Every finding on record at Southland Health and Rehabilitation

Number of residents sampled: Number of residents cited: Based on resident and staff interviews, record review, facility policy review, the facility failed to protect the resident's right to be free from physical abuse and/or sexual abuse/deprivation by staff and /or resident for four of 60 sampled residents (R) (R125, R117, R63, and R25) related to (1) failure to ensure R125 was protected from R117 and as a result, R125 was physically assaulted by R117 and (2) the facility failed to ensure R25 was protected from sexual assault by Housekeeper 1. Harm was identified to have occurred on 1/26/2025, when R125 was assaulted by R117, resulting in R125 receiving multiple skin tears to the left arm, neck, and face. Findings included: A review of a facility policy titled Abuse Prohibition dated 4/7/2025 indicated .It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. This policy applies to anyone subjecting a patient to abuse, including, but not limited to, center staff, other patients, consultants, or volunteers. 1. A review of a document provided by the facility for R125 titled Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of R125's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2024, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which revealed the resident was cognitively intact. The assessment indicated that the resident had no behaviors directed towards others. The assessment indicated the resident used a wheelchair for mobility. A review of Nurses Notes dated 1/26/2025, indicated R125 reported to the nurse he was in R63's room when R117 arrived in R63's room and asked R125 to leave. When R125 attempted to leave R117 assaulted him, resulting in the resident being physically assaulted, resulting in R125 receiving multiple skin tears to the left arm, neck, and face. A review of a progress note provided by the facility for R125 titled .Behavioral Health. dated 1/27/2025 indicated the therapist met with R125 due to staff reporting that he was involved in an altercation with another male resident (R117) in which R125 was physically attacked from behind by R117 after words were exchanged. R125 suffered physical bruising and abrasions to his face. A discussion was had regarding boundaries with his encounter with R117, and there were no further recommendations identified. A review of a care plan for R125 titled Care Plan dated 2/10/2025, indicated the resident had a physical altercation with another resident (R117) when he was visiting his female friend (R63).A review of a document provided by the facility for R117 titled Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of R117's quarterly MDS with an ARD of 1/2/2025 indicated the resident had a BIMS score of nine out of 15, which revealed the resident was moderately cognitively impaired. The assessment indicated that the resident had no behaviors directed at others. The assessment indicated the resident used a wheelchair for mobility. A review of a care plan for R117 titled Care Plan dated 1/31/2025 revealed that the resident got into an altercation with his roommate (R125) due to a female resident's friendship (R63). A review of a document provided by the facility for R63 titled Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of the annual MDS with an ARD of 1/17/2025 indicated R63 had a BIMS score of 00 out of 15, which revealed the resident was severely cognitively impaired. A review of a document provided by the facility titled (Police Department), dated 1/26/2025, indicated police arrived at the facility in response to a physical altercation between two residents over their visitation with R63. According to the police report, R117 rolled down the hallway to his female friend's room (R63), in which he observed R125 visiting. Upon R117 entering the room of R63, R117 admitted that he asked R125 to leave, and R125 told R117 no, and then both R117 and R125 began to argue. This was when R117 slapped the face of R125. Both residents were provided with a room change after this incident. A review of an untitled document provided by the facility (referred to as a follow-up to the initial State Survey Agency incident), dated 1/31/2025, indicated that on 1/26/2025, R125 was self-propelling towards the nursing station when Certified Nurse Aide (CNA) 4 observed multiple red linear areas on his face, neck, and hand. CNA4 stopped R125 and immediately called the Assistant Director of Nursing (ADON) 1 over, and the resident was assessed. R125 reported he was in the room of his female friend when R117 entered and told R125 to leave. According to R125, when he turned around, R117 began to scratch his neck and face. R125 reported he had attempted to turn around to R117, when R117 attempted to hit R125, and when R125 blocked the hit, R125 sustained additional skin tears on his left hand from R117. An interview was then completed with R117 by the facility, in which R117 admitted he slapped R125 and did not know how the scratches occurred on R125's hands, neck, and face. R117 stated he did not know since the entire incident happened so quickly. The police were notified and arrived on the scene and did not pursue charges since both men had physical and mental disabilities. There was evidence that the facility reported the initial allegation of physical abuse to the State Survey Agency (SSA) timely along with the five-day follow-up investigation. The facility was able to substantiate the allegation of resident-to-resident physical abuse. During an interview on 8/5/2025 at 8:49 am, R125 stated he remembered the incident with R117 and stated he was attacked by R117 while he was visiting with R63. R125 stated the attack scared him, and he was hurt. R125 stated he was no longer afraid of him since he no longer sees R117. During an interview on 8/5/2025 at 3:55 pm, the Director of Nursing (DON) stated that both R125 and R117 were prior roommates and were separated immediately after the resident-to-resident altercation. The DON stated R117 was very protective of R63 and stated there have been no further issues between R125 and R117. 2. A review of a document provided by the facility for R25 titled Face Sheet indicated that the resident was admitted to the facility on [DATE]. A review of a care plan for R25 titled Care Plan dated 8/9/2019 indicated the resident had a diagnosis of dementia. A review of the R25's annual MDS with an ARD of 9/11/2024 indicated the resident had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was dependent on staff for all activities of daily living (ADLs). A review of a document provided by the facility for R78 indicated the resident was admitted to the facility on [DATE]. A review of the quarterly MDS with an ARD of 12/21/2024 revealed R78 had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. A review of an untitled document provided by the facility (referred to as a follow-up to the initial State Survey Agency incident), 9/20/2024, indicated that on 9/13/2024, R78, who was a former roommate of R25, observed Housekeeper 1 enter their room and leaned over and kissed R25 on the mouth. There was no resistance made by R25. R78 stated the privacy curtain was pulled between R78 and R25, and she was able to see the incident from the mirror that faced the two residents. According to R78, no other touching happened. An interview was conducted with R25, and she denied the allegation. The report continued and indicated that Housekeeper 1 initially denied the allegation and stated he reached over R25's bed to pick up her bedding. Housekeeper 1 was then interviewed by the police and admitted that he kissed R25 on the forehead and touched her hand. Housekeeper 1 was immediately suspended pending the investigation. The police did not pursue charges. The family member (F)1 took R25 to the emergency room to be tested for sexually transmitted diseases, and the results were negative. The resident did not have a pelvic exam conducted. A review of a document provided by the facility titled ED (Emergency Department), dated 9/14/2024, indicated R25, who had a history of dementia and resided in a nursing home, was brought in by F1. According to this document, the resident denied being kissed or touched but did state she had a boyfriend at the facility who would clean her room and did not live at the facility. A review of a document provided by the facility titled Official Statement, dated 9/20/2024, indicated Housekeeper 1 was terminated due to his admission to the police of kissing R25's forehead and touching her hand. During an interview on 8/4/2025 at 8:54 am, F1 stated that the facility investigated the allegation of sexual assault and confirmed she took R25 to the emergency room to be tested for sexually transmitted diseases. F1 stated the police were called and did not press charges against Housekeeper 1 due to R25's memory problems. F1 confirmed R25 shared her incident while in the emergency room. During an interview on 8/6/2025 at 12:30 pm, R78 confirmed she remembered R25 being kissed by Housekeeper 1. R78 stated she was in bed with the privacy curtain drawn and could see R25 in bed when Housekeeper 1 entered their room and bent over to kiss R25 on the mouth. R78 revealed that Housekeeper 1 eventually left the room. During an interview on 8/6/2025 at 8:59 am, the DON stated Housekeeper 1 was immediately terminated. The DON confirmed Housekeeper 1 was terminated based on his admission to the police department. During an interview on 8/6/2025 at 9:39 am, R25 stated she did not remember being kissed by Housekeeper 1 and stated she felt safe and was treated well. (Cross Reference F745)

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure proper infection control for three of 60 sampled residents (Residents (R) 9, R 139, and R 193). Specifically, infection control measures/enhanced barrier precautions were not carried out during gastrostomy tube care. This failure increased the risk for infections and cross-contamination.Findings included:A review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne and reviewed on 12/27/2024 stated .Enhanced Barrier Precautions (EBP) are indicated for Patients with any of the following: .indwelling medical devices even if the patient is not known to be infected or colonized with a MDRO [multidrug-resistant organism].EBP expands the use of PPE [personal protective equipment] and refers to the use of a gown and gloves during high-contact activities that provide opportunities for transfer of MDROs to staff hands and clothing.Examples of high contact patient care activities requiring gown and glove use for Enhanced Barrier Precautions include:.device care or use:.feeding tube.wound care: any skin opening requiring a dressing.A review of the undated Center for Disease Control (CDC) signage titled, Enhanced Barrier Precautions stated .Everyone must: .wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use:.feeding tube.wound care: any skin opening requiring a dressing.1. A review of R9's admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed R9 was admitted with diagnoses that included but were not limited to dementia.A review of R9's quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 7/6/2025 included pressure ulcers.A review of R9's Care Plan located in the EMR under the Care Plan tab, revised 5/2/2025, revealed R9 had pressure ulcers on the sacrum and left foot with interventions including EBP secondary to pressure ulcer.A review of R9's Physician Order located in the EMR under the Orders tab included EBP starting 5/6/2025.During an observation and interview on 8/7/2025 at 8:30 AM, Licensed Practical Nurse (LPN)6/ Wound Care Nurse provided wound care for R9, who had pressure ulcers to the left foot and sacrum. LPN6 performed hand hygiene prior to donning (putting on) gloves and a gown. LPN6 removed the soiled dressing to R9's left foot, discarded dressing, cleansed wound with normal saline (NS), applied skin prep to surrounding tissue, applied alginate (salt or [NAME] of alginic acid derived from seaweed) and covered with bordered dressing, donned non-skid socks, doffed (removed) soiled gloves and applied clean gloves after she completed wound care to the left foot. LPN6 did not change gloves between clean/dirty dressings and did not perform hand hygiene. LPN6 then proceeded to do wound care to the sacral wound, donned clean gloves, but did not perform hand hygiene before donning clean gloves. R9 had a large bowel movement (BM), LPN6 cleaned BM, doffed soiled gloves, washed hands, donned clean gloves, applied a clean brief under the resident, cleansed the wound, doffed soiled gloves, and did not perform hand hygiene prior to donning clean gloves and applying clean dressings. When asked why she did not perform hand hygiene between glove changes, she said they could not take the hand sanitizer bottle with them to avoid contamination, and she didn't realize she didn't change her gloves from dirty to clean dressing application on the left foot. LPN6 stated she didn't realize she needed to perform hand hygiene between glove changes, and that's just the way she's always done it. LPN6 confirmed that there was signage outside of R193's room for enhanced barrier precautions.2. A review of R139's admission Record located under the Profile tab in the EMR revealed R139 was admitted with diagnoses that included, but were not limited t,o gastrostomy status.A review of R139's quarterly MDS located in the EMR under the MDS tab with an ARD of06/19/2024 included gastrostomy (g-tube) status.A review of R139's Care Plan located in the EMR under the Care Plan tab, revised 7/3/2025, included g-tube status and maintaining EBP.A review of R139's Physician Order located in the EMR under the Orders tab included EBP starting 5/6/2025 related to g-tube status.During an observation and interview on 8/6/2025 at 4:30 PM, R139 was in bed and receiving g-tube care by the Assistant Director of Nursing (ADON) 1. The ADON1 performed hand hygiene, donned gloves, and did not don a gown. There was no EBP signage on the resident's room door. When the ADON1 was asked if R139 was on EBP, she said, There's no sign on the door, but most residents who have a g-tube are on EBP. She revealed that this resident only got a water flush, so she wasn't sure if R139 was on EBP. The ADON1 stated she didn't wear a gown due to there not being an EBP sign on the door, and wasn't sure if she was supposed to wear one or not.3. A review of R193's admission Record located under the Profile tab in the EMR revealed R193 was admitted with diagnoses that included, but were not limited to, gastrostomy status.A review of R193's quarterly MDS located under the MDS tab with an ARD of 7/15/2025 revealed a BIMS score of zero out of 15, which indicated R193 was severely cognitively impaired and had a feeding tube.A review of R193's Care Plan located in the EMR under the Care Plan tab, revised 2/2/2024, revealed R193 had a g-tube with interventions to maintain EBP.A review of R193's Physician Orders located in the EMR under the Orders tab included EBP starting 5/6/2025 related to gastrostomy status.During an observation and interview on 8/6/2025 at 11:02 AM, R193 was lying in bed and receiving gastrostomy tube (g-tube) care by Registered Nurse (RN)1. RN1 donned gloves but did not don a gown during g-tube care. When RN1 was asked why she did not wear a gown, she stated that she was nervous and forgot. RN1 confirmed that she should have worn both gown and gloves during g-tube care. RN1 confirmed that there was signage outside of R193's room for enhanced barrier precautions.During an interview on 8/7/2025 at 10:40 AM, the Director of Nurses (DON) confirmed that it was her expectation that staff wears a gown and gloves during high-contact resident care activities, including g-tube and wound care.

