Every finding on record at Spring Creek Health & Rehab

Based on observation, record review and interview, the facility failed to ensure food items and serving utensils were properly covered or stored to prevent the potential contamination of residents' food and/or beverages; food items were sealed to prevent potential cross contamination or food borne illness, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and food items had opened dates, received dates and expiration dates. The findings are: 1. On [DATE] at 8:24 AM, 2 peach cobblers were on the back prep table uncovered and 35 biscuits on the serving line. A delivery person was going in and out the backdoor. On [DATE] at 9:31 AM, the Dietary Manager confirmed a concern existed that something could get into the peach cobblers because they were not covered. 2. On [DATE] at 8:25 AM, a plastic drink pitcher and 2 square serving pans for the steam table with serving side up were on the puree prep table. On [DATE] at 9:31 AM, the Dietary Manager confirmed a concern existed that something could fly in and land on the pitcher and the pans because they were not covered. 3. On [DATE] at 6:44 AM, after putting away food items delivered this morning, without washing her hands, the Dietary Cook proceeded to cook eggs. 4. On [DATE] at 6:45 AM, eggs and bacon/sausage were in separate steamtable serving dishes uncovered. At 9:35 AM, the Dietary Manager confirmed the food items on the steamtable should have been covered to avoid something getting into the uncovered food. 5. On [DATE] at 6:45 AM, the Dietary Cook placed gloves on her hands without washing her hands first, she then began to cook fried eggs. 6. On [DATE] at 6:46 AM, 61 food dome covers, used for maintaining room tray food temperature during transport, were on the shelf above the steamtable with the inside face up. The Dietary Consultant confirmed that something could possibly get on the inside of the food dome covers. 7. On [DATE] at 7:00 AM, a plastic storage container without a lid held serving spoons and scoops for the serving line under the puree prep table. There was not enough room between the open container and the bottom counter of the puree prep table to slide the storage container out without a hand touching the bottom of the puree prep table. The Dietary Consultant confirmed there was a need for new containers and said, I don't see how anything can get on the scoops, there is not enough room between the open container and the bottom of the puree prep table for something to get into the container and contaminate the serving spoons. 8. On [DATE] at 7:05 AM, a plastic storage container without a lid used to store adaptive bowls and plates were face up. The Dietary Manager confirmed the concern of the items not covered was that something could get into the storage container and contaminate the items used for mealtimes. 9. On [DATE] at 7:07 AM, the Dietary Cook was using a cell phone then went into the Dietary Manager's office and closed the door. When the Dietary Cook came out of the Dietary Manager's office, without washing her hands, the Dietary Cook proceeded to take food serving scoops from the storage container under the puree prep table and place them in the serving containers on the steamtable. At 9:37 AM, the Dietary Manager confirmed that hands should be washed between tasks. 10. On [DATE] at 7:21 AM, the Dietary Cook pulled the silverware cart and bowl cart to the serving line. Without washing her hands, the Dietary Cook then began serving breakfast food. 11. On [DATE] at 7:53 AM, the observations were made in the dry good storage room: a) No expiration or received dates written on the food storage container for the following cereals: wheat bran flakes with raisins; crispy rice cereal; ring-shaped toasted whole grain; toasted wheat flakes; and toasted flakes of corn. b) 1 opened bag with small bowl lids was on the third shelf. c) 1 box of ice cream cones contained an opened and unsealed bag with 1 cone in that was not sealed. d) 132 hamburger buns that expired on [DATE]. 12. On [DATE] at 10:15 AM, the Surveyor asked the Dietary Manager if it was a concern for the Dietary Manager to wear a nose ring with a small heart that swung back and forth on the right side nostril; a second piercing on the left lower lip dangled and did not look properly secured. The Dietary Manager confirmed she did not normally work with the food and stayed in the office. The Dietary Manager's office was located at the back of the kitchen, where she must pass by the food serving and preparation areas. 14.On [DATE] at 9:30 AM, the Administrator provided a policy titled, Employee Cleanliness and Handwashing Technique which shows: Policy Statement Dietary employees will dress appropriately and practice good hygiene. Policy Interpretation and Implementation: 1. Proper attire includes the following requirements: .Jewelry should be limited to allow for safe food preparations practices (no dangling earrings or large rings) .Dietary department employees are required to wash their hands on the occasions listed below: .j. any other time deemed necessary . 15. On [DATE] at 9:30 AM, the Administrator provided a policy titled, Food Receiving and Storage which shows: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation .7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system.

Based on observation, record review and interviews, the facility failed to ensure an ice chest located outside of the kitchen was insect free and an indwelling foley catheter bag was not touching the floor for 1 (Resident #1) of 1 sampled resident. The findings are: 1. On 05/02/2024 at 08:54 AM, the Surveyor observed a black oval object that had extended wings and legs lying on the ice cubes within an ice chest located outside the kitchen doors by the 300 Hall. 1a. On 05/02/2024 at 08:55 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 when was the last time the ice was passed and were all these ice chests used. CNA #3 stated the ice was passed this morning when I came in around seven twenty (7:20 AM). There is one ice chest for each hall, so they were all used. The Surveyor asked, can you describe what is in the ice in this ice chest. CNA #3 stated It looks like a bug. 1b. On 05/02/2024 at 09:02 AM, the Administrator confirmed the black object in the ice chest looked like a bug. Review of the Pest extermination information showed a contract with a (Pest Control Company Name) with an effective date of 2/2015. The agreement covers services to be rendered monthly; shall stay in effect until the said party calls our company to cancel this agreement. Service dates: 01/03/2024; 02/01/2024; 03/04/2024; 04/15/2024 monthly; on 02/15/2024 roaches in room [ROOM NUMBER] and drain flies on the 300 Hall, on 03/13/2024 roaches in the breakroom, and 04/15/2024 roaches in rooms [ROOM NUMBERS]. 50505 2. Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/2024 showed a Brief Interview for Mental Status (BIMS) Score of 00 which indicates severe cognitive impairment, and that the resident had an indwelling catheter. a. A review of Resident #1's diagnoses on the Physician Orders showed Hydronephrosis with renal and ureteral calculous obstruction (a condition of the urinary tract resulting in a decreased or no urine flow). b. The Physician's Order Summary showed Resident #1 had an indwelling urinary catheter. Order date was 03/21/24. c. The Care Plan with a revision date of 11/28/2023 showed the resident had an indwelling urinary catheter, and staff were to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. d. On 04/30/2024 at 10:11 AM, the Surveyor observed Resident #1's indwelling urinary catheter bag touching the floor on the side of the bed next to the air conditioner. e. On 05/01/2024 at 07:56 AM, the Surveyor observed Resident #1's indwelling urinary catheter bag lying wadded up on the floor. f. On 05/02/2024 at 10:41 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, how the catheter bag should be placed beside the bed. LPN #1 stated, Hangs to gravity, in a privacy bag, beside the bed. g. On 05/02/2024 at10:57 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 how the catheter bag should be placed beside the bed. CNA #1 stated, It should be the side of the bed, on the side of the stat lock (medical tape for the stabilization of the catheter tubing) and if the catheter bag will be touching the floor, it is in a basin. h. On 05/02/2024 at 11:02 AM, the Director of Nursing (DON) confirmed that the catheter bag was on the floor. i. On 05/02/2024 at 12:40 PM, the DON said there was no policy for urinary catheters. On 05/03/2024 at 11:48 AM, a policy revised on October 2018 titled, Policies and Practices-Infection Control, was provided by the Nurse Consultant which showed, .This facility's infection control policies and practices are intended to facilitate maintaining a . sanitary . environment and to help prevent and manage transmission of diseases and infections .

