bag.Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Dementia, Epilepsy, and Traumatic Brain Injury.Review of a quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment.During an observation on 2/18/2025 at 9:40 AM, Resident #11's personal refrigerator revealed a large accumulation of thick ice build-up filling half of the freezer compartment.Review of a personal refrigerator temperature log for Resident #11 dated 2/2026, revealed .temperature should be at 32-41 degrees . The log had no temperatures recorded on 8 days (2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026). Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Hypothyroidism, and Hypertension.Review of an annual MDS assessment dated [DATE], revealed Resident #31 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of a personal refrigerator temperature log for Resident #31 dated 2/2026, revealed .temperature should be at 32-41 degrees . The log had no temperatures recorded on 8 days (2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026). During an observation on 2/18/2026 at 9:45 AM, Resident #31's personal refrigerator revealed sticky brown substance, liquid to honey consistency, covering the bottom of the fridge.Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, and Heart Disease.Review of a quarterly MDS assessment dated [DATE], revealed Resident #18 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment.Review of a personal refrigerator temperature log for Resident #18 dated 2/2026, revealed .temperature should be at 32-41 degrees . The log had no temperatures recorded on 8 days (2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026). During an observation on 2/18/2026 at 9:50 AM, Resident #18's personal refrigerator revealed a plastic container of cranberry juice with an expiration date of 8/10/2025 (which was 193 days past the expiration date) and was available for resident use.Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Heart Failure, History of Stroke with Hemiplegia, and Hypertension.Review of a significant change in status MDS assessment dated [DATE], revealed Resident #9 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment.Review of a personal refrigerator temperature log for Resident #9 dated 2/2026, revealed .temperature should be at 32-41 degrees . The log had no temperatures recorded on 8 days (2/3/2026, 2/4/2026, 2/5/2026, 2/10/2026, 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026). During an observation on 2/18/2026 at 9:55 AM, Resident #9's personal refrigerator revealed an unopened milk carton with an expiration date of 1/7/2026 (which was 43 days after the expiration date) and was available for resident use. During an interview with the Director of Nursing (also Infection Control Nurse) on 2/19/2026 at 10:07 AM, revealed there have been no food-borne illness at the facility. During observations and interviews on 2/19/2026 at 2:00 PM, the Regional Director (for Housekeeping) and the Assistant Director of Nursing (ADON) confirmed the facility failed to ensure resident refrigerator temperatures were within the safe zone of 32-41 degrees, temperature logs were not documented daily, expired foods were not discarded, and the refrigerators were not maintained in a clean and sanitary manner. During an interview on 2/19/2026 at 2:20 PM, the Administrator stated the night shift nursing staff were responsible for maintaining the cleanliness and food in personal refrigerators, and to check and document temperature on the logs daily.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to label the intravenous (IV) medication tubing for 1 resident (Resident #97) of 2 residents reviewed with IV medications.The findings include:Review of the facility's policy titled, Administration Set/Tubing Changes, dated 8/2021, revealed .primary intermittent tubing is changed every 24 hours and .upon suspected contamination or when the integrity of the tubing has been compromised . Medical record review revealed Resident #97 was admitted to the facility on [DATE] with diagnoses including Cellulitis of the Lower Limb, Lung Disease, and Heart Failure.Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed Resident #97 scored a 15 which indicated the resident was cognitively intact.Review of the physician's orders revealed Resident #97 had a physician order dated 2/10/2026 for cefepime (antibiotic medication used to treat certain bacterial infection) 2 grams intravenously every 8 hours, and a physician's order dated 2/10/2026 for Vancomycin (antibiotic medication used to treat certain bacterial infection) 1 gram intravenously every 12 hours.During an observation on 2/17/2026 at 10:45 AM, revealed Resident #97 sitting in a wheelchair at bedside. An intravenous (IV) pole was near the resident, and both antibiotic medication bags were empty after the last administration and hanging from the IV pole. The tubing was still attached to the bags, and neither tubing set was labeled with the date they had been changed.Review of the Medication Administration Record (MAR) dated 2/2026, revealed Resident #97 received the Vancomycin IV medication dose ordered at 12:00 PM.During an observation and interview on 2/17/2026 at 11:15 AM, the Assistant Director of Nursing (ADON) confirmed both IV tubing sets had not been dated, and confirmed she was not able to see when they had last been changed or needed to be changed.During an observation on 2/17/2026 at 12:45 PM, revealed Resident #97 sitting in a wheelchair at bedside with an IV medication hanging on the pole, and infusing into the IV site in the resident's right upper arm. The IV medication tubing was not dated.