Based on record review and resident and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided for one of 60 sampled residents (R) (R11) related to bathing.Findings included:A review of a document provided by the facility for R11 titled Face Sheet indicated the resident was admitted to the facility on [DATE].A review of the quarterly Minimum Data Set for R11 with an Assessment Reference Date (ARD) of 6/17/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. The assessment indicated that the resident required partial/moderate assistance with activities of daily living.A review of a document provided by the facility for R11 titled Physical Functioning Instructions for the month of 5/2025 indicated the resident only received a bath on 5/6/2025. There was no evidence that the resident refused to be bathed.A review of a document provided by the facility for R11 titled Care Plan for R11 dated 6/9/2025 indicated the resident required assistance with functional mobility with activities of daily living.A review of a document provided by the facility for R11 titled Physical Functioning Instructions for the month of 6/2025 indicated the resident received a bath on 6/10/2025. There was no evidence that the resident refused to be bathed.Review of a document provided by the facility for R11 titled Physical Functioning Instructions for the month of 7/2025 was requested and not provided.During an interview on 8/5/2025 at 8:32 AM, R11 stated she had not received a bath consistently twice a week and was to receive a bath on Tuesdays and Fridays. During an interview on 8/6/2025 at 4:15 PM, the Director of Nursing (DON) confirmed all residents were to receive showers twice a week or per the preference of the resident. The DON stated there was a time when the electronic medical records were not working properly, and was unable to provide a date when this occurred. The DON revealed the residents were to receive showers, we try to do them twice a week, or more or less. The DON stated there were no facility policies for bathing.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure coordination of care was provided for one resident (R)(R118) out of one for a survey sample of 60, by failing to follow through with a consultant pulmonologist medication recommendation. This failure placed the resident at risk for delayed treatment related to her coughing. Findings included:A review of a facility policy titled Medication Orders dated 12/31/2024 indicated .Each medication order is documented in the patient's medical record with the date, time, signature, and title of the person receiving the order. Clarify the order with the prescriber.Notes the order and enters it on the Physician Order Sheet if not written there by the prescriber.Transfer orders (admission or readmission orders sent with a patient by a hospital or other health care center).The nurse will implement a transfer order without further validation if it is signed and dated by the patient's current attending physician.A review of a document provided by the facility for R118 titled Face Sheet indicated the resident was re-admitted to the facility with a diagnosis of acute and chronic respiratory failure with hypoxia (low oxygen in the bloodstream).A review of the annual Minimum Data Set (MDS) assessment for R118 with an Assessment Reference Date (ARD) of 6/18/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. A review of a document provided by the facility for R118 titled Care Plan dated 10/10/2024 indicated the resident had a history of acute and chronic respiratory failure.A review of a document provided by the facility for R118 titled After Visit Summary, dated 7/17/2025, indicated a pulmonologist ordered to administer Tessalon capsules (to relieve coughs). There was no documentation that would indicate how many capsules were to be taken or how often the medication was to be administered to the resident. A review of a document provided by the facility for R118 titled Nurse Note dated 7/17/2025 indicated the pulmonologist ordered the resident Tessalon capsules to treat her cough.During an interview on 8/6/2025 at 2:16 PM, R118 stated she had a recent appointment in the community with a pulmonologist who had ordered her Tessalon capsules for her chronic cough. The resident stated she brought in the prescription and gave it to the facility after her appointment.During an interview on 8/6/2025 at 2:18 PM, Licensed Practical Nurse (LPN) 3 stated that when a resident brought in a prescription from a physician in the community, the prescription was then given to LPN 7, who was the Nurse Manager.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure one of 60 sampled residents (Resident (R) 193) received appropriate gastrostomy tube management. Specifically, R193's gastrostomy tube had black discoloration in the tube which may indicate colonization of the tube with fungi, which could lead to infection, blockages, and/or material deterioration.Findings included:A request was made for the gastrostomy tube management policy, but it was not made available.A review of the facility policy titled Clinical Care Decision provided by the facility indicated the guidelines were to make .clinical decisions are made based upon the health care needs of the patient. Availability and access to quality health services require collaborative planning by healthcare professionals to meet the health needs of the patient. All Health Care Professionals have a responsibility to help promote that each patient's right to health care is met.A review of R193's admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed R193 was admitted with diagnoses that included, but were not limited t,o gastrostomy status.A review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 7/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R193 was severely cognitively impaired and had a feeding tube.A review of the Care Plan located in the EMR under the Care Plan tab, revised 2/2/2024, revealed R193 had a gastrostomy tube. Interventions included assessing feeding tube placement, patency, and residual every shift and before /after administration of any fluids or medications; flushing the tube with water as ordered by the physician; and maintaining enhanced barrier precautions.A review of R193's nursing Progress Notes located in the EMR under the Progress Notes tab from August 2024 to the present did not mention discoloration to the gastrostomy tube.A review of R193's NP (Nurse Practitioner) Progress Notes located in the EMR under the Scan Docs tab and dated 7/16/2025 indicated g-tube (gastrostomy tube) was in place with no documentation as to the condition of the tube.During an observation and interview on 8/6/2025 at 11:02 AM, R193 was lying in bed at a 45-degree angle. Registered Nurse (RN)1 assessed the gastrostomy tube and confirmed that the tube had black discoloration in the interior of the tube for a long time. RN1 stated that the discoloration had been there for several months, and she was not sure if anyone had reported it to the NP or Medical Director (MD), but she should have.

Based on clinical record review, facility document review, and staff interviews, the facility failed to ensure one resident (Resident (R) 25) was provided mental health services after sexual abuse which involved Housekeeper 1. This failure had the potential for R25 to suffer potential psychological stress after the event.Findings included: A review of a document provided by the facility titled Job Description, dated 2/3/2024, indicated the Social Worker was responsible for planning, organizing, and directing the overall operation of the Social Services Program to provide for the psychosocial needs of the patients and families served by the center.A review of a document provided by the facility for R25 titled Face Sheet indicated the resident was admitted to the facility on [DATE].A review of the annual Minimum Data Set (MDS) assessment for R25 with an Assessment Reference Date (ARD) of 9/11/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired.A review of an untitled document provided by the facility (referred to as a follow-up to the initial State Survey Agency incident), dated 9/20/2024, indicated that on 9/13/2024, R25 was kissed by Housekeeper 1. The police were notified, and Housekeeper 1 admitted that he kissed R25 and touched her hand.A review of a document provided by the facility for R25 titled Care Plan failed to address the sexual assault by Housekeeper 1, and that the resident, at the time of the incident, was unable to consent to the act.A review of R25's electronic medical records (EMR) failed to address psychological services after an incident of being kissed by Housekeeper 1.During an interview on 8/6/2025 at 10:43 AM, the Administrator stated a psychological visit would be made by the Social Worker (SW) if there was an allegation of abuse/neglect. The Administrator stated based on the SW's assessment, the resident would then be seen by psychological services, and then care would be planned after the event. The Administrator stated the care plan would need to be developed so the staff could monitor the resident for any associated behaviors. The Administrator stated this would be completed by the SW.During an interview on 8/6/2025 at 11:49 AM, SW1 stated she was not employed by the facility at the time R25 was kissed by Housekeeper 1. SW1 stated the resident would need to be assessed by the SW and a referral made for mental health evaluation. SW1 stated it was important to then update the resident's care plan so staff could monitor any associated psychological stress related to the incident. (Refer to F600)