Based on record review, observation and interview, the facility failed to ensure a planned fall prevention intervention was consistently implemented to decrease the potential for fall related injuries, and the environment was as free of hazards as possible, as evidenced by a fall mat with curled up, colorful items attached to it, creating a trip/fall hazard. The findings are: 1. The Care Plan completed on 03-12-2024 shows, .1/10/24 - unwitnessed fall. Fall mat effective Date Initiated: 01/11/2024 . Colorful tape to call light Date Initiated: 02/05/2024 . 1/30/24 - Unwitnessed fall. Fall mat effective Date Initiated: 01/31/2024 . 2/10/24 - fall mat effective Date Initiated: 02/12/2024 . 2/16/24- Unwitnessed fall. Fall mat effective Date Initiated: 02/19/2024 . 2/29/24 - unwitnessed fall. Will pad the corner of dressing next to bed. Date Initiated: 02/29/2024 . Unwitnessed fall. Add bolster mattress to bed. Date Initiated: 08/17/2023 . 8/18/23 unwitnessed fall - weighted blanket while in bed. Date Initiated: 08/18/2023 . 8/24/23 - unwitnessed fall. Place fall mat in room Date Initiated: 08/25/2023 . 2. On 04-30-2024 at 12:21 PM, Resident #59 was lying in bed, a cushioned fall mat was by the bed with colorful tape curled up and not secured. 3. On 05-01-2024 at 11:21 AM, Resident #59 was lying in bed, a cushioned fall mat was by the bed with colorful tape curled up and not secured. 4. On 05-01-2024 at 9:35 PM, Resident #59 was asleep in his bed and did not have a fall mat on the floor next to the bed. 5. On 05-03-2024 at 11:56 AM, the Hospice Registered Nurse (RN) confirmed the fall mat stays on the floor at night when he is asleep. The curled up item is part of the mat and not tape. Yes, it is a trip hazard. 6. On 05-03-2024 at 11:58 AM, Licensed Practical Nurse (LPN) #2 confirmed that Resident #59's fall mat had to be on the floor by Resident #59's bed at night, and there was a possibility Resident #59 could get out of bed, and the curled up item on the floor mat is dangerous and a fall hazard. 7. On 05-03-2024 at 12:19 PM, the Administrator provided the Accidents and Incidents - Investigating and Reporting policy which states, Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc , occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: This facility is in compliance with current rules and regulations governing accidents and/[NAME] incidents involving a medical device .

Based on observations and interviews, the facility failed to ensure the shower room was kept clean, and missing tiles were replaced; the 400 Hall did not have missing paint on the wall; and the furniture in the Front Lobby and in the Dayroom on the 400 Hall was not peeling and missing material. The findings are: On 04/30/2024 at 09:13 AM, the Surveyor observed several spots of dark matter on the shower room floor and missing floor tiles around the shower drain. On 04/30/2024 at 10:27 AM, the Surveyor observed a large oval area of missing paint at the entrance of the 400 Hall. On 04/30/2024 at 01:30 PM, the Surveyor observed two couches with missing or peeling material on the hand rests and top of the cushions; the walls showed missing paint, scratches, and gouges all in the Dayroom of the 400 Hall. On 05/02/2024 at 10:35 AM, the Surveyor observed 2 armchairs and an ottoman in the front lobby with missing, cracked, and/or peeling material. On 04/30/2024 at 09:17 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4, can you describe what is on the shower room floor? CNA #4 stated it looked like poop. The Surveyor asked how often the shower room was cleaned. CNA #4 stated it is supposed to be cleaned everyday by housekeeping and the CNAs have sanitizer that is supposed to be used between showers. The Surveyor asked when the shower room was usually cleaned and when was the last shower usually given. CNA #4 stated the shower rooms were usually mopped at lunch by the housekeepers and the showers were usually done by three o'clock. The Surveyor asked how long the tiles had been missing by the drain. CNA #4 stated the tiles had been missing for a long time. On 04/30/2024 at 01:48 PM, the Director of Nursing (DON) confirmed the dark spots on the shower room floor looked like feces, and said, I don't know how long the tiles have been missing, but maintenance is working on replacing them. On 04/30/2024 at 02:18 PM, the Administrator stated the missing tiles in the shower room were just brought to my attention and maintenance is taking care of it right now. It was confirmed that Housekeeping cleans the showers every day and the CNA's also have cleaner to clean the shower room.

Based on observation and interview, the facility failed to ensure a medication cup with four different medications was not left on top of a medication cart and the medication cart was locked while unattended on the 100 Hall. The findings are: On 05/02/24 at 09:14 AM, the Surveyor observed Licensed Practical Nurse (LPN) #3 walk away from the medication cart to add water to the liquid medications and left the cart unlocked with a cup of medication sitting on top of the cart. The medication cup included: 1. Lansoprazole (a medication to reduce the amount of acid your stomach makes) 15 milligram (mg) - 1 capsule. 2. Amlodipine (a medication to treat high blood pressure and chest pain) 5 mg - 1 tablet. 3. Citalopram Bupropion Hydrobromide (a medication to treat depression) 10 mg - 1 tablet. 4. Chewable Aspirin 81mg tablet - 1 tablet. On 05/02/24 at 09:15 AM, when LPN #3 returned to the medication cart, the Surveyor asked where the medication cup was located. LPN #3 said on top of the cart. The Surveyor asked if the cart was locked. LPN #3 stated, No. The Surveyor asked if the medication cart was unlocked, and the cup left on top of the cart while you went to get water. LPN #3 stated, Yes, I was nervous and forgot.