Based on manufacturer's recommendations, facility policy review, facility document review, observation, and interview, the facility failed to properly store medications in 1 of 1 medication room observed.The findings include: Review of the Tuberculin Purified Protein Derivative manufacturer's recommendations dated 10/2021, revealed .indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease .STORAGE .A vial of TUBERSOL which has been entered and in use for 30 days should be discarded . Review of the facility's policy titled, Storage of Medication, dated 1/2025, revealed .Medications and biologicals are stored properly, following manufacturer's .recommendations to keep their integrity and to support safe, effective drug administration .Medications are .stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers . During an observation on 2/18/2026 at 8:40 AM, in the medication room, with Licensed Practical Nurse (LPN) A the medication refrigerator contained 1 opened vial of .Tuberculin Purified Protein Derivative (Mantoux) .TUBERSOL .Multi-dose vial .5 mL [milliliters] .Discard opened product after 30 days . with an expiration date of 7/2028. The vial was not dated with an open date. LPN A was unaware when the vial had been opened and confirmed the vial was to be discarded 30 days after opening. LPN A confirmed she was unaware when to discard the vial because there was no open date on the vial. Review of facility documentation dated 2/18/2026, revealed .This statement is to confirm that residents that received a TB [tuberculosis] skin test, experienced no adverse reactions within the past 30 days. The residents were monitored per facility protocol following administration of the test, and no signs of allergic reaction, complications, or negative side effects were observed or reported . During an interview on 2/18/2026 at 10:52 AM, the Director of Nursing (DON) stated Tuberculin vials were to be dated when opened and discarded within 30 days of open date. The DON confirmed the vial of opened Tuberculin was not dated when opened and the DON was unaware of the date it was to be discarded since it had not been dated.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices related to indwelling urinary catheter use were followed for 1 resident (Resident #11) reviewed of 9 residents reviewed for urinary catheters. The findings include: Review of the facility's policy titled, Foley Catheter Use, dated 1/31/2025, revealed .ensure that the use of indwelling urinary catheters .prevent infections .avoid letting bag or tubing touch the floor. Review of the medical record revealed Resident #11 was readmitted to the facility on [DATE] with diagnoses of Dementia, Ureteral Calculous Obstruction [a kidney stone logged in the ureter], and Obstructive and Reflux Uropathy [a blockage in the urinary tract]. Review of a significant change in status Minimum Data Set (MDS) dated [DATE], revealed Resident #11 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #11 had an indwelling catheter. Review of the comprehensive care plan dated 1/6/2026 revealed .Indwelling catheter . During an observation on 2/17/2026 at 2:59 PM, Resident #11's urinary catheter bag and tubing were observed touching the floor. During an observation on 2/18/2026 at 10:08 AM, Resident #11's urinary drainage bag and tubing were observed lying on the floor. During an observation on 2/19/2026 at 8:16 AM, Resident #11's urinary drainage bag was observed clipped to the frame of the bed and tubing rested on the floor. During an interview on 2/19/2026 at 8:19 AM in Resident #11's room, Licensed Practical Nurse (LPN) B and surveyor observed the resident's urinary tubing touching the floor. The LPN confirmed the urinary and tubing are to be off the floor to prevent potential urinary tract infections. During an interview on 2/19/2026 at 8:23 AM, the Director of Nursing (DON) confirmed the expectation is for urinary catheter bags and tubing to be off of the floor and attached to the bed frame to prevent urinary tract infections.