Based on observation, staff interviews, record reviews, and review of the facility procedural guideline titled, Pharmacy Services Infusion Therapy Product Labels, the facility failed to ensure medications were labeled in accordance with standard requirements for one of one Residents (R) (R271) sampled for intravenous (IV) medication administration. Specifically, the date and time administration of the IV medication began and the nurse's initials that administered it were not written on R271's IV label. Findings include: Review of the facility procedural guideline titled, Pharmacy Services Infusion Therapy Product Labels dated 2019 revealed the intent was that infusion therapy products are labeled in accordance with center requirements and applicable state and federal laws. The label includes sufficient additional information as required to assure safe and efficient administration to patients. The Guidelines section included infusion products are labeled in the pharmacy with the date started, time, and RN (registered nurse) initials. Review of the clinical record for R271 revealed resident was admitted with diagnoses including but not limited to streptococcal sepsis. Review of the physician orders revealed an order dated 9/23/2023 for cefazolin 2 grams (gm) (a medication used to treat serious bacterial infections) in 50 milliliter (ml) dextrose IV piggyback (small IV bag with antibiotic), one piggyback IV every eight hours for 38 days. Review of the care plan included a problem area of vascular access related to receiving antibiotics. The goal was that the resident will experience no complications from vascular access during the review period. Interventions included administering medications as ordered, assessing signs and symptoms of infection. Observation on 10/3/2023 at 4:20 pm of R271 revealed one 50 ml bag of cefazolin 2 gm and dextrose connected to an IV infusion pump. The medication had completed infusing. The pump was on, and the alarm was audible. Further observation revealed Licensed Practical Nurse (LPN) AA entered the room and turned the IV pump off. Observation of the bag of cefazolin 2 gm and dextrose IV medication revealed it was not labeled with a date or time of administration or a nurse's initials on the bag. Interview on 10/3/2023 at 4:30 pm with LPN AA revealed she had administered the IV cefazolin 2gm in 50ml of dextrose solution. She stated she was aware she should label the IV medication bag with the administration date and time, and her initials when she began the administration, and she must have forgotten. Observation of the empty bag of cefazolin with LPN AA revealed the bag did not have a date, time, or initials on it. She verified she did not label the bag prior to administration. Interview on 10/4/2023 at 2:15 pm with Registered Nurse (RN) BB revealed when administering an IV medication, the medication should be labeled with the date and time administration of the medication began and the nurse's initials that administered it. Interview on 10/4/2023 with LPN CC revealed IV medications should be labeled with the date and time administration of the medication began and the nurse's initials that administered it. Interview on 10/5/2023 at 11:00 am with LPN DD revealed her to state the nurse administering IV medications should label the infusion bag with the date and time of administration and the nurse's initials when the medication administration was started. Interview on 10/5/2023 at 11:30 am with the DON revealed IV medications arrived at the facility with a pharmacy label that contained the medication information, and the nurse did not need to place the date and time of administration or the nurse's initials on the label when the medication administration was started. She stated the nurse documented the date and time of administration and the initials on the medication administration record (MAR) therefore it was not required for the information to be placed on the container of medication.

Based on observations, staff interviews, record review, and review of the facility procedural guideline titled, Pharmacy Services Safe Administration of Infusion Therapy Products, the facility failed to ensure infection control practice was followed during the flush procedure for a resident receiving medication via a peripherally inserted central catheter (PICC) line (a vascular access device used to safely administer medication into the bloodstream) for one of one Residents (R) (R271) sampled for intravenous (IV) medication administration. This failure had the potential of exposing R271 to infections due to cross contamination. Findings include: Review of the facility procedural guideline titled, Pharmacy Services Safe Administration of Infusion Therapy Products dated 2023 revealed the intent was to promote safe and effective administration of infusion therapy products. The Procedure section included a procedure of: The licensed nurse responsible for changing an intravenous solution is expected to follow appropriate standards of nursing practice in protecting against contamination. Review of the clinical record for R271 revealed resident was admitted with diagnoses including but not limited to streptococcal sepsis. Review of the physician orders revealed an order dated 9/23/2023 for cefazolin 2 grams (gm) (a medication used to treat serious bacterial infections) in 50 milliliter (ml) in dextrose IV piggyback, one piggyback IV every eight hours for 38 days; and an order dated 9/23/2023 for midline catheter non-valved with saline, antibiotic, saline, heparin (SASH) flush before and after medication administration intravenously every eight hours for 25 days. Review of the care plan revealed a problem area of IV therapy required due to diagnosis of sepsis. The goal was that R271 will experience no complications of IV therapy. Interventions included assessing the catheter site for signs and symptoms of infection. Observation on 10/3/2023 at 4:20 pm of R271 with one 50 ml bag of cefazolin 2 gm and dextrose connected to an IV infusion pump revealed the medication had completed infusing. The pump was on, and the alarm was audible. Further observation by two surveyors revealed Licensed Practical Nurse (LPN) AA entering R271's room and turning the pump off. She disconnected the IV tubing from the PICC line access site located in the resident's right antecubital (inner arm at elbow) area. She then cleaned the needleless connector of the PICC with an alcohol wipe, allowed the uncapped needleless connector to lie on and touch the bed linen while preparing the heparin flush, picked it up and flushed it with the heparin flush without sanitizing it. She then disconnected the heparin flush syringe and connected a disinfection cap to the needleless connector. Interview on 10/3/2023 at 4:30 pm with LPN AA revealed she was unaware that she had allowed the PICC line needleless connector to touch the bed linen prior to administering the heparin flush and after she had sanitized the connector end. She stated the needleless connector should have been sanitized just prior to administering the flush solution. She stated she had received education on infection control and IV medication administration but could not recall the date of the education. She stated her intentions with resident care were to prevent cross contamination which could potentially cause a resident's condition to worsen. Interview on 10/4/2023 at 2:15 pm with Registered Nurse (RN) BB revealed her to state when administering an IV medication or fluids, the needleless connector of the IV line should never touch an unclean surface without the cap attached to it. Interview on 10/4/2023 with LPN CC revealed she had received recent education on administering IV medications via an online platform. She could not verify the date of the education. She stated when administering an IV medication or fluids, the needleless connector of the IV line should never touch an unclean surface without the cap attached to it. Interview on 10/5/2023 at 11:00 am with LPN DD revealed her to verbalize steps taken during disconnection of IV medication administration. She stated she would disconnect the needleless connector from the IV tubing hub, would hold the needleless connector in her hand, clean the end of it, administer the flush solution, and place the protective cap onto the needleless connector. She stated the end of the needleless connector should not be allowed to touch a surface and if it did, it should be cleaned with an antiseptic wipe just prior to administering flush solution and prior to placing the protective cap on it. Interview on 10/5/2023 at 11:30 am with the DON revealed she didn't think the PICC line needleless connectors were long enough to come into contact with a surface. She stated if it did, the nurse should sanitize it prior to placing the protective cap on it and prior to administering any solution into it. She stated her expectations were for the needleless connector to be sanitized with a sanitizing wipe prior to administering any solution into it and for it to have a protective cap on it when not in use.

Based on observations, interviews with residents and staff, and record review, the facility failed to ensure the dietary services department response to grievances filed by the Resident Council Group and residents for two residents (R) (R#48 and #85) of 39 sampled residents. Findings include: 1. Record review revealed that R#85 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) Assessment on 11/25/21 revealed that R#85 had a Brief Interview for Mental Status (BIMS) of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Originally ordered 11/5/21.) During lunch observation on 1/4/22 at 1:30 p.m., R#85 was observed sitting up in her wheelchair in her room, eating off a Styrofoam-style take out tray. She said that the food was not good. She stated that it did not have a taste and was cold. She said that she loved vegetables and did not get any on her tray. No vegetables were observed on resident's lunch tray. R#85 stated that she had written on her tray ticket what she liked and didn't like, but it didn't do any good (e.g., no changes were made in food served to support her preferences). She further stated that she had spoken with the kitchen staff, and it does no good. During lunch observation and resident interview on 1/5/22 at 1:22 p.m. with R#85, the resident was sitting up in her wheelchair in her room eating off Styrofoam-type take out trays with a small amount of chopped meat, and mashed potatoes with brown gravy; however, no vegetables were noted on R#85's tray. During observation, R#85's tray ticket was reviewed, and revealed large portions of vegetables were to be served. R#85 said that she does not like eating off Styrofoam and was unsure how long she had been eating with plastic silverware. R#85 said that she does not get vegetables, but she loved them. She stated that the meat was a mystery meat, that it does not look like meat loaf. R#85 ate approximately four to five bites of the meat but no mashed potatoes. Review of the Diet Spreadsheet with approval date of 1/4/22 revealed that a regular diet for lunch on Tuesday (1/4/22) was to receive eight-ounce ladle of chili, one baked potato, four-ounce (serving) of green peas, one roll, and one slice of pound cake. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that lunch on Wednesday (1/5/22) was to receive (regular diet) three-ounce slice of meat loaf, four-ounce (serving) of mashed potatoes, four-ounce (serving) of purple hull peas, choice of roll, and one serving of a cookie or ice cream. Review of Tray Ticket dated 1/7/22 revealed that R#85 was to get large portions of vegetables, and that R#85 disliked peas and carrots. 2. During an interview on 1/4/2022 at 12:28 p.m., Resident (R) #48 stated that meals were not what they should be. There was no milk for breakfast, and they can't get milk when they choose cereal for breakfast. R#48 stated the Resident Council had made many complaints about the food during the meetings, but no one from the kitchen had come to address their concerns with them. A review of the Skilled Inpatient Services Grievance/Concern Guideline for Patients dated 2020, showed that grievances may be filed with the center or other entities the patient chooses. It was also the intent of the center to support each patient ' s right to voice concerns and to assure that after receiving a concern/grievance, the facility will actively seek a resolution and keep the patient (or representative) apprised of the progress toward resolution. A review of the Resident Council Meetings Minutes from January 2021 to December 2021 revealed the following: On 4/7/21 residents had concerns about food presentation. Residents stated sometimes they could not tell what the meal was supposed to be by looking at the food presented on the tray. Residents reported that soups and drinks tasted watered down, and bread-type foods with breakfast were soggy. On 4/13/21 residents stated the above concerns, but additionally stated the eggs served during breakfast were watery. It was noted that the Dietitian discussed food concerns with group members. On 4/21/21 residents discussed food concerns to include meat being too tough to cut at times, food presentation, eggs, and watery juice. Food Service Manager (FSM) made a visit to the meeting and discussed food preferences and food portions. On 5/20/21 residents discussed food quality at the Resident Council meeting. On 6/10/21 residents discussed food presentation at the Resident Council meeting. On 7/8/21 residents requested baked potatoes to be placed on the menu and how they disliked diced potatoes as served on the menu. On 9/15/21, residents discussed that breakfast breads were soggy when served on plates and requested that breads served at breakfast time be placed in plastic bags. On 10/07/21 residents discussed the grits and oatmeal were served cold and hard, and portion sizes were too small. Residents requested cabbage greens to be served more often and staff was forgetting to serve condiments with their meals. The FSM was noted to have attended this meeting to respond to food service requests. On 11/4/21 residents discussed that potatoes were not fully cooked. Residents stated that they understood that kitchen did not have some foods but requested that if kitchen staff could do better with the foods that they did have it would be appreciated. Residents also discussed that pizza was a blob of dough and did not resemble pizza at all. Rice did not resemble rice in appearance. Chili was cold as if it had been refrigerated and not heated thoroughly. Residents further discussed that they had not had soup in a while, there were no tops or straws for cups, and the food was awful at best. Residents also stated that they would like cereal to be added to the regular breakfast and portion sizes of meats are too small and/or too difficult to eat. On 12/9/21 residents discussed that grits and oatmeal was inedible and they would like cereal instead since the breakfast was always cold. Residents approved to begin to request department managers be invited to the Resident Council meetings. Residents also discussed that the grill cheese was always burned as well as pizza. Residents further discussed not receiving soups or vegetables. Residents also discussed that weekend meals are terrible. The Administrator discussed a convenience menu to residents. This menu consisted of sandwiches such as ham, peanut butter and jelly, and grilled cheese. A review of the Resident Council Meeting Minutes showed that old business was discussed during each meeting, but there was no resolution documented to the concerns related to the facility food. During an interview on 1/06/2022 at 4:36 p.m., FSM AA stated that she attended the Resident Council meetings and the few complaints that she was aware of had been addressed. FSM AA stated that she would provide documentation of when concerns were addressed. Documentation was requested twice and was not provided. During an interview on 1/07/2022 at 9:48 a.m., Registered Dietitian (RD) EE stated that the expectation was the food should be warm and palatable when served to residents. RD EE stated if foods were not warm when served, then the nursing staff was expected to warm the food in the microwave in the nurse pantry and take the temperature of the food prior to service. RD EE stated in regard to food that was not served tender enough to cut with a plastic knife, from that point forward, the dietary department would monitor residents who need more assistance. During an interview on 1/7/2022 at 12:08 p.m., Activities Director (AD) JJ stated that the process for informing the appropriate department manager about the information discussed during the Resident Council meetings was when a subject was brought up in the meeting, she would invite the manager to that current meeting if the manager was available. If the manager was not available, then the issues would be brought up in the morning meetings. AD JJ stated the manager would be informed verbally, and the grievance would be documented in TSI Service Recovery Opportunity (SRO) which is an internal system for grievances which was accessed by the department managers. AD JJ stated that managers had a certain amount of time to respond to the grievance. AD JJ stated that managers would respond in TSI, speak with residents one on one and or follow up at the next meeting. AD JJ stated that the last time there was a concern for the dietary department was November 2021. During an interview on 1/7/2022 at 12:50 p.m., Social Services Director (SSD) II stated all department managers had access to SRO. If there was a concern for a department, the concern would be assigned to that the department and the manager received an email about the grievance. During an interview on 1/07/2022 at 2:05 p.m., the Administrator stated that it was her expectation that staff documented grievances voiced by the residents. The grievances were to be delegated to the appropriate department, the grievance was to be investigated, a correction plan completed, and the resolution reported to the person who filed the grievance. The Administrator further stated that it was an expectation that the dietary manager was to review the grievances filed for the dietary department and respond appropriately to the grievances filed.