Based on observation and interview the facility failed to ensure that used COVID-19 testing supplies were disposed of properly to prevent the development and transmission of communicable diseases and infections. The failed practice had the ability to affect all 80 residents who resided in facility according to the Midnight Census provided by the Administrator on 03/27/23 at 10:57 AM. The findings are: a. On 03/28/23 at 9:45 AM, there were 20 to 25 Covid test cards in an opened ziplock bag, the ends of the swabs extended past the top of the bag and prevented closure, on top of a table in the corner of the Conference Room. Each card had a swab sticking out of the top and was dated on the front indicating the test had been performed. Next to the tests was a written log of testing completed. The tests were recorded from January and February 2023. The last recorded date was 02/11/23. b. On 03/28/23 at 10:09 AM, the Surveyor asked the Administrator for documentation of the COVID-19 testing procedure utilized by the facility. The Administrator provided a copy of the COVID-19 Antigen card followed when testing. The card did not include information concerning test disposal. The Surveyor asked the Administrator for the test disposal instructions. She stated, I will get that from the DON [Director of Nursing]. c. The COVID Antigen Test Disposal instructions provided by the DON on 03/28/23 at 10:36 AM stated, .Once testing is complete, results are documented, and all testing supplies are disposed of in a biohazard bag. Supplies: completed test with swab, gloves, and test packaging . d. On 03/28/23 at 10:38 PM, the DON accompanied the Surveyor into the Conference Room and was shown the bag of completed COVID tests/swabs. The Surveyor asked the DON if it is important to dispose of used COVID tests. The DON stated, Yes. The Surveyor asked why it is important to dispose of used COVID tests. The DON stated, Infection. The Surveyor asked her to expand on her answer. The DON stated, To control, to stop the spread of germs. The DON was asked if the used testing supplies located in the Conference Room should have been disposed of. The DON stated, Yes. I did not know they were here. I'll take care of it and do some in-servicing. e. The facility policy titled, Dressings, Soiled/Contaminated, provided by the Administrator on 03/29/23 at 1:51 PM did not address the disposal of any biohazardous material other than dressings. 47916

Based on observation, record review and interview, the facility failed to ensure expired food items were promptly removed from stock / discarded by the expiration or 'use by' dates and dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 72 residents who received meals from the kitchen (total census: 72), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 8:55 A.M., a 64-ounce carton of vanilla soy milk was stored on a shelf in the refrigerator with an expiration date of [DATE]. 2. On [DATE] at 9:02 A.M., there were 4 cartons of soy milk stored in a milk crate in the walk-in refrigerator with expiration dates of [DATE]. 3. On [DATE] at 9:06 A.M., the following observations were made on the bread rack in the kitchen: a. There were 4 bags of slider buns with 8 buns in each bag, stored on the bread rack in the storage room. The buns were sage in color. The Dietary Supervisor was asked to describe the appearance of what was found on the buns. She stated, They have a black color. b. There were two more bags of slider buns stored on the bread rack in the storage room. The bottoms of the buns were moist and damp. The Dietary Supervisor was asked to describe the appearance of what was found on the buns. She stated, They are moist at the bottom. 4. On [DATE] at 11:16 A.M., Dietary Employee #1 took pans from the Dietary Supervisor and, without washing his hands, picked up glasses, with his fingers inside of them, and placed them inside the pans, then poured water into the glasses to be served to the residents with their lunch. 5. On [DATE] at 11:19 A.M., Dietary Employee #1 opened the refrigerator door and took out pitchers that contained beverages. Without washing his hands, he picked up glasses by their rims and poured beverages to the served to the residents with lunch. At 12:13 P.M., Dietary Employee #1 was asked, What should you have done after touching dirty objects and before you handled clean equipment? He stated, I should have washed my hands. 6. On [DATE] at 11:42 A.M., Dietary Employee #2 picked up a bag that contained a paper bowl from the storage room and untied it. She removed a bowl from the bag and gave it to a staff member. Without washing her hands, she picked up glasses that contained beverages with her bare hand, placed them into a pan and covered them with plastic wrap. At 12:14 P.M., Dietary Employee #2 was asked, What should you have done after touching dirty objects and before you handled clean equipment? She stated, Washed my hands. 7. On [DATE] at 11:50 A.M., Dietary Employee #3 was wearing gloves on her hands when she picked up the lids from the pans of food on the steam table. Without changing gloves and washing her hands, she picked up a clean blade and placed it onto a blender to be used in pureeing foods to be served to the residents who required pureed diets. At 12:12 P.M., Dietary Employee #3 was asked, What should you have done after touching dirty objects and before you handle clean equipment? She stated, I should have washed my hands.

Based on observation, record review and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician to minimize the potential for [CONDITION(S)] or other respiratory complications for 1 (Resident #275) and failed to ensure oxygen was administered only when ordered by a physician to prevent potential complications for 1 (Resident #274) of 6 (Residents #3, #59, #34, #274, #275, and #37) sampled residents who received oxygen therapy. The findings are: 1. Resident #275 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/3/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. A Physician's Order with a start date of 9/29/21 documented, .Oxygen as needed for shortness of breath 2 liters / min [per minute] per nasal cannula . b. On 10/11/21 at 10:45 A.M., Resident # 275 was in bed with oxygen on and running at 3 liters per minute via nasal cannula. c. On 10/12/21 at 8:49 A.M., Resident # 275 was sitting in a wheelchair in her room with oxygen on and running at 2.5 liters per minute via nasal cannula. Resident #275 was asked, What is your oxygen usually set at? Resident #275 stated, Usually at 2 liters per minute, but they raise it here when I'm hurting. Resident #275 was asked, Do you raise the oxygen? Resident #275 stated, No, I haven't raised it here. d. On 10/14/21 at 3:15 P.M., Resident # 275 was sitting in a wheelchair in her room with oxygen on and running at 3 liters per minute via nasal cannula. e. On 10/14/21 at 3:22 P.M., Licensed Practical Nurse (LPN) #1 was asked, Can you tell me what [Resident #275's] oxygen is running at? LPN #1 stated, It should be at 2. LPN #1 was asked, What is it on? LPN #1 stated, It's on 3. LPN #1 asked Resident #275, Did you change the oxygen? Resident #275 stated, I haven't touched it. Yesterday it was on 2.5 but no, I haven't touched it. f. On 10/15/21 at 10:35 A.M., the Director of Nursing (DON) was asked, Should oxygen be administered per the Physician Orders? The DON stated, Yes. 2. Resident #274 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS was not yet completed at the time of the survey. a. The Care Plan dated as initiated 10/07/21 did not address the use of oxygen. b. The Physician Orders dated to be active as of 10/11/2021 did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] c. On 10/11/21 at 12:40 P.M., Resident # 274 was in the dining room receiving oxygen via nasal cannula at 2 liters per minute. d. On 10/14/21 at 3:25 P.M., LPN #1 was asked, Does [Resident #274] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? LPN #1 stated, I don't know, but we can get one if we need to. e. On 10/15/21 at 10:35 A.M., the DON was asked, Should there be a Physician's Order for oxygen administration? The DON stated, Yes. 3. An Oxygen Administration policy provided by the Administrator on 10/14/21 at 3:45 P.M. documented, . The purpose of this procedure is to provide guidelines for safe oxygen administration . verify that there is a physician's order for this procedure . adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Complaint # (AR 096) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure soiled disposable briefs were properly disposed and bed linen was clean to provide a safe, sanitary, and homelike environment for 1 of 1 case mix resident (Resident (R) #5). This failed practice had the potential to affect all 77 Residents that resided in the facility per the Resident Census and Condition of Resident form dated 2/1/2021. The findings are: Resident # 5 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/3/20 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); and was rarely or never understood scored, required limit assistance one person assist with toileting, was frequently incontinent of bladder and bowel. a. On 2/2/21 at 6:55 a.m., Resident #5 was sitting in his recliner and his room watching T.V. (television). There was a white brief filled with brown stool laying on the floor next to the resident recliner. There was not a bedspread covering the resident's bed. There were brown stains and food particles spread on top of the white linen on the bed. The resident was asked if he had put the brief in the floor. His words were not clear and this surveyor was unable to understand what he was saying. b. On 2/2/21 at 7:33 a.m., Certified Nursing Assistant (CNA) #1 entered the resident ' s room. CNA #1 set-up the resident meal tray. The stool filled brief remained on the floor, next to his recliner. CNA #1 did not remove the soiled brief from the floor. After performing hand hygiene, CNA #1 exited the resident room. c. On 2/2/21 at 7:45 a.m., CNA #2 entered the resident ' s room. She stated, Let me get my gloves. She then picked up the stool soiled brief from the floor and disposed of it. CNA #2 was asked does he remove his own brief. She stated, Someone has to take his clothes off him, and it has to be someone he knows. CNA #2 stated, I'm going to have to strip his bed too. CNA #2 was asked, Why are you going to strip his bed? CNA#2 stated, It has crumbs and stains on it. CNA #2 was taking the resident into his bathroom. Resident #1 was asked, Is it okay if I come in the restroom to watch her care for you? The resident became very agitated and started making loud noises. This surveyor was unable to watch his care. d. On 2/2/21 at 7:55 a.m., CNA #1 was asked should you pick a soiled brief up off the resident floor. She stated, I didn't see a soiled brief on his floor. She was asked, Should residents linens remain free of brown stains and crumbs? She stated, Yes. She was asked, Who is responsible for keeping residents' bed clean and soiled brief off the floor? She stated, CNAs. e. A Quality of Life -Homelike Environment Policy documented, . 1. Staff shall provide person-centered care that emphasis the residents' comfort . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include a. Clean, sanitary and orderly environment . e. Clean bed .

