Every finding on record at St Andre Health Care Facility

2. On 06/09/25 at 12:20 p.m., observed an oxygen concentrator at the bed side of Resident #10. The tubing was still attached to the machine. Resident #10 stated that [he/she] no longer uses O2 but machine is at [his/her] bedside. Resident #10 stated that they have not used O2 for a month. On 6/10/25 at 1:10 p.m. the surveyor confirmed in an interview with the Unit Manager that Resident #10 no longer uses the O2, and she will remove the concentrator. Based on observations, record reviews, interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care. ( #10, #13 and #23) Findings: 1. On 6/9/25 at 9:24 a.m. during an observation of Resident #13 and Resident #23s room. The tubing on an oxygen (O2) concentrator next to Resident #23's bed was draped over the machine without being stored in a sanitary manner. The tubing on the concentrator next to Resident #23's bed was draped over the concentrator and the nasal cannula was directly on the floor. On 6/11/25 a surveyor reviewed Resident #13's Order Summary/Report shows the following order dated 2/26/25 Oxygen Continuous O2 at 2 liters/minute via nasal cannula. Attempt to wean O2 to keep sat at 90% or higher. every shift On 6/11/25 a surveyor reviewed Resident #23 Order Summary/Report shows an active order dated 5/5/25 Oxygen at 2 LPM via nasal cannula PRN. Monitor oxygen saturation every shift as needed for hypoxia. On 6/11/25 at 11:00 a.m. a surveyor interviewed Certified Nursing Assistant and was told that oxygen tubing should be stored coiled up in a bag when not in use. They did not know why the tubing for Resident #13 and Resident #23 were not stored in a bag. On 6/11/25 at approximately 11:15 a.m., the findings were discussed with the Charge Nurse who confirmed that Resident #13 and Resident #23 were currently using oxygen and the tubing needs to be stored in a sanitary manner between use. The tubing was immediately replaced and bags provided for sanitary storage.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ceiling tile and support structure, and the large floor mixer, 3 of 3 days of survey. Additionally, the reach-in refrigerator was found to have a bag of cookie dough that was undated and unlabeled. Findings: On 6/9/25 at 9:15a.m. the initial tour of the kitchen was conducted with the Food Service Director (FSD) the following was observed: -an open bag of cookie dough not labeled and not dated in the reach in refrigerator; -several stained ceiling tiles throughout the kitchen; -rust covered support struts of the ceiling; - a long cob web hanging from the ceiling containing an insect; -discolorations of ceiling tile near dish machine, upon closer examination it was determined that the area was covered with a heavy layer of dust and when touched with the tip of a broom created a heavy falling of dust and debris in the area. On 6/10/25 at 7:30 a.m., during a tour of the kitchen the following was observed: dust strings hanging from the ceiling. On 6/11/25 at 9:50 a.m., during a tour of the kitchen the following was observed: -large cobwebs in several areas of the kitchen. -dust covering a glove holder positioned over the clean bowls. - large mixer that was covered with a plastic bag, and when the bag was removed a large amount of dried debris was seen around the machine. -Additionally, a small to moderate amount of dust was observed on the outside of the ice machine. The above was confirmed with the Food Service Director at that time and she stated that We have a lot of dusting to do.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 3 of 3 units. Findings: On 6/11/25 at 1:30p.m. during a tour of the facility with the Administrator, the following were observed and confirmed: Third Floor: -Doorway next to stairwell near room [ROOM NUMBER] needs corner protector replaced. -room [ROOM NUMBER]: Stained ceiling tile near window. -Room: 304Wall gouged near bathroom door. -Room: 308- Stained ceiling tile. -Room:310- Stained ceiling tile in corner. -Room: 313- Bathroom has two holes in the wall that need repair. -Room: 318- Stained ceiling tile. -Bathing Suite: Baseboard broken in two places and tile missing. Second Floor: -Common area: 2 holes in the wall behind coffee bar that need repair. -Room: 212- Stained Ceiling tile in the bathroom. -Room: 214- Bathroom door has two holes. -Room: 215- Water in sink took a long while to heat up. -Room: 222- Wall in bathroom has 5 holes that need repair. First Floor: -Sun room all the way to the left after entering has stained ceiling tiles. -Room: 101-Counter under sink needs repair - rough surface. -Room: 102- Bathroom door has 2 holes that need repair. -Room: 104- Bathroom wall has 2 holes that need repair. -Room: 117- Stained ceiling tile above toilet.