Based on facility policy review, observation and interview, the facility failed to provide milk products for 2 meals, affecting 85 of 87 residents in the facility. The findings include: Review of the facility's policy titled, Receiving, revised ,d+[DATE] showed .Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items .If quality is unacceptable, the item(s) will be immediately returned for credit . During an observation with Dietary Cook #1 on [DATE] at 10:18 AM, in the walk-in cooler, showed 40 expired individual serving chocolate milks dated [DATE] and 60 expired individual serving chocolate milks dated [DATE]. During aniInterview with the Dietary Cook #1 on [DATE] at 10:23 AM, in the kitchen, showed the milk was to be picked up and returned by the milk provider today ([DATE]). Continued interview showed the milk was usually provided to all the residents and the milk was not provided on the morning breakfast tray. During an interview on [DATE] at 10:27 AM, the Administrator stated the residents did not receive milk for breakfast and lunch on [DATE] and stated .it was her expectation for herself or the dietary manager to be contacted when food items are not available . Continued interview confirmed the facility failed to provide the milk for the residents for 2 meals on [DATE].

Based on product label review, facility policy review, facility vendor instruction review, observation, and interview the facility failed to maintain a safe and sanitary food procurement and storage of thickened liquids affecting 2 Residents (#3 and #71) of 2 resident reviewed for thickened liquids, during meal observation, and failed to maintain a clean and sanitary kitchen which had the potential to affect 85 of 87 residents. The findings include: Review of a product label .[name of distributor] . Thickened Orange Juice from concentrate undated, showed, .directions after opening may be kept up to 7 days under refrigeration . Review of the facility policy Warewashing, revised 9/2017 revealed .All dishware, serviceware, and untensils will be cleaned and sanitized after each use . Review of the facility vendor instructions for the 3-compartment sink, undated revealed, .submerge in sanitizer sink for one minute . Resident #3 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebrovascular Accident, Hypertension, Dementia, and Dysphagia. Review of a Physician order dated 4/26/2023 showed Resident #3 was to have nectar thickened liquids. Resident #71 was admitted to the facility on [DATE] with diagnosis to include Sepsis, Cerebral Infarction, and Dysphagia. Review of a Physician order dated 9/16/2023, showed resident was to have nectar thickened liquids. During an observation on 9/25/2023 at 11:14 AM, in Resident #3's room, showed an opened, undated container of thickened orange juice sitting in room temperature water in a pink plastic wash basin. The container of thickened liquid was not cool to touch. During an observation on 9/25/2023 at 11:49 AM, in Resident #71's room, showed a an opened, undated container of thickened orange juice sitting in a pink plastic wash basin. The container of thickened liquid was not cool to touch. During an interview on 9/25/2023 at 12:07 PM, showed the Director of Nursing confirmed the containers of thickened orange juice in Resident #3 and #71's rooms had been opened and were undated and sitting at room temperature. During an observation on 9/26/2023 at 12:40 PM, Dietary Cook #1 washed and rinsed dishware to include tray line containers and then submerged the dishware into the sanitizer sink for 10 seconds and placed items to dry. During an interview on 9/26/2023 at 12:46 PM, Dietary Cook #1 stated she normally washes items in the 3-compartment sink and only submerges items 10 to 15 seconds in the chemical sanitizer. During an interview on 9/27/2023 at 8:05 AM, the District Dietary Manager confirmed the facility failed to follow the chemical vendor instruction by not submerging the dishware for one full minute per instruction. 48581

Based on facility policy review, observation and interview the facility failed to ensure kitchen equipment was maintained in good repair in 1 of 1 kitchen which had the potential to affect 85 of 87 residents. The findings include: Review of the facility's policy titled, Food Storage, revised 9/2017 showed .All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of FDA Food Code .freezer temperatures will be maintained at a temperature of 0 .or below . Review of a Freezer Temperature Log for September 2023 showed the freezer temperatures ranging from 16 to 18 degrees above the freezer-maintained guidelines. During an observationon 9/25/2023 at 10:24 AM, with Dietary Cook #1, showed a large amount of ice accumulation around the walk-in freezer door with the freezer temperature to be at 17 degrees. During an interview on 9/25/2023 at 10:28 AM, in the kitchen, Dietary Cook #1 confirmed the freezer door had been a concern for some time and the freezer temperature consistently runs between 16 to 18 degrees. During an interview and review of the documentation from a refrigeration vendor with the Administrator on 9/26/2023 at 10:31 AM, showed the freezer door was initially ordered on 7/26/2022 and was measured wrong per the vendor and the correct door had not arrived. Continued interview confirmed the freezer door had been a concern for over a year and the facility failed to have the freezer door replaced to maintain the appropriate freezer parameters.