Complaint (AR 068) was substantiated, all or in part, with deficiency cited at F689. Based on observation and interview the facility failed to ensure vaping devices and smoking liquid containing nicotine were kept secure and not accessible to cognitively impaired residents. This failed practice had the potential to affect 12 residents who were cognitively impaired and who ambulate/propel self, according to a list provided by the Administrator on 07/22/2020. The findings are: 1. On 07/22/2020 at 5:52 A.M., two vaping devices and two 60 ml (milliliter) bottles containing 6 mg (milligrams) of nicotine smoking liquid were sitting on the nurse's desk unattended. The nurse's desk was accessible to any passerby. 2. On 07/22/2020 at 6:00 A.M., a staff member left the nurses desk leaving the vaping devices and the nicotine liquid unattended. 3. On 07/22/2020 at 6:13 A.M., Licensed Practical Nurse (LPN) #1 was asked, Have you ever seen anyone use a vape or e-cigarettes inside the building? She stated, No The surveyor pointed out the 2 vaping devices and 2 bottles of nicotine liquid on the desk and asked, Are those smoking vapes? She stated, Yes and juice She was asked who they belonged to. She stated, They are mine. She was asked, Do you leave them on the nurses' desk? She stated, Yes. Photo taken of vaping devices on the desk. She was asked, Where do you use them? She stated, Out front. She was asked, Do they contain nicotine? She stated, Yes. She was asked, Can residents wander behind the nurse's desk. She stated, Uh, huh. (Yes) 4. On 07/22/2020 at 6:53 A.M., the 2 vaping devices and the 2 bottles of nicotine liquid were unattended at the nurse's desk. 5. On 07/22/2020 at 11:42 A.M., the Director of Nurses was asked, Is it acceptable for staff to leave vaping devices and nicotine liquid unattended on the nurse's desk? She stated, No, not where a resident can reach. It should be in their personal belongings. 6. On 07/22/2020 at 11:54 A.M., the Administrator was asked, Is it acceptable for staff to leave vaping devices and nicotine liquid unattended on the nurse's desk? He stated, No, they should not. He was asked if the facility had a policy on staff smoking and or vaping. He stated, I don't have anything . that's just standard of practice.