Based on observations, record review, and interviews the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance and provide meals that were palatable, attractive, and at a safe and appetizing temperature for six residents (R) (R#48, #32, #296, #67, #85, and #44) of 39 residents sampled residents. Findings include: 1. Record review revealed that R#48 was admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#48 revealed a Brief Interview for Mental Status (BIMS) score of 15, meaning that R#48 is cognitively intact. During an interview on 01/04/22 12:28 p.m., R#48 stated that the Resident Council had a meeting last month. R#48 stated that the biggest complaint in the past meetings was about the food. R#48 stated that the residents have requested to have cereal and milk in the mornings for breakfast, but it has not happened. 2. Record review revealed that R#32 was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE] for R#32 revealed a BIMS score of 13, indicating mild cognitive impairment. On 1/04/22 at 1:29 p.m. R#32 was observed eating her lunch. She stated that food was not good; the food was cold and that the meat was tough. She stated that the taste overall was just not good. On 1/05/22 at 2:35 p.m. R#32 stated that she had chicken for lunch and that it was tough and dry, and the potato was not cooked well. 3. Record review revealed that R#296 was readmitted to the facility on [DATE]. A review of the Annual MDS dated [DATE] for R#296 revealed a BIMS score of 13, indicating mild cognitive impairment. Review of R#296's medical record revealed no evidence of her likes and/or dislikes. Review of the meal ticket for R#296 dated 1/7/22 revealed NAS diet with no evidence of dislikes or preferences listed. During an interview with R#296 on 1/4/22 at 10:10 a.m., she stated that the food was cold (all meals), she was served items that she cannot eat (bacon, ham), and that the meals were served on Styrofoam-like take out trays with plastic silverware for all meals. She said that she did not like this, and that she did not even go to restaurants that serve on Styrofoam-like containers. During lunch observation on 1/4/22 at 1:15 p.m., R#296 was served chili, peas and a baked potato. Resident said she did not like chili (gives her heartburn). Reviewed R#296's lunch meal ticket which only listed her name, room number with diet ordered; however, no likes and/or dislikes listed. During breakfast observation on 1/5/22 at 9:13 a.m., R#296's meal ticket was observed to be blank other than diet listed. She was served on Styrofoam-like carry out tray. She was served grits, which appeared to be thick and pasty white colored. During interview with R#296 on 1/5/22 at 9:18 a.m., she said that she did not like grits and that nobody from dietary had spoken with her about her dislikes. During observation and interview with R#296 on 1/5/22 at 1:32 p.m., her lunch tray observed with one roll, unknown substance of ground meat which appeared hard on top with gravy, mashed potatoes with gravy, and a dark gray colored unknown type of beans serving. The resident said that the tea was kind of sweet but that she liked unsweet tea. She said, What does not kill you, makes you stronger. Resident stated, while pointing to the unknown substance of ground meat, that it looked very hard. During observation of breakfast on 1/6/22 at 9:30 a.m., R#296 was sitting up in her bed, eating approximately her meal. The tray had grits on it which the resident did not touch. Her meal ticket remained without preferences. During observation of lunch on 1/6/22 at 1:30 p.m., R #296 was sitting up in her wheelchair, served her lunch tray which contained sweet tea, a small corn on the cob, half of sweet potato, and a small piece of chicken breast. She said that the food was lukewarm and that the sweet tea would have to be diluted with water. 4. Record review revealed that R#67 was readmitted to the facility on [DATE]. Review of R#67's Admission MDS assessment dated [DATE] revealed a BIMS score of 15, meaning that R#67 is cognitively intact. Review of the meal ticket for R#67 dated 1/7/22 revealed regular diet with dislikes for eggs and grits. During initial tour of the facility on 1/4/22 between 10:00 a.m.-11:00 a.m., R#67 stated that the facility food was not good (cold food). During observation and resident interview on 1/4/22 at 1:30 p.m., R#67 said that she ate only the vegetable and bake potatoes for lunch due to the chili giving her heartburn. During lunch observation on 1/6/22 at 1:15 p.m., revealed R#67 sitting up in her recliner, finishing her lunch, in which she was served a small corn on the cob, half of a sweet potato, red velvet cake, yogurt, and chicken. The resident stated that she did not enjoy the chicken, that it was hard to cut, so she did not eat it. The chicken was observed and appeared to be dry. 5. Record review revealed that R#85 was admitted to the facility on [DATE] with a diagnosis of diabetes, and below the knee amputation (BKA). Review of the Quarterly MDS assessment dated [DATE] revealed that R#85 had a BIMS of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of vegetables with her meals. (Originally ordered 11/5/21.) Review of the tray ticket dated 1/7/22 revealed that R#85 was to receive large portions of vegetables, and that R#85 disliked peas and carrots. During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting in her room eating her lunch off a Styrofoam-like take out tray. She stated that the food was not good, had no flavor and was cold. During observation, she said that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on her lunch tray. She stated that she does not eat chili, which was served for lunch, due to it giving her heartburn. She said that when she asks for an alternate vegetable, she received a sandwich. During lunch observation and resident interview on 1/5/22 at 1:22 p.m., R#85 sitting in her wheelchair in her room eating lunch from a Styrofoam-type take out tray. The tray contained a small amount of chopped meat, and mash potatoes with brown gravy; however, no other vegetables were noted on R#85's tray. During observation, R#85's tray ticket was reviewed, and revealed large portions of vegetables were to be served. R#85 said that she did not like eating off Styrofoam and was unsure how long she had been eating with plastic silverware. R#85 said that she did not get large portions of vegetables, but she loved them. She further stated that the meat was a mystery meat, that it does not look like meat loaf. During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting in her room eating lunch from a Styrofoam-like take out tray. The tray contained a small ear of corn, half of a sweet potato, red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. The resident said that the chicken looked so tough. R#85's tray ticket review revealed large portions of vegetables. 6. Record review revealed that R#44 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] revealed that R#44 had a BIMS of 15, meaning that R#44 is cognitively intact. On 1/4/22 at 11:27 a.m. in an interview with R#44, he stated the food wasn't consistent. He stated that he was on a diet and was told he can't have fried chicken, but he receives fried fish some days. He stated the kitchen is constantly saying they don't have some items. During an observation and interview with R#44 on 1/4/22 at 12:29 p.m. he was served chili and half of a baked potato for lunch. He stated that he doesn't really eat chili, so he requested a second baked potato. He was served an additional baked potato but was told by staff that he couldn't get any extra butter because there wasn't any left. Review of facility policy titled Menus with copyright date of 2020 revealed that it was the intent of the facility to provide meals based on a menu following established national guidelines. Further review revealed that menu items will be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. The menu alternates of similar nutritive value will be offered to patients daily and as needed. A review of the Resident Council Meetings Minutes from January 2021 to December 2021 noted the following: On 4/07/21 residents had concerns about food presentation. Residents stated sometimes they could not tell what the meal was supposed to be by looking at the food presented on the tray. Residents reported that soups and drinks were watered down, and breaded food with breakfast was soggy. On 4/13/21 residents stated the above concerns, but additionally stated that the eggs served during breakfast were watery. It was noted that Dietician discussed food concerns with group members. On 4/21/21 residents discussed food concerns to include meat being too tough to cut at times, food presentation, eggs, and watery juice. Food Service Manager made a visit to the meeting and discussed food preferences and food portions. On 5/20/21 residents discussed food quality. On 6/10/21 residents discussed food presentation. On 7/08/21 residents requested baked potatoes to be placed on the menu and how they disliked diced potatoes served on the menu. On 9/15/21, residents discussed that breads were soggy when served on places and requested that breads served at breakfast time be placed in plastic bags. On 10/07/21 residents discussed that grits and oatmeal were served cold and hard, and portion sizes were too small. Residents requested cabbage greens to be served more often and staff was forgetting to serve condiments. Food Service Manager was noted to have attended the meeting to respond to food service requests. On 11/04/21 residents discussed that potatoes were not fully cooked. Residents stated that they understood that kitchen did not have some foods but requested that if kitchen staff could do better with the foods that they did have it would be appreciated. Residents also discussed that pizza was a blob of dough and did not resemble pizza at all. Rice did not resemble rice. Chili was cold as if it had been refrigerated. Residents further discussed that they had not had soup in a while, there were no tops or straws for cups, and the food was awful at best. Residents also stated that they would like cereal to be added to regular breakfast and portion sizes of meats are too small or too difficult to eat. On 12/09/21 residents discussed that grits and oatmeal was inedible and they would like cereal instead since the breakfast was always cold. Residents approved to begin to request department managers into the resident council meetings. Administrator discussed convenience menu to residents. Residents also discussed that the grill cheese was always burned as well as pizza. Residents further discussed not receiving soups or vegetables. Residents also discussed that weekend meals are terrible. A test tray observation was started on 1/06/22 at 1:00 p.m. During this observation the meal was placed on the cart at 1:00 p.m. After all trays on the cart were passed to residents, the test tray was removed and sampled by anonymous staff at 1:28 p.m. They stated that the sweet potato was a little under cooked, the corn was dry and cooked too long. Staff stated that the chicken was okay but missing something. Staff reported that food was better than it had been in the past but that residents still complained about the food all the time. During an interview on 1/06/22 at 4:36 p.m., Food Service Manager (FSM) AA stated that she attended the Resident Council Meetings and the few complaints that she was aware of had been addressed. FSM AA stated that she would provide documentation showing concerns were addressed. The information was requested twice, but no documentation was provided. During an interview on 1/07/22 at 9:48 a.m., Registered Dietitian (RD) EE stated the expectation was the food should be warm and palatable when served to residents. RD EE stated that if foods were not warm when served, then the nursing staff was expected to warm the food in the microwave in the nurse pantry and take the temperature of the food prior to service. RD EE stated in regard to food that was not served tender enough to cut with plastic knife, from this point forward, the dietary department would monitor residents who needed more assistance. During an interview on 1/07/22 at 2:05 p.m., the Administrator stated that it was her expectation that staff would document grievances that were voiced by residents. The grievances were to be delegated to the appropriate department, the grievance would be investigated, a correction plan would be completed, and the resolution would be reported to the person who filed the grievance. The Administrator further stated that it was the expectation that the dietary manager was to review the grievances filed for the dietary department and respond appropriately to the grievances filed.