Based on observations and interviews, the facility failed to maintain a safe, comfortable, and homelike environment for 1 of 4 hallways observed, affecting 8 of 16 rooms (RM 400, RM 401, RM 405, RM 409, RM 410, RM 411, RM 413, and RM 415) on the 400 hallway. The findings include: During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], looking out the window, showed 4 air filters lying on a concrete pad. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], showed a visible gap to the outside at the upper right corner of the PTAC unit (a heating and cooling unit in the wall). Further observation showed the PTAC unit was loose from the wall. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], showed dried brownish colored streaks dripping down the wall beside A bed. Further observation showed the privacy curtain separating A and B bed in room [ROOM NUMBER] was dirty with dark debris and stained. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in rooms [ROOM NUMBERS], showed in the view looking out into the courtyard had 3 hospital beds with mattresses, 2 of the beds covered with linens, 2 empty yellow barrels labeled linen, a folded wheelchair against wall, a grill beside the wheelchair, and 2 empty cardboard boxes one lying at foot of bed the other on a metal patio table. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], showed the hand soap dispenser in the bathroom did not have an outer covering for the residents in the room to push to dispense soap for hand hygiene. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in rooms [ROOM NUMBERS], showed the view looking out of windows an old rusty white metal shed, inside the shed showed a riding lawn [NAME] with multiple items (construction debris) and various broken items stacked up inside the shed and lying on the ground around the outside of the shed. The ground was covered with loose brown rock, trash debris, and weeds. During an interview on 9/27/2023 at 1:15 PM, the Administrator confirmed there were 4 air filters lying on the concrete pad outside the window of room [ROOM NUMBER]. The PTAC unit in room [ROOM NUMBER] had a gap visible to the outside and was loose from the wall. The wall in room [ROOM NUMBER] had dried brown streaks on the wall beside A bed and the privacy curtain in the room was dirty and stained. The hand soap dispenser in the bathroom of room [ROOM NUMBER] did not have an outer covering making it difficult for the 2 residents in the room to wash their hands. The exterior view the residents had in rooms 409, 411, 413, and 415 were not pleasant to look at and the facility failed to provide and an optimal homelike environment.

Based on facility policy review, observation, and interview, the facility failed to ensure 2 of 8 hand sanitizing stations were in a good working order on 1 hallway (400 hall) of 4 hallways observed, failed to ensure the staff had performed appropriate hand hygiene during meal observation on 1 of 4 hallways observed for dining, and failed to properly store the emergency water supply in a sanitary manner in one storage room (laundry storage room) observed. The findings included: Review of the facility's policy titled, Handwashing/Hand Hygiene, revised date 8/2019, showed .Hand hygiene products and supplies .alcohol-based hand rub .shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before and after direct contact with residents .Before and after eating or handling food .Before and after assisting a resident with a meal . Review of the facility's policy titled, Infection Prevention and Control Program, revised date October 2018, showed .infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation on 9/25/2023 at 11:55 AM, on the 400 hallway, showed 2 of 8 hand sanitizer stations (1 station at the dining room entrance and 1 station beside courtyard exit door) did not function appropriately and did not dispense the hand sanitizing product. During an observation on 9/25/2023 at 3:20 PM, showed the same 2 of 8 hand sanitizer stations on the 400 hallway remained in a non-working order. During an observation on 9/25/2023 at 12:05 PM, showed the Certified Nursing Assistant (CNA) #1 had been observed touching Resident #17's bed rail, overbed table, had went into another room (room [ROOM NUMBER]) to grab a metal chair, grabbed items out of the linen cart located on the 400 hallway, returned to Resident #17's room and had begun to touch items on her meal tray. Further observation showed the CNA #1 did not perform hand hygiene before preparing to feed Resident #17. During an interview on 9/25/2023 at 12:19 PM, the CNA #1 confirmed she failed to offer or provide hand hygiene to Resident #17 prior to the meal being served and she failed to perform hand hygiene before assisting Resident #17 with meal service. During an interview on 9/27/2023 at 10:15 AM, in the Director of Nursing (DON) office, the Administrator (ADM) and the DON stated it was the facility's expectation for the staff to perform hand hygiene before and after providing resident care and especially during resident meal service. The ADM and DON confirmed the facility failed to perform appropriate hand hygiene during the meal service. During an observation on 9/27/2023 at 1:15 PM, the Administrator confirmed the hand sanitizer station hanging on the wall at the courtyard exit door and the hand sanitizing station by the dining room did not function properly. During an observation on 9/27/2023 at 3:40 PM, in the laundry storage room, showed 17 cases (6 one-gallon plastic containers in each case) of distilled water had overturned on the floor and 16 additional cases had been stored and stacked directly on the floor. During an interview on 9/27/2023 at 3:57 PM, the ADM and the Maintenance Director confirmed the cases of water had not been stored in a sanitary manner and should have been stored off the floor.