Based on observation, interview and record review the facility failed to ensure nails were trimmed, smooth and free of jagged edges to promote good personal hygiene and grooming for 3 (Residents #6, #27 and #59) of 15 (Residents #2 #6, #16, #19, #26, #27, #33, #34, #43, #50, #59, #66, #67, #77, and #129 ) sampled residents who were dependent for nail care and reside on the 400 and 200 halls according to a list provided by the Administrator on 07/10/2020 at 12:15 P.M. This failed practice had the potential to affect 59 residents who are dependent for nail care based on a list provided by the Administrator on 08/04/2020. The findings are: 1. Resident #27 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/2020 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and required extensive physical assistance of one person for personal hygiene. a. The Resident's plan of care documented, .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 10/12/2019 . b. On 07/06/2020 at 10:16 A.M., the resident was sitting in the day room in a Broda chair with eyes closed. A dark brown dried substance was under his fingernails. Photo taken. 2. Resident #59 had a [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 06/08/2020 documented the resident scored 4 (0 - 7 indicates severely impaired) per a Brief Interview for Mental Status (BIMS) and required limited physical assistance of one person for personal hygiene. a. The Resident's plan of care documented, .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 03/02/2020 . b. On 07/06/2020 at 10:01 A.M., the resident's fingernails were in varying lengths from approximately 1/8 to 1/2 an inch past the tips of the fingers, with fingernail polish chipped and faded. Both index fingernails had broken jagged edges. Photo taken. 3. Resident # 6 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 04/05/2020 documented the resident scored 01 (00 to 07 indicates severe impairment) on the BIMS and required 1-person physical assist with bed mobility, personal hygiene and bathing and 2 plus person physical assist with transfer and dressing. a. The Care Plan with a review date of 02/24/2020 documented Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . The resident has potential impairment to skin integrity r/t (related to) immobility and frequent incontinent episodes of B&B (Bowel and Bladder) . Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short . b. On 07/07/2020 at 10:09 A.M., the resident's fingernails on the right hand were approximately 3/4 to 1 inch in length past the end of the fingers with a dark brown and yellow dried substance underneath the nails. The fingernails on the left hand were jagged and approximately 3/4 to 1 inch in length past the end of the fingers with a dark brown and yellow dried substance underneath the nails. 4. On 07/9/2020 at 3:15 P.M., the Administrator and the Director of Nursing were asked, Should a resident's fingernails have dried brown substance under the nails? The Director of Nursing stated, No 5. On 07/10/2020 at 9:30 A.M., Licensed Practical Nurse #1 was asked, Should a resident's fingernails have dried brown substance under the nails? She stated, No She was asked, Should a resident's fingernails be jagged or rough on the edges? She stated, No She was asked, Who is responsible for ensuring a resident's fingernails are clean, trimmed and filed. She stated, All of us. 6. A document titled Care of Fingernails/Toenails provided by the Director of Nursing on 07/10/2020 at 9:41 A.M. documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections .nail care includes daily cleaning and regular trimming .trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, interview and record review the facility failed to ensure staff wore Personal Protective Equipment (PPE), face covering mask, appropriately to prevent the possible spread of respiratory infection such as COVID-19. This failed practice had the potential to affect 82 residents in the facility according to the Resident Census and Conditions of Residents provided by the Administrator on 07/06/2020. The findings are: 1. On 07/22/2020 at 5:43 A.M., Certified Nursing Assistant (CNA) #1 was walking around the front of the nurses' desk from the 300 hall toward the 200 hall. Her hair was up in a ponytail. A face mask was hanging from the ponytail by the ear loop with the face mask at the back of her head leaving her mouth and nose uncovered. She stopped to talk with a resident who was sitting in a wheelchair. The staff member was standing approximately 2 ½ to 3 feet in front of the resident while talking. 2. On 07/22/2020 at 5:45 A.M., CNA #1 was asked, When are you supposed to wear a face mask? She stated, At all times. She was asked, Were you wearing a mask when you were walking down the hall and stopped to talk to a resident? She stated, No, I was running to get my inhaler. 3. On 07/22/2020 at 11:42 A.M., the Director of Nurses was asked, What is the proper way for staff to wear PPE, specifically a mask? She stated, We only allow surgical masks for staff, it is to cover their nose completely, their mouth, below their chin with the ear loops properly in place behind their ears, .anytime in the facility or in contact with a resident. She was asked, Should a mask be worn hanging from a ponytail at the back of the head, not covering the nose and mouth? She stated, No. 4. On 07/22/2020 at 11:54 A.M., the Administrator was asked, What is the proper way for staff to wear PPE, specifically a mask? He stated, Applied with elastic around the ears and the mask covering the nose and mouth. He was asked, Should a mask be worn hanging from a ponytail at the back of the head, not covering the nose and mouth? He stated, No. 5. A Policy and Procedure titled, Personal Protective Equipment-Using Face Masks, provided by the Administrator on 07/22/2020 documented, . be sure the face mask covers the nose and mouth .

Based on observation, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items in 1 of 1 kitchen, and mechanical soft hot food items (ground meats) were maintained at a temperature of 135 degrees Fahrenheit (F) or above while awaiting service in 1 (400 Hall unit dining room) of 2 dining rooms, to prevent potential food borne illness. These failed practices had the potential to affect 78 residents who received meals from the kitchen (total census: 80), and 2 residents who received mechanical soft diets in the 400 Hall unit dining room, as documented on the diet list dated 2/14/19. The findings are: 1. On 2/13/19 at 9:39 a.m., Dietary Employee #1 gave a packet of crackers to a resident. Without washing her hands, she picked up glasses by their rims and poured beverages to be served to the residents during the lunch meal. 2. On 2/13/19 at 10:14 a.m., Dietary Employee #1 dried her hands with a paper towel. After drying her hands, she dried around the sink with the same paper towel. The paper towel dropped onto the floor. The employee picked up the paper towel and threw it away. Without rewashing her hands, she picked up clean utensils by the ends opposite the handles and placed them on individual napkins for the residents to receive with their lunch trays. 3. On 2/13/19 at 10:35 a.m., Dietary Employee #1 picked up individual small cartons of half and half and placed them in a container on the counter. Without washing her hands, she picked up glasses by their rims and placed them on trays to be used to serve beverages to the residents during the lunch meal. 4. On 2/13/19 at 10:45 a.m., Dietary Employee #1 picked up a bag of tea from the storage room and placed it on the counter. Without washing her hands, she picked up glasses by their rims and placed them on a tray. The glasses were to be used to serve beverages to the residents during the lunch meal. 5. On 2/13/19 at 10:49 a.m., Dietary Employee #1 turned on the sink faucet and obtained water. She then touched the faucet handle to turn off the water, contaminating her hands. Without washing her hands, she began to pick up glasses by their rims and place them on the residents' meal trays. 6. On 2/14/19 at 11:58 a.m., the temperature of the food items in the Pyrex dishes on top of the food cart in the 400 Hall unit dining room were checked and read by Certified Nursing Assistant #1 with the following results: Ground pork loin: 105 degrees Fahrenheit (F); Ground turkey with gravy: 125 degrees F. The above food items were not reheated before being served to the residents.

Based on observation of the 4:00/5:00 p.m. medication pass on 2/11/19 and the 8:00 a.m. medication pass on 2/12/19, record review and interview, the facility failed to ensure physician's orders were followed to maintain a medication error rate of less than 5% and prevent potential complications for 3 (Residents #12, #10 and #16) of 12 residents observed during the medication passes resulting in medication errors. Medication errors were made by 3 Licensed Practical Nurses (LPNs #3, #4, and #5) of 4 LPNs who administered medications. The failed practice had the potential to affect 53 residents who received medications administered from these Nurses, according to a list provided by the Administrator on 2/12/19. The medication error rate was 6.12%, based on observation of 49 medications administered and a total of 3 errors detected. The findings are: 1. Resident #12 had a [DIAGNOSES REDACTED]. On 2/11/19 at 4:23 p.m., LPN #3 administered the [MEDICATION NAME] 25 mg to the resident with water and no food. At 5:15 p.m., the evening meal service began, and the first meal tray was served to a resident in the main dining room. 2. Resident #10 had a [DIAGNOSES REDACTED]. A physician's order dated 10/22/18 documented the resident was to receive [MEDICATION NAME] Solution 100 units per milliliter subcutaneously (SQ) before meals via sliding scale, Inject as per sliding scale: if (blood glucose) 0 - 149 = (administer) 0 U (units); 150 - 200 = 2 U; 201 - 250 = 4 U; 251 - 300 = 6 U; 301 - 350 = 8 U; 351 - 400 = 10 U; 401+ (plus) notify Medical Doctor . a. On 2/11/19 at 4:45 p.m., LPN #4 performed a Capillary Blood Glucose (CBG) test, with a result of 200 milligrams per deciliter (mg/dl), which per the sliding scale order, would require 2 units of [MEDICATION NAME]. At 4:47 p.m., LPN #4 administered 2 units of [MEDICATION NAME]to the resident via SQ injection. At 5:18 p.m., 33 minutes after the [MEDICATION NAME] injection, the resident received a meal tray. b. A manufacturer's insert for the [MEDICATION NAME] documented, .eat a meal within 5-10 minutes after taking ([MEDICATION NAME]) . 3. Resident #16 had a [DIAGNOSES REDACTED]. A physician's order dated 1/12/17 documented the resident was to receive Delzicol Capsule Delayed Release (DR) 400 mg (milligram) ([MEDICATION NAME]), 1 capsule by mouth two times a day and, Do not chew or crush. On 2/12/19 at 5:02 p.m., LPN #5 opened the Delzicol DR 400 mg capsule and crushed the pellets inside. As she was crushing the contents of the capsule, she stated another LPN had, looked it up and it was, .fine to crush the medication.