Based on observations and interviews, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 3 survey days. (6/11/25). Findings: On 6/11/25 at 9:50 a.m. - Observed through the window that 1 of 2 dumpsters were uncovered, for 1 of 3 days of the survey. This was confirmed with the Food Service Director at the time of the observation.

Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 2 Residents (R) reviewed for new admissions (R72). Findings: Review of facility policy Care Planning revised 2/17 states, . Care, treatment, and services are planned to ensure that they are appropriate to the resident's needs, goals and preferences. Therefore, it is the policy of St. [NAME] Health Care Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, preferences, limitations, and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals with the resident that are reasonable and measurable . Within forty-eight (48) hours of admission, a baseline care plan is implemented for each resident which is to include instructions needed to provide effective and person-centered care. The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . R72 was admitted to the facility on [DATE] for rehabilitation with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R72's clinical record reveled the following Social Service Notes: Social Service Admission Note dated 6/24/2022 states, [ .SW and [he/she] discussed [his/her] chronic health issues, the uncertainty with this current issue and [he/she] admits to feeling depressed at times. [He/she] says [he/she] has been honest with his Cousin and told [him/her] that if [he/she] needs an amputation and goes home, [he/she] will end things. [He/she] reports [heshe] agreed to talk with [him/her] before doing anything and says [he/she] would do that. At this time, [he/she] is waiting to see if the current course of treatment will work . SW anticipates the need to closely monitor and support [his/her] psychosocial wellbeing as well as to assist with d/c planning.] Social Service note dated 6/27/2022 states, [ .Nursing reports [his/her] IV antibiotics are ordered to run through July 23rd and [he /she] has a wound vac placed on [his/her] heel.coupled with [his/her] therapy sessions ending early due to [his /her] verbal and near physical abuse, this has yet to be successful. Discussed [his /her] short temper, [his /her] calling therapy staff names, such as little[OBSCENITY] and Big[OBSCENITY] and yelling and gesturing wildly as if to hit them. [He/she] quickly became upset and said that they keep telling [him/her] not to put weight on [his /her] foot and [he/she] isn't, I only put my toes down. [He/she] further stated, then let me go home and I will end this. [Resident] states [he/she] has a bottle of sleeping pills that only [he /she] knows the location of and if [he/she] has to go home without [his/her] foot or otherwise physically limited, [he /she] will end things. SW confirmed that the pills are at home .Charlie's demeanor is somewhat gruff, simple and black and white minded with a quick temper when triggered .] Review of admission Minimum Data Set (MDS) dated [DATE] indicated R72 has a Basic Interview for Mental Status (BIMS) of 15 of 15. Review of Section D: Mood indicated that R72 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble falling or staying asleep, or slept too much and felt tired or had little energy . During an interview on 7/12/22 at approximately 12:14 p.m. R72 indicated that he/she lives alone and is not able to walk right now. He/she refused to discuss his/her statements made to social services at this time. During an interview on 7/12/22 at 1:09 P.m., the Social Services Director (SSD) indicated that R72's social worker was not in the facility, but she was aware of R72's statements of self-harm. She further indicated that social services were responsible to create and update their own care plans. At this time SSD confirmed that R72 did not have goals and interventions in place for his/her psychosocial needs. Review of R72's signed Provider orders dated 6/24/22 revealed the following: Order with start date of 6/22/22 to apply wound vac to right foot cleanse wound then apply black foam dressing cover with drape tac if needed. Run at 125 mm/hg and change M-W-F [Monday-Wednesday-Friday] and as needed QD [daily] PRN [as needed]. Order with start date of 6/23/22 [MEDICATION(S)] HCL solution use 2000 mg intravenously. One time a day for [CONDITION(S)]. Order with start date of 6/22/22 for [MEDICATION(S)] HCL solution Reconstituted 2GM Use 2 gram intravenously every 123 hours for [CONDITION(S)] until 7/23/22. Review of R72's care plan initiated on 6/24/22 , most recently updated 6/27/22 does not include goals and interventions for mood and behavior, presence of a PICC line, IV antibiotic use, wound vac or therapy interventions. During an interview on 7/12/22 at 12:18 p.m. Certified Nursing Assistant (CNA)3 indicated that care she provides to the residents is charted on the kiosk and if an intervention is in place it should be on there and if there's anything new it should be reviewed during report. During an interview on 7/13/22 at 10:59 a.m., Registered Nurse (RN)4 indicated that the Unit Manager was responsible to complete baseline care plans upon admission, but they need to include goals and interventions for the resident's diagnoses. RN4 further indicated that the care plan is used to post to the CNA's task list. During an interview on 7/13/22 at 12:10 p.m. Registered Nurse (RN)5 indicated that baseline care plans were completed by the Unit Manager, but they should address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/13/22 at approximately 1:48 p.m., the surveyor confirmed the lack of a baseline care plan with the Director of Nursing.