Based on observations, record review and interviews, the facility failed to follow the care plan related to a prescribed diet as ordered for one resident (R) (R#85) of 39 sampled residents. Findings include: Resident R#85 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment on 11/25/21 revealed that R#85 had a Brief Interview for Mental Status (BIMS) of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#85's care plan, originally dated 6/15/21, revealed that R#85 was at risk for altered nutrition status related to food preferences. Interventions were to provide diet as prescribed. During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting up in her room eating her lunch. She was observed to be served a baked potato and a bowl of chili. She stated that the food was not good, had no flavor and was cold. During observation, she stated that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on the resident's lunch tray. R#85 said that she does not eat chili due to it giving her heartburn. She said that when she asks staff for an alternate, she would usually just get a sandwich. During lunch observation and resident interview on 1/5/22 at 1:22 p.m. with R#85, the resident was sitting up in her wheelchair in her room eating lunch. She was observed to have been served a small amount of chopped meat and mashed potatoes with brown gravy. There were no vegetables observed on R#85's tray. During a review of the meal ticket placed on R#85's tray, it was noted that she was supposed to receive large portions of vegetables. R#85 said that she does not get vegetables, but she loved them. She stated that the meat was a mystery meat, that it does not look like meat loaf. R#85 ate approximately four to five bites of the meat but no mashed potatoes. During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting up in her room eating lunch. She was served a small ear of corn, half of sweet potato, a slice of red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. She said that the chicken looked so tough. R#85's meal ticket was reviewed and revealed that she was supposed to receive large portions of vegetables were to be served. Interview with Certified Nursing Assistant (CNA) BB on 1/6/22 at 1:25 p.m., she confirmed that resident did not have large portions of veggies on her tray. During an interview with the Food Service Manager (FSM) AA on 1/6/22 at 1:32 p.m., she said that a large portion of vegetables could be a bigger portion of the regular and/or additional extra vegetable. She confirmed that R#85 did not like peas, so if peas were served, then R#85 would not get a vegetable at all. She further added it would depend on what else was on the tray line, what was already prepared, and what R#85's preferences were. She did state that green peas were served on Tuesday for lunch and field peas on Wednesday for lunch. The FSM confirmed that the staff should be following the Physicians order related to the residents diet. Interview with the Director of Nursing (DON) on 1/6/22 at 2:00 p.m., when asked about large portions of vegetables for R#85, she said that she would think it would mean an extra scoop of vegetables. During a telephone interview with the Corporate Certified Dietary Manager (CDM) DD on 1/6/22 at 5:23 p.m., she stated that they were resident-centered, meaning that they honor the preferences of the resident. When asked about the nutritional value of the food when substituting vegetables (when a resident did not like what was served and the kitchen was aware of this dislike), she confirmed there should be something of the same nutritional value served in the place of what the resident did not like. In an interview with the Registered Dietitian (RD) on 1/7/22 at 9:20 a.m., she confirmed that a large portion of vegetables would be extra or additional vegetables and stated that if there was a vegetable that was being served that a resident did not like, then it should be substituted for another vegetable. The RD stated she expected that all residents are to get what was on the dietary spreadsheet for a meal (meat, starch, and vegetable). Review of the Diet Spreadsheet with approval date of 1/4/22 revealed that a regular diet for lunch was to receive an eight-ounce ladle of chili, one baked potato, a four-ounce (serving) of green peas, a roll, and one slice of pound cake. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that a regular diet lunch was to consists of a three-ounce slice of meat loaf, a four-ounce (serving) of mashed potatoes, a four-ounce (serving) of purple hull peas, choice of roll, and one serving of a cookie or ice cream. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that a regular diet for lunch was to be served one breast of Italian baked chicken, one-half of a baked sweet potato, one-half of corn on the cob, a roll, and red velvet cake. Review of Tray ticket dated 1/7/22 revealed that R#85 was to get large portions of vegetables, and that R#85 dislikes peas, and carrots.

Based on observations, record review, review of policy facility titled Menus and interviews, the facility failed to ensure that one resident (R) (R#85) of 39 sampled residents received a diet that was well-balanced and followed physician orders. Findings include: Review of facility policy titled Menus with copyright date of 2020 revealed that it is the intent of the facility to provide meals based on a menu following established national guidelines. Further review revealed that menu items will be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. The menu alternates of similar nutritive value will be offered to patients daily and as needed. Record review revealed that R#85 was admitted to the facility on [DATE] with a diagnosis of diabetes, and below the knee amputation (BKA). Review of the Quarterly Minimum Data Set (MDS) Assessment on 11/25/21 revealed that R#85 had a Brief Interview for Mental Status (BIMS) of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of vegetables with meals. (Originally ordered 11/5/21.) Review of the Diet Spreadsheet with approval date of 1/4/22 revealed that a regular diet for lunch on Tuesday (1/4/22) was to receive eight-ounce (serving) of chili, one baked potato, four-ounce (serving) of green peas, one roll, and one slice of pound cake. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that lunch on Wednesday (1/5/22) was to receive (regular diet) three-ounce slice of meat loaf, four-ounce (serving) of mashed potatoes, four-ounce (serving) of purple hull peas, choice of roll, and one serving of a cookie or ice cream. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that a regular diet for lunch on Thursday (1/6/22) was to be served one breast of Italian baked chicken, half of baked sweet potato, half of corn on the cob, roll, and red velvet cake. Review of Tray ticket dated 1/7/22 revealed that R#85 was to get large portions of vegetables, and that R#85 disliked peas and carrots. During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting up in her room eating her lunch. She was observed to be served a baked potato and a bowl of chili. She stated that the food was not good, had no flavor and was cold. During observation, she stated that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on the resident's lunch tray. R#85 said that she does not eat chili due to it giving her heartburn. She said that when she asks staff for an alternate, she would usually just get a sandwich. During lunch observation and resident interview on 1/5/22 at 1:22 p.m. with R#85, the resident was sitting up in her wheelchair in her room eating lunch. She was observed to have been served a small amount of chopped meat and mashed potatoes with brown gravy. There were no vegetables observed on R#85's tray. During a review of the meal ticket placed on R#85's tray, it was noted that she was supposed to receive large portions of vegetables. R#85 said that she does not get vegetables, but she loved them. She stated that the meat was a mystery meat, that it does not look like meat loaf. R#85 ate approximately four to five bites of the meat but no mashed potatoes. During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting up in her room eating lunch. She was served a small ear of corn, half of sweet potato, a slice of red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. She said that the chicken looked so tough. R#85's meal ticket was reviewed and revealed that she was supposed to receive large portions of vegetables were to be served. In an interview with Certified Nursing Assistant (CNA) BB on 1/6/22 at 1:25 p.m., she confirmed that R#85 did not have large portions of vegetables on her tray. She said that staff are to look at the resident's tray ticket before giving resident a tray to ensure the resident received what was ordered. During an interview with the Food Service Manager (FSM) AA on 1/6/22 at 1:32 p.m., she said that a large portion of vegetables could be a bigger portion of the regular and/or additional extra vegetable. She confirmed that R#85 did not like peas, so if peas were served, then R#85 would not get a vegetable at all. She further added it would depend on what else was on the tray line, what was already prepared, and what R#85's preferences were. She did state that green peas were served on Tuesday for lunch and field peas on Wednesday for lunch. The FSM confirmed that the staff should be following the Physicians order related to the residents diet. During a telephone interview with the Corporate Certified Dietary Manager (CDM) DD on 1/6/22 at 5:23 p.m., she stated that they were resident-centered, meaning that they honor the preferences of the resident. When asked about the nutritional value of the food when substituting vegetables (when a resident did not like what was served and the kitchen was aware of this dislike), she confirmed there should be something of the same nutritional value served in the place of what the resident did not like. Interview with the Registered Dietitian (RD) on 1/7/22 at 9:20 a.m., she confirmed that a large portion of vegetables would mean an extra serving of vegetables and stated that if there was a vegetable that was served that a resident did not like, then it should be substituted out for another vegetable. She said that she expected that all residents were to get what was on the dietary spreadsheet for a meal (meat, starch, and vegetable).