Based on review of facility policy, observation, and interview the facility failed to properly label and store medications and supplies in 1 of 1 medication rooms. The findings include: Review of the facility policy, Storage of Medication dated ,[DATE], revealed, .Medications and biologicals are stored properly .Refrigerated medications should be kept in closed and labeled containers .Outdated .medications are immediately removed from stock . Observation with the Director of Nursing (DON), on [DATE] at 12:00 PM, in the Medication Refrigerator located in the Medication Room, revealed 1 vial of [MEDICATION NAME] Purified Protein Derivative 5 units/0.1 milliliters opened and approximately ½ empty with no opened date. Continued observation revealed discard opened product after 30 days labeled on the box. Further observation, of the top shelf of the medication cabinet, revealed 100 [MEDICATION NAME] 50 milligram tablets expired ,[DATE]. Interview with the DON on [DATE], at 12:00 PM, in the Medication Room, confirmed the vial of [MEDICATION NAME] Purified Protein Derivative was available for resident use and did not have an opened date label affixed to the vial. Continued interview confirmed the [MEDICATION NAME] Purified Protein Derivative multi-dose vial was to be dated when opened and discarded 30 days after opened date. Further interview confirmed expired [MEDICATION NAME] tablets were available for resident use and should have been discarded.

Based on review of the facility's Trial Balance report, medical record review, and interview, the facility failed to ensure the trust fund accounts for 4 residents (#27, #42, #44, and #58) of 25 residents with trust fund accounts of 32 residents sampled did not exceed the $2000.00 Supplemental Security Income (SSI) resource limit . The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #27 had a current balance of $2084.97. Medical record review revealed Resident #42 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #42 had a current balance of $2361.63. Medical record review revealed Resident #44 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #44 had a current balance of $2640.34. Medical record review revealed Resident #58 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #58 had a current balance of $2217.19. Interview with the Assistant Business Office Manager (ABOM) on 1/23/19 at 2:59 PM, in the social service office, confirmed 4 residents (#27, #42, #44, and #58) had over $2000.00 in their trust fund accounts as of 1/22/19. Interview with the Social Worker on 1/23/19 at 3:02 PM, in the social service office, confirmed there were 4 residents who had greater than $2000.00 in their trust funds. Further interview confirmed the facility failed to keep resident trust fund balances under $2000.00 for residents #27, #42, #44, and #58.

Based on medical record review and interview, the facility failed to ensure a PRN (as needed) order for a [MEDICAL CONDITION] drug (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days without a Physician's documented rationale for use of the drug for 1 resident (#9) of 5 residents reviewed for unnecessary medications of 29 residents sampled. The findings include: Medical record review revealed Resident # 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the current physician's orders [REDACTED].Order Date .7/13/18 .[MEDICATION NAME] (antianxiety medication) 1 MG (milligram) TABLET .EVERY 4 HOURS AS NEEDED . Medical record review of the Medication Regimen Review dated 8/27/18 revealed .This resident is currently on the anxiolytic (medication for anxiety) therapy [MEDICATION NAME] 1mg q4h (every 4 hours) PRN .PRN [MEDICAL CONDITION] orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order . (46 days after the order date). Interview with the Director of Nursing (DON) on 1/24/19 at 9:47 AM, in the DON's office, confirmed the facility failed to ensure the PRN order for [MEDICAL CONDITION] medication was limited to 14 days without the Physician's documented rationale.