Based on medical record review, review of facility policy, observation, and interviews, the facility failed to ensure a resident was clinically appropriate to self administer an inhaler on 3 of 3 survey days. (R65). Findings: Review of facility policy Self-Administration of Medications reviewed 8/21 states, .Specific orders for self-administration of medication by the resident must be written by the physician .An Assessment for Self-administration of Medications will be completed and signed by a licensed nurse and resident prior to initiation of self-administration . Medication Nurse shall record each shift, name of medication, number of times self-medicated on medication administration record. R65 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R65's signed medication orders with start date of 9/8/21 for [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for SOB/ wheezing. The order did not indicate that it was a self-administrated medication. Review of R65's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R65's clinical record lacked evidence that he/she was assessed to self-administrate an inhaler. During observations of R65 on 7/11/22 at 11:38 a.m., 7/12/22 at 10:35 a.m. and 2:15 p.m., and on 7/13/22 at 8:24 a.m. an [MEDICATION(S)] inhaler was noted on the top shelf of the residents three teared side table. During an interview on 7/13/22 at 12:10 p.m. Registered Nurse (RN)4 indicated that R65 has had his/her inhaler at bedside for a long time and just assumed that a self-administration assessment was done and that an order was needed for a resident to have medications at bedside. RN4 indicated that she does not ask the resident if he/she used the inhaler. During an interview on 7/13/22 at 1:25 p.m., 2nd floor Unit Manger (UM) confirmed that R65 does not have an order to self-administer his/her inhaler and a self -administration assessment was not completed. On 7/13/22 at approximately 1:49 p.m., the surveyor confirmed the above findings with the Director of Nursing.

Based on observations, record reviews and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment on 3 of 3 resident units and in the facility's laundry room. Findings: On 7/11/2022, at 12:20 p.m., during observation of laundry room, with the Director of Environmental Services (EVS) and an EVS worker; there was a light to moderate level of dust on most flat surfaces in the room. Observed very heavy level of dust on top of the top of all washing machines and dryers. Both employees stated that there is no cleaning schedule for the area, and there is no list of things to be done/cleaned. This was confirmed with the Director of Environmental Services at that time. On 7/13/2022, at 12:00 p.m., during tour of the facility with the Director of Environmental Services and the Administrator the following was observed and confirmed at the time of the tour: First Floor findings: Resident room 101 - 2 stained ceiling tile Resident room 112 - 1 stained ceiling tile Second Floor findings: Resident room 210 - Two (2) broken ceiling tiles Resident room 212 - Gouge in wallpaper near bathroom door down to sheetrock, creating an uncleanable surface Resident room 213 - Bathroom door and door frame have deep gouges and part of frame missing Third Floor findings: Resident room 301 - Bathroom door has deep gouges near base and rough to touch Resident room 318 - Stained ceiling tile