Based on observation, interview, record review, and facility policy review, the facility failed to ensure two of three staff implemented standard precautions when providing care for three of 25 sampled residents (Residents (R)#40, R#88, R#99) as evidenced by staff failing to perform handwashing or hand hygiene with gloves changes. The findings include: Record Review of the facility's reviewed and updated for release November 2015 policy titled Contact Precautions under the sub-heading Gloves and Hand Hygiene revealed the following: Hand hygiene should be completed prior to donning gloves. Gloves should be worn when entering the room and while providing care for the resident. Gloves should be changed after having contact with infective material (e.g., fecal material and wound drainage). Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. The policy does not address handwashing or hand hygiene between glove changes. Record Review of the facility's reviewed and updated for release November 2015 policy titled Using Gloves revealed the following Perform hand hygiene after removing gloves. Gloves do not replace hand hygiene. Disposable (single-use) gloves should be replaced as soon as practical when contaminated or as soon as feasible if they are torn or punctured and when they exhibit signs of deterioration or when their ability to function as barrier is compromised. 1. Record review of R#40's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of R#40's medical record revealed the resident is currently being treated for [REDACTED]. Observation of incontinent care provided to R#40 on 1/11/18 at 10: a.m. by Certified Nursing Assistant (CNA) CC assisted by CNA DD revealed both CNAs washing their hands prior to setting-up the equipment to be used. Both CNAs removed gloves and performed hand hygiene prior donning clean gloves to begin resident care. CNA CC opened the resident brief, obtained a clean wash cloth and placed it in the soapy water. After wringing the washcloth out, she opened the labia and cleaned from front to back repositioning the washcloth with each wipe. After completion, she removed the glove on her right hand using her gloved left hand contaminating it. CNA CC donned a clean glove on her right hand but failed to perform hand hygiene with the glove change and failed to change both gloves. CNA CC obtained a clean wash cloth wetting it in the soapy water. She cleaned the bilateral groin area of the resident repositioning the washcloth with each wipe. CNA CC removed her gloves and donned cleaned gloves failing to perform hand hygiene. R#40 was rolled to her side by CNA DD. CNA CC proceeded to clean the resident's rectal area from front to back repositioning the wash cloth with each wipe. CNA CC removed her gloves and donned clean gloves failing to perform hand hygiene with the glove change. A clean brief was obtained and placed on the resident and fastened. CNA CC removed her gloves and washed her hands. CNA DD with assistance from the resident put her pants on, repositioned her and covered the resident. CNA DD removed her gloves and washed her hands. Interview on 1/11/18 at 10:40 a.m. with CNA CC and CNA DD, at Unit 500 nurse station, both CNAs were asked if they received training on hand hygiene and glove use. Both CNAs responded yes. Both CNAs were asked if they received training on when it was appropriate to wash their hands or perform hand hygiene with glove use. Both CNAs responded yes. Both CNAs were asked did they know they was supposed to wash their hands or perform hand hygiene between glove changes? CNA DD stated she did know she needed to do that. CNA CC stated she did not know she was to do that. Record Review of an In-service titled Handwashing, Hand Hygiene and Gloves Use dated 6/2/17 revealed CNA CC was in attendance. 2. Record review of R#88's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of R#88's physician's orders [REDACTED]. Wipe with skin prep. Cover with Vaseline gauze, non-stick [MEDICATION NAME] and secure with clear film dressing. Change twice per week and PRN. Observation of wound care on 1/09/18 at 10:48 a.m. revealed R#88 had a skin tear to her left lower leg. Licensed Practical Nurse (LPN) BB washed her hands prior to donning gloves. LPN BB proceeded to remove the old dressing from the skin tear. LPN BB removed her gloves and donned a clean pair of gloves. LPN BB failed to wash her hands or perform hand hygiene before donning a clean pair of gloves. LPN BB cleaned the wound from dirty to clean with NS and gauze. She pat dried the area with a clean gauze. She removed her gloves and donned a clean pair of gloves. She once again failed to wash her hands or perform hand hygiene before donning the clean gloves. She wiped the wound with a skin prep and covered it with a Vaseline gauze. She removed her gloves. No hand hygiene or hand washing was performed after glove removal. She opened a cover dressing and then donned a clean pair of gloves. She applied the cover dressing and affixed it with a clear dressing. She removed her gloves and washed her hands. 3. R #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], coded the resident as having a Brief Interview for Mental Status (BIMS) score of four which indicates severe cognitive impairment. Review of the medical record revealed a pressure ulcer on R #99 right heel which was first discovered on 5/8/15. Observation of wound care on 1/9/18 at 3:15 p.m., to R #99 right heel and right great toe by LPN BB revealed the following: LPN BB washed her hands, put on gloves, and removed the dressing to R #99 right great toe. LPN BB then changed her gloves, without washing her hands, and cleaned the wound and put a clean bandage on the right great toe. LPN BB then proceeded to change gloves and wash her hands. She removed the dressing from the right heel ulcer. She then changed her gloves without washing her hands, and cleansed the wound. She changed gloves again without washing hands and placed a clean bandage on the right heel. She them removed her gloves and washed her hands. LPN BB changed her gloves three times during the dressing changes without completing hand hygiene. Interview with the DON, in her office, on 1/11/18 at 10:50 a.m. regarding the issue of staff failing to perform hand hygiene or handwashing between glove changes, the DON said staff is constantly trained on glove use and hand hygiene. The DON said she feels this is an opportunity for education and training with the staff. The Administrator and Regional Nurse were present during the interview.

Based on resident, family, and staff interview, medical record review, and review of facility policy, the facility failed to complete the baseline care plan summary and provide a copy to the resident and resident representative for five of five sampled residents (Residents (R)#187, R#237, R#238, R#239, R#364) who were new admissions to the facility. The findings include: 1. R #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a baseline care plan, dated 12/30/17. Further review of the baseline care plan revealed the section, written summary of the baseline care plan, was left blank. The section marked Representative signature was also blank. In an interview with the Director of Nursing on 1/11/18, at 10:00 a.m., she acknowledged the baseline care plan was not complete. 2. Review of the medical record for R #237 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The medical record revealed a Baseline Care Plan form dated 12/21/17 that was partially completed. The section titled Written Summary of Baseline Care Plan was blank. The section titled Completion Signatures was blank for the resident and resident representative. There was no evidence in the medical record that a summary of the care plan was provided to the resident or resident's representative. Interview with R #237, in his room, on 1/9/18 at 9:00 a.m. revealed he did not know anything about care planning and he was not given a copy of the care plan when admitted to the facility. R#237 stated I just go to therapy when they tell me, but it isn't helping. 3. Review of the medical record for R #238 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The medical record revealed a Baseline Care Plan form dated 1/3/18 that was partially completed. The section titled Written Summary of Baseline Care Plan was blank. The section titled Completion Signatures was blank for nursing, resident, and resident representative. There was no evidence in the medical record that a summary of the care plan was provided to the resident or resident representative. Interview with the family of R #238, at the bedside, on 1/9/18 at 10:27 a.m. revealed she and the resident did not participate in any care planning on admission. She further revealed there was no copy of a care plan provided to her or her husband. The family of R #238 stated Who should I tell that his medication dosage of [MEDICATION NAME] (a dementia medication) isn't right? 4. Review of the medical record for R #239 revealed she was admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. The medical record revealed a Baseline Care Plan form dated 12/16/17 and a second one dated 12/28/17 that were partially completed. The section titled Written Summary of Baseline Care Plan was blank for both forms. The section titled Completion Signatures for the form dated 12/16/17 was blank for the resident and resident representative. The form dated 12/28/17 was blank for nursing, resident, and resident representative. There was no evidence in the medical record that a summary of the care plan was provided to the resident or resident representative. Interview with R #239 in her room, on 1/9/18 at 9:45 a.m. revealed she doesn't remember if anyone discussed her care plan with her when she was admitted or readmitted but stated I like my husband and daughter to handle all those things. R #239 's family was not available for interview. Interview with the Director of Nursing (DON) in her office, on 1/10/18 at 10:00 a.m. revealed nursing does a baseline care plan on admission and then they hold an Interdisciplinary team (IDT) meeting within 48 - 72 hours with the resident and/or family and go over the care that needs to be provided to the resident based on question that are asked. The DON stated, They document on the Care Plan form that the family was informed. After reviewing the medical records for R #237, R#238, and R#239, the DON confirmed there was no documentation to indicate that the baseline care plan was summarized or provided to the resident or resident representative. The Regional Nurse (who was present in the office at the time of the interview) stated An audit was recently done on the baseline care plans and they were found to be lacking. That is all part of the new changes and there is a learning curve for everybody. Review of the facility's document titled Care Plan/RAI policy dated 2016 revealed a preliminary care plan is developed upon the patient's admission. The preliminary care plan is used only until the comprehensive care plan has been developed. There were no other guidelines for a baseline care plan. Interview with the DON in the hall outside her office, on 1/10/18 at 12:55 p.m. revealed the facility does not have a policy that includes the baseline care plan. She stated I checked with corporate and they are working to incorporate the new baseline care plan into their care plan policy. Until it is done their recommendation is to follow the regulation and its' guidance. Interview with Licensed Practical Nurse AA, at the nurse desk, on 1/10/18 at 3:25 p.m. revealed the Minimum Data Set (MDS) nurses write the care plans. LPN AA stated Any nurse can write a care plan and the admission nurse starts the process. I did receive education on the new baseline care plans back in October, but I haven't had to do one because long term care doesn't get new admissions very often. 5. Record review of R#364's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of R#364's Baseline Care Plan (no completion date) revealed the sections titled Initial Goals, Dietary Orders, Therapy Services, Social Services, Activities of Daily Living, Bowel and Bladder, Skin Concerns, Physician Orders, Medication and Outside Coordination sections are complete. However, the sections titled Signatures of Interdisciplinary Team Members Contributing to Baseline Care Plan, Written Summary of Baseline Care Plan, Completion Dates, and Completion Signatures sections are blank.