Based on facility policy review, medical record review, review of a facility investigation, observation, and interview, the facility failed to prevent verbal abuse for 1 resident (#1) of 5 residents reviewed. The facility's failure resulted in actual harm to Resident #1. The findings included: Review of the facility policy, Abuse, Neglect, Exploitation, and Misappropriation of Property reviewed on 5/22/17 revealed .Abuse Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Abuse includes physical abuse, mental abuse, verbal abuse .willful means non-accidental, or not reasonably related to the appropriate provision of ordered care and services, depending on the context .Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment .any other statements or behavior that a reasonable person would consider to be humiliating, demeaning or threatening to a resident .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .or within their hearing distance . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact and independent with daily decision making, required extensive assistance of 2 persons for bed mobility, transfers, and required extensive assistance of 1 person for toilet use, was always incontinent of bowel and bladder, and required set up assistance for eating. Review of a facility investigation dated 6/2/17 revealed .CNA (Certified Nursing Assistant) had hurt (Resident #1) feelings. When the nurse asked how, resident .stated had turned the call light on and CNA came into the room and said 'How come you are so impatient? Can't you wait a f .ing 30 seconds?' .Abuse Coordinator was notified immediately at 0500 (5:00 AM). Upon CNA's arrival at 0620 (6:20 AM) was sent home by charge nurse .(Resident #1) has not made accusations of this type in the past nor has the staff person been accused of this type of treatment in the past. Incident was substantiated and CNA was terminated on 6/2/17 . Review of a witness statement dated 6/2/17 obtained by the facility from Registered Nurse (RN) #1 revealed .This nurse was in (Resident #1's room) helping CNA (#3) on shift with bed A and bed B .(Resident #1) said this CNA (CNA #1) hurt her feelings when asked how. Resident (#1) said she turned her call light on and CNA (#1) came into room and said 'How come you are so impatient. Can't you wait a (expletive) 30 seconds to get here.' Resident was reassured she could put her light on anytime this was her home and that .she could always ask for the nurse if something bothered her or hurt her feelings . Review of a witness statement dated 6/2/17 obtained by the facility from CNA #1 revealed .After coming in from smoking (Resident #1) (and) (another resident's) call lights were on. (CNA #2) went to get (Resident #1) .needed to be changed .I assisted (CNA #2) in changing (Resident #1) and positioning her in the bed. As (CNA #2) took the trash and linen I assisted (another resident) off the toilet and back to bed. (Resident #1) was yelling my name from her room to which I asked her to give me a moment. After putting (another resident) in the bed I turned (Resident #1) light and TV off telling her that her yelling was waking the other residents and reassuring her that I had come back like I stated I would. I asked her if she needed anything else and she said no so I shut her door on my way out as she had asked me to do so . Review of a witness statement dated 6/2/17 obtained by the facility from CNA #3 revealed .(Resident #1) .stated she pressed her call light and when (CNA #1) came in she said can't you give me a f .ing 30 sec (seconds) charge nurse was in the room when resident was talking . Review of a witness statement dated 6/2/17 obtained by the facility from the Social Worker (SW) revealed .SW spoke (with) (Resident #1) after reports of concern (with) CNA (#1). (Resident #1) told me that on Thursday CNA (#1) .had hurt her feelings. Resident said she pushed call light (at) approximately 12:00 (midnight) to have her light turned off and door closed. She said that CNA (#1) was mean and said, 'Can you wait one f .ing 30 seconds? You are so impatient .' . Medical record review of a Physician's Progress Note dated 6/3/17 revealed .mood and affect .normal mood and affect . Medical record review of a Nurse's Progress Note dated 6/4/17 revealed .Resident is pleasant mood no complaints verbalized . Medical record review of the Social Service Note dated 6/12/17 revealed .A (alert and) O (oriented) x 3, ST (short term)/LTM (long term memory) intact .may require cues/supervision with decision making in certain situations .(no) concerns voiced . Review of CNA #1's termination notice dated 6/2/17 revealed .It was allegedly reported that (CNA #1) cursed at a resident when resident turned her call light on for assistance. This is in violation of Policy and Procedure .Physical mistreatment or abusive language to any individual . Interview with Resident #1 on 6/13/17 at 11:00 AM, in the resident's room, revealed the resident had put her call light on about 12:00 midnight (6/1/17) to have a CNA turn her light off, CNA #1 came in her room and said your so impatient, can't you wait a f .ing 30 seconds. Continued interview confirmed Resident #1 stated made me feel awful. Interview with the Administrator on 6/13/17 at 12:00 PM, in the Administrator's office, revealed there were no witnesses to the incident. Interview with the Administrator on 6/13/17 at 2:25 PM, in the Administrator's office confirmed CNA #1 was terminated for verbal abuse. Interview with the Social Worker on 6/13/17 at 3:00 PM in the Social Worker's Office revealed Resident #1 had told her she had put her call light on to have light turned off and door shut, CNA #1 said to her can't you wait a f .ing 30 seconds you are so impatient, Resident #1 said it really hurt her feelings but other than that she was ok. Interview with CNA #1 on 6/13/17 at 3:15 PM by telephone confirmed she had come in after a smoke break and several call lights were on, went in to change (Resident #1) then told her I would be right back after getting another resident off the toilet. Continued interview revealed the resident was yelling my name and I said f .ing s .t in the hallway. Continued interview revealed (Resident #1) thought it was directed at her. Interview with the Administrator on 6/13/17 at 3:45 PM in the Administrator's Office, revealed CNA #1 stated she might have dropped the f bomb. Further interview revealed CNA #1 stated she may have cursed in the hallway. Interview with Registered Nurse (RN) #1 on 6/13/17 at 3:50 PM by telephone confirmed RN #1 was assisting CNA #3 with Resident #1's roommate when Resident #1 stated her feelings were hurt from a statement CNA #1 made, How come you are so impatient, can't you wait a f .ing 30 seconds.