Based on observation and record review, the facility failed to ensure [MEDICATION NAME]was administered no more than 10 minutes prior to a meal per the manufacturer's specifications, to prevent a significant medication error which could result in complications related to [DIAGNOSES REDACTED] for 1 (Resident #10) of 1 sampled resident who received [MEDICATION NAME] Insulin. This failed practice had the potential to affect 2 residents who received [MEDICATION NAME] Insulin, as documented on a list provided by the Administrator on9/27/19. The findings are: Resident #10 had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].= (administer) 0 U (units); 150 - 200 = 2 U; 201 - 250 = 4 U; 251 - 300 = 6 U; 301 - 350 = 8 U; 351 - 400 = 10 U; 401+ (plus) notify Medical Doctor . a. On 2/11/19 at 4:45 p.m., Licensed Practical Nurse (LPN) #4 performed a Capillary Blood Glucose (CBG) test, with a result of 200 milligrams per deciliter (mg/dl), which per the sliding scale order, would require 2 units of [MEDICATION NAME]. At 4:47 p.m., LPN #4 administered 2 units of [MEDICATION NAME]to the resident via SQ injection. At 5:18 p.m., 33 minutes after the [MEDICATION NAME] injection, the resident received a meal tray. b. A manufacturer's package insert for the [MEDICATION NAME] documented, .eat a meal within 5-10 minutes after taking ([MEDICATION NAME]) . c. This medication error was significant based on the classification of the medication, anti-diabetic / insulin.

Based on observation, record review and interview, the facility failed to ensure licensed nursing staff followed manufacturer's instructions for the reconstitution of an intravenous (IV) antibiotic to ensure accurate administration of the medication and prevent potential complications for 1 (Resident #332) of 1 sampled resident who received IV antibiotics. The failed practice had the potential to affect 1 resident who received IV antibiotics, as documented on the Order Listing Report provided by Nurse Consultant on 2/14/19 at 2:46 p.m. The findings are: Resident #332 had a [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED]. until 2/21/19 23:59 (11:59 p.m.) reconstitute with 0.9% Sodium Chloride, administer 50 mls (milliliters) over 30 minutes . b. On 2/12/19 at 3:00 p.m., Licensed Practical Nurse (LPN) #3 entered R332 the resident's room to administer the [MEDICATION NAME] Sodium Solution. The LPN reconstituted [MEDICATION NAME] with normal saline using a vial mate adapter. The [MEDICATION NAME] was thoroughly dissolved in the solution; however, approximately 2 ml of the liquid solution was left in the [MEDICATION NAME] antibiotic vial when the LPN initiated the IV infusion, and the LPN did not attempt to add the remaining [MEDICATION NAME] to the IV bag. LPN #3 removed her gloves, washed her hands and told the resident that the pump should not alarm until the IV had infused, then left the room. c. On 2/12/19 at approximately 3:35 p.m., the Director of Nursing (DON) was asked to accompany the surveyor to the resident's room. On the way, she was asked, Should the LPN ensure all the medication in a vial has been added to the IV prior to infusing a medication? The DON stated, Yes, but sometimes gravity will pull the medication back into the vial. She was asked when the LPN should recheck the IV infusion after initiating it and stated, It depends, I usually go back in 10-15 minutes. Upon arrival to the resident's room, the DON assessed the infusion, stopped the pump and removed the IV bag with the [MEDICATION NAME] vial attached. There was approximately 2 ml of fluid remaining in the vial. The DON turned the bag upside down and squeezed air into the vial and then released it, so the contents would drain into the bag. The DON then restarted the infusion of [MEDICATION NAME]. d. On 2/14/19 at approximately 1:38 p.m., LPN #4 was asked about her training on the administration of IV medications and stated, I received my IV training in my LPN curriculum and I have taken the IV Certification for the Long-Term Nurse Education Program here. She was asked if she had administered the IV medication for Resident #332 and to describe the process for the reconstitution of the [MEDICATION NAME]. She stated, Yes, I have given (Resident #332's) 1 gm [MEDICATION NAME] IV .after mixing the vial contents, the solution should be milked down into the bag before starting the IV. All the vial contents should be in the bag; I go back every 10 minutes to make sure infiltration has not occurred .if all contents in the vial do not drain into the IV bag, then the medication amount ordered could be wrong and the resident's infection not be treated correctly, and she could remain sick. e. On 2/14/19 at 2:25 p.m., LPN #2 was asked about her training on the administration of IV medications and stated, Yes, I was taught in LPN school and received a class here on administration of medications. It depends on the type of vial connection to the IV bag, but all the contents of the vial should be mixed and added back to the IV bag or they would not receive the complete treatment and could get a worse infection. f. The manufacturer's instructions for the Baxter vial mate adapter were received from Nurse Consultant #1 on 2/14/19 at 2:55 p.m. and documented . 7. Hold bag with vial down . Squeeze bag to force solution into vial until half full . Shake to suspend drug in solution . Ensure drug is completely dissolved. 8. Hold bag with vial upside down . Squeeze bag to force air into vial . Release to drain suspended drug from vial . Repeat steps 7 and 8 until vial is empty and solution is thoroughly mixed .9. Administration: Remove container administration port protector. Attach administration set per its directions. Ensure that the vial is empty of drug and solution. Repeat step 8 if drug and solution remain in vial .