Based on observation, confidential interview and facility policy review, the facility failed to provide comfortable sound levels for 4 of 16 residents interviewed during the survey. Findings include: A review of a facility policy titled Noise and Sound Control dated October 2016, revealed, 1. As with any health-care center, the atmosphere should be calm, organized, and as quiet as possible. Associates should refrain from making loud noises or talking in a loud voice. Do not shout from one room or section to another. Observation during the four days of the survey, 11/28/16 through 12/1/16 by four surveyors, revealed numerous doors slamming each day throughout the day. Review of two grievances related to noise over the past six months revealed the following resident complaints: 1) a resident on the 500 hall complained about slamming doors from sun up to sun down, and 2) a resident's family member complained that the daytime staff were so loud that the residents in the TV room could not hear the television. 1) During a confidential interview with Resident A (R A) on the 300 hall on 11/29/16 at 9:29 a.m., R A stated the noise woke her up at night. During a follow up interview on 12/1/16 at 2:42 p.m., R A stated the slamming of doors during the day bothered her, especially when she tried to nap, and the loud staff voices at night woke her up. 2) During a confidential interview with Resident B on the 500 hall on 11/28/16 at 3:59 p.m., R B stated there were a lot of doors slamming all the time. Observation on 12/1/2016 at 2:51 p.m. near room [ROOM NUMBER] revealed several very loud staff voices in the 500 hall dining room talking. During follow up interview on 12/1/16 at 2:52 p.m., R B stated most of the door slamming was in the evening, when R B was trying to relax in her room before bed. R B thought there might be a storage room near her room and the staff was busy and didn't think about closing the door, and just let it slam. 3) During a confidential interview with Resident C on the 400 hall on 11/29/16 at 9:24 a.m., R C stated staff cleaned the floors at night with a machine which was noisy. Observation in the middle of the 400 hall on 12/1/16 at 2:47 p.m. revealed eight staff moving through the hallway talking very loudly, yelling, as far as approximately 15 feet, to one another as they walked down the hall. During a follow-up interview on 12/1/16 at 2:46 p.m., with Resident C stated staff slammed doors all through the hallway, and it woke her up at night, and also when she rested during the day. 4) During a confidential interview with Resident D on the 400 hall on 11/29/16 at 10:29 a.m., Resident (R) D stated staff slammed the doors all day long. During a follow up interview on 12/1/16 at 3:17 p.m., R D stated the door slamming woke her up at night and during the day when she was trying to nap. R D stated the loud staff voices have also woken her up at night. R D stated, I thought it was a party house. I'm glad to hear laughter; it does a person good to hear laughter, but some of them need to learn politeness, and respect of others. Most of us who live here are older. During interview on 12/1/16 at 2:06 p.m., the Maintenance Supervisor (MS) stated the majority of the doors had hydraulic closers, but some of the doors had closers which contained springs that needed regular adjustment in order to not slam when let go. During an interview on 12/1/16 at 2:19 p.m., with the Administrator revealed the facility received two formal grievances regarding noise, and after resolution, the residents were satisfied. Also, the facility offers an opportunity during care plan meetings for residents and families to voice concerns about their environment, as well as personal questions asked to the residents about any environmental concerns. During the interview, the Administrator stated, Oh, I just noticed the door slam, I think it was the mail room door. The Administrator acknowledged the door slamming and loud voices was a staff problem, as well as a door closing problem, however, she was not aware of any residents with complaints about noise.

Based on observation, review of the facility's recipes for pureed food, review of facility policy, and interviews, the facility failed to follow the pureed recipes during preparation of 1 of 1 meal observed for 19 of 19 residents that received a pureed diet to ensure the nutritive value of the food as planned. . Findings include: During the kitchen inspection on 11/30/16 at 11:29 a.m., the dietary staff was observed to prepare the pureed menu for lunch. Dietary Staff UU pureed food items for lunch without use of a recipe or measuring utensils. The staff pureed green beans, kernel corn, meat, bread, and canned peaches. The staff poured the green beans into the blender with the liquid from the cooking pot without measuring the amount of liquid. The staff added thickener without measuring to get an appropriate puree texture. Next the staff pureed kernel corn with a its cooking liquid and thickener was added; again the employee failed to measure the liquid or thickener. The puree corn still had the skins of the corn intact within the puree. The pureed kernel corn did not have a smooth texture. The Dietary Staff UU pureed the bread by blending dry bread into bread crumbs. The staff did not count the slices of bread but used a loaf and a half of bread. The staff then added water and thickener (without measuring) to the blender to achieve the pureed texture. The staff then added onion powder to the pureed bread without measuring. When asked, the Dietary Staff UU indicated the pureed bread didn't have any flavor so she added it for flavor. When asked, the staff indicated she does use pureed menus. However no pureed menus were observed in the preparation area. On 11/30/16 at 11:43 a.m. during an interview, the Dietary Manager (DM) indicated the staff should not have pureed the corn. She indicated the corn was only an alternate to the green beans and was not on the menu. The DM removed the pureed kernel corn from the tray line. The DM further stated the staff should have followed the puree dietary guidelines and recipes from the menu book. The puree recipe for Green Beans indicated the prepare according to regular recipe and to blend green beans until desired consistency, adding 1 TSP (teaspoon) food thickener per serving. The facility recipe guide for puree textures indicated CORN - restricted. The pureed corn and peas that are planned for this diet are commercially-prepared. These products are smooth and do not present a choking hazard to the resident. The puree recipe for Bread of Choice indicated the ingredients as 32 slices of bread with ½ cup of food thickener bulk with 1 Quart of water or juice. The recipe indicated staff should 1. Prepare Slurry (pureed bread) 2. Process until smooth adding 1 oz (ounce) slurry per portion. NOTE: Amount of thickener required may vary relative to liquid content of cooked product for best results, alternate adding thickener with processing, checking product consistency periodically. The puree bread recipe did not indicate any added flavoring.

Based on observation, interview, and policy review, the facility failed to serve food in a sanitary manner in one of three dining rooms. Findings included: Observation on 11/28/16 of the noon meal starting at 12:10 p.m. of the main dining room revealed numerous Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) with bare hands served the residents' drinking glass by the rim of the glass, where the residents would drink from. Further observation during this meal revealed the staff when opening the milk cartons placed their ungloved finger inside the carton to open them. Interview with the Director of Nursing (DON) on 12/1/16 at 12:04 p.m. revealed the staff should not carry the glasses by the rims and should not put their fingers inside the milk cartons. Interview with Education Coordinator (EC) on 12/1/16 at 12:15 p.m. revealed the staff should not touch the rims of the residents' glasses and not put their fingers inside the milk cartons. The EC stated she would educate the staff regarding these issues. Review of the Departmental Guidelines dated November 2015 indicated, utensils, cups, glasses and dishes should be handled in such a way as to avoid touching surfaces with which food or drink should come in contact. Fingers are to be kept out of food.