Based on medical record review and interview, the facility failed to investigate and report an injury of unknown origin for 1 resident (#91) of 4 residents reviewed for accidents. The findings included: Medical record review revealed Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].x-ray L) (left) foot . Further review of the medical record revealed a physician's orders [REDACTED].Fracture of phalanx (toe) of foot .fracture of left great toe . Medical record review of a nursing note dated 12/16/15 at 9:30 AM revealed .pain in L) foot .[MEDICAL CONDITION] and cool to touch . Further review of a nursing note dated 12/16/15 at 12:15 PM revealed .x-ray results show fracture of L) distal phalange .sister at facility and states .sees .for her arthritis . Physician's office was notified and the resident was scheduled for an appointment on 12/17/15. Medical record review of a care plan dated 12/16/15 revealed .1) Refer to orthopedic 2) x-ray left foot . Further review of a care plan dated 12/17/15 revealed .shoe left foot . Interview with the Director of Nursing on 1/20/16 at 11:48 AM, in the Administrator's office confirmed the facility did not conduct an investigation of the fracture of unknown origin and stated .Has a history of osteopenia and uses her foot to propel herself, dances around, and was being seen by Orthopedist before admission here . Interview with the Administrator on 1/20/16 at 11:48 AM, in the Administrator's office confirmed the facility did not conduct an investigation of or report the fracture of unknown origin and stated .We did not report it .

Based on medical record review, observation, and interview, the facility failed to administer one medication per the Physician's order for one resident (#3) of 4 residents observed during 26 medication observation opportunities. The findings included: Medical record review prior to administration of the ordered medications as transcribed onto the medication administration computer screen with Registered Nurse (RN #2) revealed .[MEDICATION NAME] Propionate 50 mcg (micrograms) 1 spray in each nostril daily . Observation in the resident's room on 1/21/16 at 8:22 AM, revealed RN #1 administered 2 sprays of [MEDICATION NAME] Propionate in each of the resident's nostrils. Medical record review of the printed Physician's Order dated 12/28/15 revealed .[MEDICATION NAME] Propionate 50 mcg 1 spray in each nostril daily . Medical record review of a Telephone Order dated 7/16/15 revealed Decrease [MEDICATION NAME] nasal spray to 1 spray each nostril QD (daily). Interview with RN #1 on 1/21/16 at 8:30 AM, in the 200 hall confirmed 2 sprays of [MEDICATION NAME] Propionate were administered to each of the resident's nostrils.