Based on interview and record review and policy review the facility failed to update/implement a care plan in the area of respiratory for 1 of 23 residents (R) reviewed for comprehensive care plans. (R65). Findings: Review of facility policy Care Planning revised 2/17 states, . Care, treatment, and services are planned to ensure that they are appropriate to the resident's needs, goals and preferences. Therefore, it is the policy of St. [NAME] Health Care Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, preferences, limitations, and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals with the resident that are reasonable and measurable .The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . R65 was originally admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R65's physical orders signed 7/12/22 revealed the following orders: Order with start date of 6/6/22 for [MEDICATION(S)] Aerosol Powder Breath Activated 100-25 MCG/INH ([MEDICATION(S)]-Vilanterol) 1 puff inhale orally one time a day for [CONDITION(S)]. Rinse mouth out after use. Order with start date of 6/6/22 for Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH ([MEDICATION(S)]) 1 puff inhale orally one time a day for [CONDITION(S)]. Rinse mouth after use. Order with start date of 9/8/21 for [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for SOB/ wheezing. Review of R65's care plan initiated on 11/24/20 and most recently updated on 6/15/22 lacked interventions to address R65's respiratory diagnosis. During an interview on 7/13/22 at 12:10 p.m. Registered Nurse (RN)5 indicated that care plans were updated by the Unit Manager and the Director of Nursing, but they should address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/13/22 at 1:25 p.m., 2nd floor Unit Manger (UM) confirmed that R65's care plan does not address interventions for [CONDITION(S)] and that she and the Minimum Data Set (MDS) nurse are responsible to update care plans. On 7/13/22 at approximately 1:48 p.m., the surveyor confirmed the lack of updating/implementing the careplan with the Director of Nursing.

Based on record review and interview, the facility failed to follow their Elopement/Missing Resident policy and procedure for 1 of 1 sampled resident's. (#1) Finding: The facilities Elopement/Missing Resident policy and procedure directs staff to assess the resident upon admission for their risk of elopement. Resident #1 was admitted to the facility on [DATE]. On 7/11/22 a surveyor reviewed Resident #1's clinical record. Resident #1's clinical record lacked evidence that an elopement assessment was completed upon admission. On 7/12/22 at 1:55 p.m., during an interview with the Director of Nursing (DON), the surveyor confirmed that an Elopement assessment was not completed.

Based on observations, interviews and policy review the facility failed to ensure foods were dated and labeled in, the reach in freezer, dry storage room and walk in freezer. In addition, the facility failed to discard outdated and obvious freezer burned food on 1 of 3 survey days. Findings: Review of provided Dining Services Storage Policy, undated states, Leftover food that is to be put in the freezer for use again must be used within 90 days of date it was put into the freezer. If an item is open from the freezer, you must label item with what it is and an open on date. Item will be used by the expiration date on package if there is no expiration date on the package item will need to be used within 90 days. Review of facility policy Receiving and Storing of Food and Supplies reviewed 2/18 states, .Unserved foods from previously prepared menus must be discarded after ninety-six (96) hours. Foods that may be frozen safely, such as meat, may be frozen, retained and used within 90 days . During an initial walk through of the kitchen on 7/11/22 at 9:17 a.m. the following was observed: Reach in freezer contained 1-1-quart plastic container covered with saran wrap with obvious freezer burn labeled canned pumpkin dated 2/20/22; and 1 -4-quart clear plastic container with plastic cover labeled canned pumpkin dated 3/20/22 with obvious freezer burn. 1-1-quart clear plastic container covered with saran wrap with obvious freezer burn labeled apples dated 5/27/22. 1 -6-quart clear plastic container with plastic lid with obvious freezer burn, labeled lemon cheesecake dated 4/10/22. 1 opened large plastic bag wrapped in saran wrap labeled cranberry opened and undated. 1 pastry bag with a white substance, wrapped in saran wrap unlabeled and undated. Dry storage room 1-1.9-quart plastic bottle of pure sesame oil, 1/4 remaining open and undated on shelf. Walk in freezer 1 large bag of waxed beans wrapped in saran wrap opened und undated. 1 large bag of pepperoni wrapped in saran wrap with obvious freezer burn undated. During an interview on 7/11/22 at 9:20 a.m. Operations Coordinator (OC) stated it was her understanding that there was a 30-day limit to keeping opened food in the refrigerator or freezer and that they do no label food when opened and use the manufactures date for expiation even when opened. During a follow up interview at 10:15 a.m., OC indicated that the facility uses serve safe guidelines for food storage and the facility also uses the state regulations. At this time OC confirmed above findings. The facility did not provide serve safe guidelines by the end of survey. During an interview on 7/12/22 at 11:12 a.m. Cook Supervisor (CS) indicated that all food should be dated and labeled with open date regardless if it is in storeroom, freezer, or refrigerator and food in refrigerator should be thrown away in 3 days, and food can be in the freezer for up to 90 days. She further indicated that food with obvious freezer burn should be thrown away. On 7/13/22 at approximately 1:28 p.m., the above was discussed with the Director of Nursing.