Based on observation, record review, policy review, and interviews, the facility failed to provide activities that met the mental, physical, and psychosocial needs for three (Resident (R) 27, R35, and R76) of four residents sampled for activities. Findings include: 1. Review of the clinical record, for R27, revealed she was admitted on [DATE] with the following diagnoses, which include but not limited to: malignant neoplasm of stomach, gastro-[MEDICAL CONDITION] reflux disease (gerd), and dementia. Review of the current Comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Brief Interview of Mental Status (BIMS) score of four which was severely cognitively impaired and not interviewable. It was identified that it was very important to R27 to have books, newspapers, and magazines to read, to listen to music, to be around animals such as pets, to do things with groups of people, to do favorite activities, to go outside to get fresh air when the weather is good, and to participate in religious services. Review of documentation titled ACTIVITY ASSESSMENT annual assessment dated [DATE], indicated, Resident prefers to spend time in group activities of choice. Resident enjoys sitting at the main nursing station with other residents talking and watching staff member and visitors. Resident attends group activities of choice and engage the activities that she attends.8. Resident stated during her interview that listening to music is very important to her. Activity Plan .Activities will encourage resident to continue to attend large group activities of choice and encourage . Review of care plan dated 11/30/16 documents, Resident needs assistance to participate in activity groups due to cognitive impairment. GOALS: Resident will accept assistance with participation in activities .INTERVENTIONS: .In room visits for social stimulation if resident cannot attend activities, .Involve resident in activities of interest., Provide redirection to keep resident involved in activity group, . Care plan dated 11/30/16 indicated Resident needs assistance to participate in activity groups due to cognitive impairment. GOALS: Resident will accept assistance with participation in activities .Interventions: .In-room visits for social stimulation if resident cannot attend activity group, . Review of the activity calendars, for R27, dated September, October and November 2016, indicated R27 attended activities 2 times a week. On 11/29/16 at 9:07 a.m., R27 was observed in the day room during TV time not watching TV. R27 was observed asleep. On 12/1/16 at 9:31 a.m., R27 was observed in the day room during TV time. Not watching the TV. Then R27 was observed to have her head up while a visiting choir was singing. There was staff present, but there was no attempt by the staff to engage R27 in the singing activity. On 12/1/16 11:50 a.m., an interview with the Activity Director (AD) in the activity room regarding activity ' s for R27 revealed the AD stated R27 has had a decline with attentiveness. I should have updated the care plans. 2. The clinical record for R35 was reviewed indicating an admitted d of 10/31/05 and [DIAGNOSES REDACTED]. Current comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the Brief Interview of Mental Status (BIMS) score could not be completed. R35 was totally dependent on staff for activities of daily living (ADL's). Activity assessment dated [DATE], indicated R35 .2.c. receives 1:1 visits from the staff. She feels the employee badge and hands and face and receives hugs and touching her face and hands. d. She read the braille bible and the braille magazines she receives.3. She is content with her braille rewarding material.religious services were all very imp; to her. Care plan with the next review date 12/31/16, indicated .Resident is able to communicate using Braille. Use touch to communicate. Resident may attempt to sign in hands .GOALS: will continue to recognize family, current friends and staff by touch .INTERVENTION: Allow Resident to use sense of touch when identifying staff, .Encourage to participate in activities, .Provide direction using touch to assist patient in completing task, . Care plan with the next review date 12/31/16, indicated, Resident spends little time involved in activities related to inability to communicate verbally or visually with others GOALS: Activities will provide one to one visits through her braille group for spiritual and social communication.INTERVENTION .Assess residents activity preference for likes, dislikes or other interest. Interact with resident while providing care by touch:, Braille book in resident room . Assist resident with set up for reading. Care plan with the next review date 12/31/16, indicated, communication deficit related to [DIAGNOSES REDACTED] and [MEDICAL CONDITION].use sense of feel when attempting to communicate and identify the speaker/staff will open her hands and allow the speaker to perform sign language in her hands to improve communication at times. GOALS: Staff will anticipate and provide daily needs INTERVENTIONS .Allow resident to use sense of feel by touching during communication, when using sign language sign in resident's hand Use Braille literature and posters in resident's room to help with sign language during communication. On 11/28/16 at 10:10 a.m., R35 was observed sitting in a high back chair with her head down in the day room during a television activity and music. There was no staff present to engage R35, who is deaf and blind, during this activity. On 11/29/16 at 11:10 a.m., R35 was observed sitting in a high back chair with her head down in the day room during a television activity and music. There was no staff present to engage R35, who is deaf and blind, with this activity. On 11/30/16 at 10:30 a.m., Certified Nursing Assistant (CNA) HH was observed to communicate by touch with R35. R35 responded back with touch and a head nod. During the survey R35 was not observed in her room engaging in any activities. There were observed several braille books on the counter top across the room from her bed. On 12/1/16 at 9:15 a.m., R35 was observed in the back of the day room in her high back chair with her head down. The TV was on and there was no interaction from staff with R35. On 12/1/16 at 10:57 a.m., R35 was observed sitting in the very back of the day room during singing by a volunteer group. There was no interaction, or attempts by staff to provide touch communication or sign language to R35 during this observation. On 12/1/216 at 11:16 a.m., R35 was observed in a high back chair near the nurse ' s station after the music activity was over. Observation revealed staff failed to interact or engage with R35. R35 was observed every day throughout the survey always in the day room for activities but without sensory stimulation. The observations revealed that staff failed to provide encouragement or assistance to R35 during activities. On 11/29/16 at 10:08 a.m., an interview at the 400 hall nurses' station with the Unit Manager (UM) JJ indicated there was a company that comes in and interacts with R35, using sign language, only on Mondays. On 11/30/16 at 10:47 a.m., an interview with CNA HH at the 400 hall nurses' station indicated I communicate with the charts on the door in her (R35) room. R35 usually response by nodding her head. She will touch and feel you to identify that she knows you On 12/1/16 at 11:36 a.m., an interview with the AD indicated that she does kiss/hugs (touching) whenever she passes by R35. While in the day room it is my responsibility to do sensory stimulate for her (R35); however, R35 usually is not in the dayroom, she is usually in her room with books. On 12/1/16 at 12:07 p.m., an interview with Certified Occupational Therapist Assistant (COTA) GG in the conference room indicated she was not familiar with R35. COTA GG indicated therapy is responsible for talking with the direct care staff about a resident's level of need. On 12/1/2016 at 12:40 p.m., an interview with Therapy Supervisor (TS) FF indicated R35 had not been assessed, to determine if she required any therapy services, since 1/29/14. There was no sensory assessment provided at this time indicating what stimulation R35 would benefit from. The TS FF indicated there was no occupational therapist at that time familiar with R35. Cross reference 282 3. Review of the clinical record, for R76, revealed the Diagnoses: [REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] revealed R76 had short and long term memory problems and displayed no behaviors. She required extensive to total assistance with all activities of daily living (ADL). The MDS revealed it was very important for her to listen to music she liked and somewhat important to keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather was good, and participate in religious services or practices. She receives hospice services. The Care Area Assessment (CAA) for activities did not trigger. The CAA for cognition dated 10/25/16 revealed that R76 had a cognitive deficit, dementia, and [MEDICAL CONDITION]. It also indicated R76 is soft spoken and has limited vocabulary. Review of the 10/10/16 annual Activity Assessment revealed R76 spent her time in her room or in the TV room/common area. She sometimes attended church/bible study in the TV room but was passive during these times. R76 had strong family support, they came daily to visit with her, feed her, and sit outside with her to get fresh air. She listened to gospel music in her room. R76 was under hospice care and unable to participate in any part of the activity program. The resident had minimal interaction with others, she would look, but did not respond. Her activity level did not change since her last assessment. Her son stated during the MDS interview that it was very important for the resident to listen to gospel music, and it was also important for her to visit with her family, get fresh air, and to listen to the church groups sing. The activity plan was to ensure she was brought to spiritual singing activities, provided one-on ones, and to check with the family regarding any other need. Review of the 10/20/16 care plan documented she spent little time involved in activities related to decline in physical function. The interventions included: assessing activity preference, for R76, for likes, dislikes, or other interests, encouraging her to discuss reasons for lack of involvement, talking with R76 while providing care, encouraging her to socialize during one on one activities as desired, counseling her as needed, observing for changes in mood, and reporting to the physician as needed. Review of the facility policy titled, Activities and Social Services dated October 2016, indicated, residents are encouraged to choose the types of activities and social events in which they prefer to participate. When developing the resident's activity and social care plan, the resident should be given an opportunity to choose when, where, and how he/she should participate in activities and social events. Activities, social events, and schedules should be developed in conjunction with the resident's interests, assessment and plan of care. Observation on 11/29/16 at 2:54 p.m. and 4:21 p.m. revealed R76 sat in a Broda chair in her room, positioned against the wall, and was not able to see the TV. The TV was on, not to a church program or gospel music. The staff had placed her by the wall in an area that R76 was unable to see the TV. Observation on 11/30/16 at 10:15 a.m. revealed R76 in bed on her back. The TV was on a cabinet across from her roommates ' bed, and the wall, by the TV, was observed to prevent R76 from seeing the TV. The TV was on, but not on a church program or gospel music, that had been previously requested, and the resident was not able to see the TV from her bed. There was an activity of music and exercise occurring in the TV/common area, while the resident was in her bed. Observation on 11/30/16 at 11:03 a.m. and 11:47 a.m. revealed R76 sat in a Broda chair in the TV/common area. The TV was on the weather channel. Her eyes were closed. Staff were occasionally walking by the TV/common area, but staff provided no stimulation or interaction with the resident. Observation on 11/30/16 at 2:45 p.m. revealed R76 sat in a Broda chair in her room with her eyes closed. The TV was on, but not on a spiritual or music channel that had previously been indicated was the resident ' s preference. Observation on 11/30/16 at 4:23 p.m. revealed R76 in bed on her back. The TV was on a western show, but the resident was unable to see the TV from her bed. The facility at that time was having a movie and popcorn activity, but R76 was not present. Observation on 12/1/16 at 10:20 a.m. revealed R76 in bed and the TV was on a talk show, and not a spiritual or music channel that had previously been requested for the resident, in addition to this the resident could not see the TV from her bed. Observation on 12/1/16 at 2:45 p.m. revealed R76 sat in a Broda chair in her room. The TV was on and turned to a western show. The staff had positioned R76 against the wall which prevented the resident from being able to see the TV. Interview with Activity Assistant (AA) BB on 11/30/16 at 3:15 p.m. revealed R76 is able to shake her head yes and no. AA BB would bring her out to the TV/common area and place her by the TV. She would also bring R76 a blanket. AA BB also stated she placed a CD player in her room because the family stated she really loved music. This CD player was placed in the resident ' s room so any staff member could turn the CD player on so the resident could listen to music. Interview on 12/1/16 at 2:50 p.m. with Certified Nursing Assistant (CNA) LL who was assigned to R76 revealed her activities consisted of range of motion and taking her to the common area when there was an activity going on there.

Based on observation, interview and Medication Storage in the Care Center policy review, the facility failed to ensure Insulin was discarded after 28 days after the vial was opened on 1 of 6 medications carts (100 hall medication cart). Findings include: A review of a policy titled Medication Storage In the Care Center dated January 2016 revealed the following, Medications .are stored safely .following manufacturer's recommendations or those of the supplier.17. Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication . A review of a policy titled Pharmacy Phax dated 10/12 revealed the indicated, . Lantus . Storage Conditions, Opened . Shelf Life after 1st Use, 28 Days . During a medication observation on 11/28/16 at 11:37 a.m., the 100 hall's medication cart had one vial of Lantus with an open date of 10/26/16. The Lantus vial indicated to discard the open vial after 28 days, which would have been five days prior on 11/23/16. An interview with the 100/200 hall Supervisor Registered Nurse (RN) RR indicated the Lantus vials should have been discarded 28 days after opening.

Based on observation, interview, record review, facility policy review, and review of the Center for Disease Control guidelines, the facility failed to ensure handwashing was complete as indicated by the facility policy and Center for Disease Control (CDC) guidelines after removing gloves and providing care for 2 randomly observed residents for infection control (R35, R74) and leaving a residents room with trash and enter another residents room. (room [ROOM NUMBER], room [ROOM NUMBER]) Finding included: A review of the facility policy titled Using Gloves dated November 2015. The policy indicated, .Perform hand hygiene after removing gloves. Gloves do not replace hand hygiene. Review of the facility policy titled Standard Precautions undated. The policy documents, When to Wash Your Hands .Before and after treating a patient. After touching blood or any other body fluid .After touching an object or surface that is or may be contaminated. As soon as you remove your gloves .How to Wash Your Hands .Clean your whole hand, under your nails, between your fingers, and up your wrist. Later for at least 10 to 15 seconds.After 30 seconds of washing, hands are mostly free of germs.When to Wear Gloves, before wearing gloves, wash and dry your hands well .Avoid touching uncontaminated areas or items with contaminated gloves. Remove gloves right after use. Wash hands and put on clean gloves between patient and procedures. Review of the facility policy titled When & (and) How to Wash Your Hands dated 9/4/15. The policy indicated, .Before and after caring for someone who is sick .After changing diapers, .After touching garbage, . Review of Center for Disease Control (CDC) dated 8/4/15, indicated http://www.cdc.gov/handwashing/ when-how-handwashing html, When should you wash your hands? .Before and after caring for someone who is sick . 1. On 11/28/16 at 945 a.m., Certified Nursing Assistant (CNA) MM was observed to come out of room [ROOM NUMBER] with a bag of trash in her hand. CNA MM walked across the hall with the trash bag in her hand and enter room [ROOM NUMBER] to get her jacket. There was no handwashing observed upon entering room [ROOM NUMBER]. CNA MM indicated at that time she should have thrown the trash bag away and washed her hands before entering room [ROOM NUMBER]. 2. On 11/30/16 at 11:03 a.m., CNAs NN and CNA OO were observed to enter R35's room place on gloves and attach the pad under R35 to a stand up lift. Neither CNA performed hand washing prior to providing care for R35. CNA OO was observed to wipe R35's bottom as CNA NN removed the soiled brief from R35. Both CNAs placed the clean brief on R35 and pulled up R35's pants with the dirty gloves still on. CNA OO removed the gloves and placed on clean gloves. CNA OO removed the trash from the trash can and the bed, entered the bathroom and removed the gloves. CNA OO hand washed for 10 seconds. CNA OO then turned the paper towel handle with clean hands, got paper towels and dried her hands. CNA OO turned the water off and exited the room. CNA NN was observed to assist R35 down in the wheelchair with the dirty gloves still on. CNA NN removed the dirty gloves and pushed R35 in the wheelchair out the room back to the day room. There was no handwashing observed prior to CNA NN leaving the room. On 11/30/16 at 11:21 a.m., an interview with CNA NN in the conference room indicated she should have hand washed prior to entering R35's room before providing care. CNA NN also stated her dirty gloves should have been removed after changing R35's brief and hand washed. Then handwashing after providing care, before leaving the room. On 11/30/16 at 11:45 a.m., an interview with CNA OO in the conference room indicated, she should have washed her hands upon entering R35's room to provide care. CNA OO indicated she should have moved the dirty gloves after providing care for R35 and washed her hands CNA OO further stated she should have washed hands before exiting R35's room with the trash. CNA OO and should have washed her hands for 20 seconds. CNA OO was not aware of the Center for Disease Control (CDC) guidelines. CNA OO also stated she thought the paper towel handle was clean and could be touched after handwashing was completed. 3. On 12/1/16 at 11:09 a.m., Certified Nursing Assistant (CNA) PP was observed to take R74 into the bathroom to toilet. With clean gloves on CNA PP checked R74's brief to see if it was wet. With the same gloves on CNA PP pulled up R74's pants, sat R74 in her wheelchair and placed the hand brace on R74's right hand without removing gloves or hand washing. CNA PP stated at that time she should have removed the gloves after pulling up R74's pants and hand washed.