Based on observation, review of facility policy, and interview, the facility failed to maintain a sanitary kitchen by not properly cleaning kitchen equipment and storing, dating, and labeling prepared food for one of one kitchen reviewed. The findings included: Observation with the Assistant Dietary Manager and Dietician, on December 1, 2014, at 6:55 p.m., in the kitchen, revealed dried food on two of four muffin tins. Further observation revealed the muffin tins stored on a rack with other kitchen bake ware. Observation with the Assistant Dietary Manager and Dietician, on December 1, 2014, at 7:05 p.m., in the walk-in cooler revealed a container partially covered with plastic wrap that contained stewed beef with broth. Further observation revealed two containers dated 'November 23' of hard boiled eggs. Observation with the Assistant Dietary Manager and Dietician, on December 1, 2014, at 7:20 p.m. in the walk-in freezer revealed four undated, unlabeled angel food cakes. Review of facility policy Leftover Food Usage, (undated), revealed "...food items must be used within 48 hours...frozen leftover food items must be used within 2 months..." Continued review of Reusable Food Storage Containers, (undated), revealed "...foods...will be stored in nonporous containers that can be completely sealed..." Interview with the Assistant Dietary Manager on December 3, 2014, at 7:25 p.m., in the kitchen, confirmed the facility failed to clean the muffin tins, cover the stewed beef, discard the expired hard boiled eggs and date the four angel food cakes.

Based on medical record review and interview, the facility failed to issue a Notice of Medicare Provider Non Coverage for two (#131 and #87) of three residents reviewed for liability notices. The findings included: Resident #131 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Summary dated July 16, 2014, revealed the resident was discharged home with family and home health on July 4, 2014. Resident #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Discharge Summary dated August 8, 2014, revealed the resident was discharged home with family on July 15, 2014. Interview on December 3, 2014, at 1:15 p.m., with the Administrator in the Administrator's office, revealed resident #131 and resident #87 were not issued letters of Notice of Medicare Provider Non Coverage,"they were missed". Continued interview confirmed the residents were discharged home and had not given the opportunity to appeal the decision, as the the letters had not been issued.

Based on medical record review, review of facility policy, and interview, the facility failed to provide a written thirty day notice of a discharge, to one resident (#70) and/or representative of the resident, of five residents reviewed. The findings included: Resident #70 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #70 was discharged to (his/her) Power of Attorney (POA) on September 25, 2014. Medical record review revealed no written thirty day notice of pending discharge. Review of the facility policy Transfer or Discharge Documentation, revised October 2013, revealed "...an appropriate notice was provided to the resident and/or representative..." Telephone interview with the POA on December 2, 2014, at 6:30 p.m., confirmed no written thirty day notice of discharge was received from the facility. Interview with the Administrator on December 3, 2014, at 10:30 a.m., in the Administrator's office, confirmed the facility failed to send the POA a thirty day notice of discharge. Complaint #

Based on medical record review, review of facility policy, and interview, the facility failed to complete a discharged medical record for one resident (#70) for one resident of five residents reviewed. The findings included: Resident #70 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #70 was discharged to (his/her) Power of Attorney (POA) on September 25, 2014. Medical record review revealed incomplete discharge instructions for Resident #70. Continued review revealed the discharge instructions were not signed by the resident, POA, or staff. Further review revealed no discharge note from nursing or social services including date, time of discharge, summary of the resident's medical, physical, and mental condition, and the disposition of the personal effects. Review of facility policy Transfer or Discharge Documentation, revised October 2013, revealed "...information pertaining to the...discharge of a resident will be documented in the resident's medical record..." Interview with the Director of Nursing on December 2, 2014, at 1:20 p.m., in the Social Service office, confirmed no documentation of a nursing discharge note. Further interview confirmed no knowledge of time the resident was discharged , with whom, mode of transportation, or if discharge instructions were given to the resident and/or POA. Interview with the Social Service Director on December 3, 2014, at 9:30 a.m., in the Social Service office, confirmed the arrangement and oversight of Resident #70's discharge. Further interview confirmed the facility failed to complete the discharge documentation. complaint #