Based on observation and interview, the facility failed to ensure hot food were maintained at or above a temperature of 135 degrees Fahrenheit (F.) while awaiting initiation of the meal service; failed to ensure staff washed their hands and donned gloves prior to handling a resident's food; failed to ensure an ice machine and can opener were maintained in clean condition and the ice in the machine was not contaminated during handling; and, failed to ensure an opened container of lemon juice was refrigerated after opening per the manufacturer's instructions, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 78 residents who received meals from the kitchen (total census: 83), as documented on a list provided by the Administrator on 4/3/18. The findings are: 1. On 3/19/18 at 12:27 p.m., during lunch, Certified Nursing Assistant (CNA) #1 was assisting residents in the secure unit dining room. With her bare hands, she picked up a resident's toast, placed meat from the resident's plate on the toast, folded the toast, and cut the folded toast in half with a knife. Without washing her hands, she turned to a second resident at the same table and picked up that resident's toast from her plate and performed the same actions. She then picked up the sandwich she had made and offered it to the resident. Without washing her hands, CNA #1 continued to assist other residents. CNA #1 used her left hand to brush a wisp of hair away from her face, scratched her head, and then without washing her hands, served bowls of dessert to residents in the dining room. CNA #1 moved a chair between 2 residents, and still without washing her hands, picked up a sandwich with her bare hands and offered it to a resident. a. On 3/19/18 at 2:45 p.m., CNA #1 was asked Can I ask you a few questions? CNA #1 stated, It was the sandwich, wasn't it? She was asked, What about the sandwich? CNA stated, I should have used a knife and fork instead of bare hands or gloves to feed a resident. She was asked, Did you touch your hair and scratch your head and continue to touch the food? The CNA stated, I should never have touched myself or my hair, then touch food. b. On 3/22/18 at 8:42 a.m., the Director of Nursing (DON) was asked, Should staff touch a resident's food with bare, unwashed hands when serving food or assisting a resident to eat? The DON stated, Absolutely not. The DON was asked, Should staff continue to serve food or assist a resident to eat with bare, unwashed hands after touching their hair or scratching their head? The DON stated, No. c. The facility policy, Assistance with Meals, provided by the DON on 3/22/18 at 9:12 a.m., documented, .All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. 2. On 3/21/18 at 11:08 a.m., a can opener mounted to the end of the counter had shavings of metal on the blade. On 3/22/18 at 3:42 p.m., Dietary Employee #1 was asked how often the can opener was cleaned and stated, Every day. 3. On 3/21/18 at 11:58 a.m., the upper, interior surfaces of the ice machine on the 300 Hall had an accumulation of wet black/grayish residue on both sides that could potentially drip onto the ice. On 3/22/18 at 3:00 p.m., Dietary Employee #1 was asked who used the ice from the 300 Hall ice machine and how often the ice machine and scoop holder were cleaned. She stated, That's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms. We use the one in the kitchen to fill beverages served to the residents at meals. We clean the ice machines every week. 4. On 3/21/18 at 12:06 p.m., Dietary Employee #2 propped a gray rubber container against the edge of the ice machine and began to scoop ice into the container. The bottom of the container slipped into the machine and came in contact with the ice. On 3/22/18 at 11:05 a.m. Dietary Employee #2 was asked, Where is the appropriate place to set the container when scooping ice? He stated, I'm supposed to place the container for ice on a cart. 5. On Thursday, 3/22/18 at 8:34 a.m., an opened bottle of lemon juice was stored inside a cabinet. The juice had a cloudy sediment at the bottom of the container. The label on the bottle documented, Refrigerate after opening . The Unit Coordinator was asked, What do you use the lemon juice for? She stated, We used it to cook on Wednesday. 6. On 3/22/18 at 12:12 p.m., food awaiting the lunch meal service was in glass containers on a cart. The temperatures were checked by the Activity Coordinator with the following results: Mashed potatoes - 131.5 degrees Fahrenheit. English peas - 118.7 degrees Fahrenheit. Ground roast beef with gravy - 104.3 degrees Fahrenheit. Roast beef with gravy - 109 degrees Fahrenheit. The Food Service Manager was immediately informed by the surveyor of the above temperatures and took the food back to the kitchen to be reheated. On 3/22/18 at 3:46 p.m., the Activity Coordinator was asked if food temperatures were routinely checked prior to starting the meal service and stated, No, are we supposed to? I guess we will temp them in case if it gets cold. That way, we will warm them up.

Based on observation, record review, and interview, the facility failed to ensure the physician was immediately consulted upon identification of a wound to the ankle, to ensure the appropriate treatment was provided and promote continuity of care for 1 (Resident #432) of 2 (Residents #229 and #432) sampled residents who were new admissions in the last 30 days. The failed practice had the potential to affect 5 residents who were admitted to the facility in the past 30 days, as documented on the New Admissions list as of 3/23/18. The findings are: 1. Resident #432 had [DIAGNOSES REDACTED]. a. The Nursing Admit / Readmit Assessment and Care Plan dated 3/15/18 documented the resident was admitted from a hospital for rehabilitation; scored 7 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status; required limited assistance with bed mobility, transfers, dressing, and toilet use; had a skin tear to the back of the left hand; had a red, non-tender wheal to the right outer ankle; had gangrene to the third and fifth toes of the left foot; had a total Braden pressure ulcer risk score of 19 (19-23 indicates no risk); had a pressure ulcer or potential for pressure ulcer development and, .Intervention: Assess/record/monitor wound healing . Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Medical Doctor) . b. The Physician order [REDACTED]. One time a day related to Gangrene . There was no documentation of a treatment order for a reddened area to the right ankle. c. Progress Notes dated 3/18/18 (Sunday) at 5:10 p.m. by Weekend Registered Nurse (RN) #1 documented, Right lateral ankle with sore uncovered . quarter size, reddened, dry, no drainage . area cleaned with wound cleanser, medi honey and triple antibiotic ointment dry dressing. There was no documentation the physician was consulted for treatment orders. d. On 3/20/18 at 9:25 a.m., the resident had a dressing dated 3/18/18 to the right outer ankle. e. On 3/20/18 at 10:47 a.m., the Treatment Nurse removed the dressing dated 3/18/18 from the resident's right outer ankle. There was a reddened area that measured approximately 3 inches by 3 inches, dry and flaking in spots, with a dark, red area in the center of the wound. The wound was approximately quarter-sized. The Treatment Nurse stated, .will have to contact the doctor for a treatment order . also waiting to hear back from the doctor about a treatment for [REDACTED]. f. On 3/20/18 at 10:54 a.m., the Treatment Nurse stated, The APRN (Advanced Practice Registered Nurse) just got here, and I'm going to have her look at her (resident's) feet for treatment orders, and the doctor will be here tomorrow too, but I do have a call into him. g. On 3/20/18 at 11:25 a.m., the Treatment Nurse stated the APRN had assessed the wound to the right outer ankle and, .resident had an old brown recluse (spider bite), and she (APRN) ordered treatment and an x-ray just to assess. h. On 3/22/18 at 4:10 p.m., the Director of Nursing (DON) was asked, When should the doctor be notified of a skin concern? She stated, As soon as the nurse finds it. The DON was asked if the resident's wound to the right outer ankle was reported to the physician promptly and stated, (Weekend RN #1) should have (consulted the physician) when she documented it in the Progress Notes on 3/18/18.