Based on interviews and observations the facility failed to ensure staff followed the Centers for Disease Control (CDC) recommendations for infection control practices regarding personal protective equipment (PPE) and hand hygiene practices and failed to handle linen in a manner to prevent the spread of infection on 1 of 3 units. (first floor) Findings: The Centers for Disease Control and Prevention's (CDC) Coronavirus Disease 2019 (COVID-19) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated November 4, 2020, stated the PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Facemask/Respirator, Eye Protection, Gloves, and Gowns. In addition, the most recently updated recommendations on 12/14/2020 states the following: Hand Hygiene: (HCP) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. A review of CDC recommendations for Health Care Associated Infections, Appendix D - Linen and Laundry Management, last reviewed 3/27/2020, recommended the following for Long-Term Care Facilities: Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. On 2/23/2021 at approximately 9:00 a.m., during an interview with the Director of Nursing, she stated the 1st floor is the 14-day quarantine unit for new admissions which require PPE's for droplet precautions. On 2/23/2021 at 2:20 p.m., observations of the following on the first floor, 14- day quarantine unit for new admission: 1. Housekeeper exiting room [ROOM NUMBER] a droplet precaution room with a gown and gloves on, placed the residents coffee cup on his housekeeping cart. He then stepped back to the doorway of room [ROOM NUMBER] and doffed his gown and gloves. Then took the coffee mug off his cart and brought it down the hall and placed it on to another cart. He then returned to his housekeeping cart and pushed it to the next room's doorway and started to don a new gown. No hand hygiene was preformed after leaving room [ROOM NUMBER], handling the resident's coffee cup or prior to gowning for the next room. 2. At approximately 2:23 p.m., observations of the Registered Nurse (RN) placing a medicine cup, containing medications, with a spoon and cup of water just inside doorway of room [ROOM NUMBER], a droplet precaution room. He then donned a gown, leaving it hanging down his chest only protecting his arms, entered the room and administered the medication, via a spoon, to the resident, without wearing gloves. He then exited the room doffing the gown and sanitized his hands. At this time, in an interviewed with the RN, he stated room [ROOM NUMBER] was on contact precautions and when he administers medication he stated, I just go in, I put a gown on sometimes. If it's direct care then gowns, gloves. When asked why he did not wear gloves while administering medications via a spoon to the resident he state, If I'm not touching anything, no. 3. At 2:27 p.m., observation of a Certified Nurse Aide (CNA) who was training a CNA, coming down the quarantine hallway. CNA had a balled up jonnie and bed sheets/blanket in her ungloved hand. At this time in an interview with the CNA she confirmed the linen was soiled stating, we rolled it up and gave her dry sheets. It's just a little damp and stated, I usually put it in a bag. On 2/23/2021 at 12:32 p.m., the above infection control concerns were discussed with the Director of Nursing.

Based on observations, interviews, and record review, the facility failed to ensure a care plan was updated to reflect the resident's current needs in the area of infection control for 1 of 18 sampled residents (#42). Finding: On 11/18/19 at 9:30 a.m., a surveyor observed the entrance to Resident #42's room was posted with signage instructing to stop and check with nurse before entering. The surveyor also observed personal protective equipment (PPE) hanging from the entrance door. On 11/18/19 at approximately 10:00 a.m., in an interview with the charge nurse, the surveyor asked if any residents were currently on infection control precautions. The charge nurse stated Resident #42 required contact precautions for VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]) in his/her urine. On 11/19/19 at 11:50 a.m., in an interview with a Certified Nurses Aide-Medications (CNA-M), the surveyor asked what type of precautions the resident requires. The staff stated he/she's on precautions to prevent him/her from getting an infection. On 11/19/19 at 11:55 a.m., in an interview with the charge nurse, the surveyor asked what type of precautions the resident requires. The charge nurse stated he/she is on reverse precautions because his/her blood levels are low and he/she [MEDICAL CONDITION]. It's to protect him/her. The surveyor asked if the resident has a history of VRE. The charge nurse stated he/she had VRE and we are treating him/her as if he/she is colonized. he/she has his/her own bathroom and we use universal precautions when we provide care for him/her. A review of Resident #42's clinical record revealed [DIAGNOSES REDACTED]. Nursing documentation dated 3/25/19, revealed a note which stated, call to New [MEDICAL CONDITION] Specialist - (Resident #42) will continue on Neutropenic Precautions indefinitely status [REDACTED]. Neutropenic precautions include gloves and mask upon entry into room unless providing personal care, at which time, gloves, gown and masks need to be worn. A review of the current care plan, last revised 10/28/19, and a review of the CNA Kardex, last revised 8/13/19, did not indicate Resident #42's requirement for reverse precautions. In addition, the care plan and Kardex did not indicate a [DIAGNOSES REDACTED]. On 11/19/19 at 12:15 p.m., in an interview with a surveyor, the Director of Nursing, confirmed Resident #42's care plan and CNA Kardex did not include the necessary information of the resident's need for reverse precautions, or that contact precautions were required when staff provide care to prevent transmission of VRE, a multidrug resistant organism.