Complaint # (AR 404) was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure prompt efforts were made to resolve grievances and residents were kept apprised of the progress toward the resolution to support the right to voice grievances for residents who lived on 1 (400-Hall) of 4 halls. The failed practice had the potential to affect 18 residents who resided on the 400 Hall Secured Dementia Unit, as documented on the Census by Hall List provided by the Administrator on 8/12/16. The findings are: 1. The March 2016 through July 2016 Resident Council Minutes documented the following, as of 8/17/16 at 11:55 a.m.: a. The Resident Council Minutes dated 3/17/16 documented, .Invited (Director of Nursing) to council meeting. She ask residents if they wanted to voice their opinions. Residents stated other than ice not being passed they (illegible) pretty happy . The form was signed by the Administrator. b. The Resident Council Minutes dated 4/16/16, .Old Business-Ice Not being passed . New Business .Ice not being passed was improved for all agree . The form documented the Activity Director was the staff member present and the report was signed by the Administrator. c. The Resident Council Minutes dated 5/18/16, .Old Business-Ice Not being passed . New Business .Ice not being passed (this was crossed out and documentation stated corrected now) . The form documented the Activity Director was the staff member present and the report was signed by the Administrator. d. The Resident Council Minutes dated 6/14/16, documented no minutes for Old Business or New Business. The form documented the Activity Director was the staff member present and the report was signed by the Administrator. e. The Grievance log documented the Resident Council filed a Grievance on 6/15/16. That grievance documented, Ice not being passed daily. The log documented the date the grievance was resolved as 6/26/16 and a General Description of Resolution of Staff inserviced. f. The Resident Council Minutes dated 7/13/16, .7. Old Business .Ice Not being passed . Was this issue resolved t your satisfaction? (circled yes) all agree .New Business .1. N/A (non applicable) . The form documented the Activity Director was the staff member present and the report was signed by the Administrator. 2. On 8/13/16 at 2:25 p.m., in resident room [ROOM NUMBER], there were no water pitchers for the A or B beds. An alert and oriented resident in the B bed stated, I wonder why they don't bring us any ice water anymore. We used to get ice water and we don't anymore. On 8/14/16 at 1:10 p.m. and on 8/16/16 at 10:20 p.m., the resident had no water pitcher in her room. 3. On 8/13/16 at 2:25 p.m., rounds were made on rooms on the 400 hall. At this time, the following observations were made; none of the water containers in the rooms had documentation on them that the residents wanted or needed ice omitted from their water. a. room [ROOM NUMBER] - The water in the pitchers for the A or B bed had no ice. There were no straws or glasses by the pitchers for the residents to use. b. room [ROOM NUMBER] - The water in the pitchers for the A or B bed had no ice. There were no straws or glasses by the pitchers for the residents to use. c. room [ROOM NUMBER] - The water in the pitchers for the A or B bed had no ice. There were no straws or glasses by the pitchers for the residents to use. d. room [ROOM NUMBER] - The water in the pitcher for the B bed had no ice. There was no straw or glass by the pitcher for the resident to use. There was no water pitcher for the A Bed. e. room [ROOM NUMBER] - The water in the pitchers for the A or B bed had no ice. There were no straws or glasses by the pitchers for the residents to use. f. room [ROOM NUMBER] - there was no water pitcher in the room for either the A or B bed residents. g. room [ROOM NUMBER] - There was a pitcher of water in the room, but there no ice in the water. There was no straw or cup for the resident to use. h. room [ROOM NUMBER] - The water in the pitchers for the A or B bed had no ice. There were no straws or glasses by the pitchers for the residents to use. 4. On 8/16/16 at 10:45 a.m., a Resident Group Interview was conducted with 4 alert and oriented residents. The residents were asked if ice water was being provided on the halls. All members of the group agreed that sometimes they had to get their own water and sometimes the staff would fill the roommates water pitcher with ice water, but not theirs. One resident stated, This happens more often than not. They further stated it depended on what aides were on the halls. A resident stated, This has been a problem for some months; it will get a little better, then they will stop passing ice water again. 5. On 8/17/16 at 11:30 a.m., the Administrator provided a list of residents who resided on the 400 hall Secure Unit. The list was to document residents who were to receive nothing by mouth. Of the 18 residents on the hall, there were no residents listed who could not have water in their room to drink. 6. The Policy and Procedure for Serving Drinking Water provided by the Administrator on 8/17/16 at 11:30 a.m. documented, Purpose - The purposes of this procedure are to provide the resident with a fresh supply of drinking water and to provide adequate fluids for the resident . Verify that there is NOT a physician's orders [REDACTED]. Residents who are not permitted to have ice may receive tap water only. (Note: Notice on resident's drinking cup will be marked Omit Ice.)

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered only in the presence of a physician order, to ensure the oxygen was medically necessary and to enable the physician to determine the proper flow rate to prevent potential complications for 1 (Resident #1) of 3 (Residents #1, 2 and 4) case mix residents who received oxygen. This failed practice had the potential to affect 20 residents who received oxygen, as documented on a list provided by the Director of Nursing (DON) on 5/25/16 at 4:59 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 4/20/16 documented the resident scored 12 (7-12 indicates moderately impaired in cognitive skills) on the Brief Interview for Mental Status, required extensive assistance of two or more staff for bed mobility and transfers and limited assistance of one staff member for dressing, and received oxygen therapy while a resident. a. As of 5/23/16, the Care Plan, not dated, did not address the use of Oxygen. b. As of 5/23/16, the was no documentation on the Order Review Report, Active During: 4/1/16 through 5/31/16, of a physician order [REDACTED].>c. On 5/23/16 at 12:05 a.m., Resident #1 was in bed with an oxygen concentrator in the room and powered on. The resident's nasal cannula was laying on the bed. At 12:25 a.m., Licensed Practical Nurse #1 (LPN) entered the room and placed the nasal cannula on the resident. At 5:37 a.m., Resident #1 was awake and sitting in wheelchair coloring. The resident was receiving oxygen via a nasal cannula at 2 liters per minute. At 7:40 a.m., Resident #1 was up in a wheelchair and her breakfast was delivered. The resident was receiving oxygen via a nasal cannula at 2 liters per minute. d. On 5/24/16 at 9:45 a.m., Resident #1 was in the bathroom and was not wearing the nasal cannula. The oxygen concentrator was set to 2 liters per minute. The oxygen tubing was in a bag on top of the concentrator. Resident #1 was asked, Are you breathing all right with your oxygen off? The resident stated, Yes, I know when I need it and I'm okay now. At 2:45 p.m., Resident #1 was sitting in her recliner watching television. The resident was receiving oxygen at 2 liters via nasal cannula. Resident #1 was asked, How long have you been on oxygen? She stated, I was on it for a couple of years, but I got off of it with therapy. Then Medicaid cut my therapy after 90 days, and I had to go back on it. e. On 5/24/16 at 6:45 p.m., LPN #2 was asked for the physician order [REDACTED]. At 6:56 p.m., the DON was asked for a physician's orders [REDACTED]. f. On 5/25/16 at 2:22 p.m., LPN #1 was asked, Do you need an order to administer oxygen? Has (Resident #1) received oxygen before May 1, 2016? Was there an order for [REDACTED].#1 stated, .I'm not sure ma'am. When I came to work here (approximately 6 weeks ago), she had it. I would say that you would need an order because oxygen is a medication. She has always had it .Before that night (5/1/16), she has had oxygen on, except when she comes out of her room and she takes it off herself.