Based on observations and interviews, the facility failed to ensure the resident environment remained free of accident hazards as is possible related to hot water temperatures over 120 degrees Fahrenheit in resident rooms on 2 of 3 floors on 1 of 3 survey days. Finding: On 1/7/19 at 9:11 a.m., a surveyor observed a water temperature of 120.9 degrees Fahrenheit in room [ROOM NUMBER], posing a burn risk to the resident. A surveyor also observed elevated hot water temperatures on 1/7/19 at 11:45 a.m. on the first floor, including the following Resident rooms: room [ROOM NUMBER] at 122.3 degrees Fahrenheit, room [ROOM NUMBER] at 122.2 degrees Fahrenheit and room [ROOM NUMBER] at 122.4 degrees Fahrenheit. On 1/7/19 at 12:24 p.m., in an interview with the Acting Director of Nursing, he/she confirmed there had been no burn incidences by hot water in the past 3 months. On 1/7/19 at 12:37 p.m., the surveyor and Food Services Director, who was filling in for the Director of Environmental Services, together observed Resident room [ROOM NUMBER] with a water temperature of 121.9 degrees Fahrenheit. On 1/7/19 at 2:15 p.m., in an interview with maintenance personnel, he/she stated the mixing valve was stuck and a plumber is on the way to the facility. On 1/7/19 at 3:00 p.m., the survey team leader confirmed the finding in an interview with Administrator.

Based on record review and interview, the facility failed to monitor and document targeted behaviors to support the use of an antipsychotic and antianxiety medication for 1 of 5 residents reviewed for unnecessary medications (Resident #72). Finding: Resident #72's clinical record contained a physician's orders [REDACTED]. Additionally, on review of Resident #72's clinical record, the surveyor noted an order, dated 12/13/18, for [MEDICATION NAME] (an anti-anxiety medication) for anxiety. A review of Resident #72's clinical record revealed the facility was monitoring daily for the targeted behavior of [MEDICAL CONDITION], but there was no evidence of monitoring for behaviors associated with [MEDICAL CONDITION] or anxiety. In an interview with the Interim Director of Nursing, on 1/08/19 at 2:34 p.m., the surveyor confirmed that Resident #72 was not monitored for side effects or the presence of behaviors related to use of an anti-anxiety and antipsychotic medication.

Based on observations and interviews, the facility failed to ensure the resident environment was clean and homelike on 3 of 3 resident floors. On 1/9/19 at 9:15 a.m., during tour of the facility, the surveyor and Director of Environmental Services observed the following findings: -Resident room [ROOM NUMBER] had long tears and worn areas in wall paper approximately 2 feet in length from bed along wall. -Resident room [ROOM NUMBER] had worn wall paper and gouged sheet rock approximately 1 foot in length from bed along wall. -Resident room [ROOM NUMBER] had 2 wood closet doors that were marred and a soiled/stained privacy curtain. -Resident room [ROOM NUMBER] had sheet rock in disrepair behind the toilet in the bathroom and floor edges were duct taped between the doorway threshold from the bathroom into the Resident's room. -Resident room [ROOM NUMBER] had marred walls and chipped paint on the left wall as you enter the room. -Resident room [ROOM NUMBER] had marred walls and chipped paint on the wall as you enter the room. -Resident dining area on the 3rd floor had a table missing laminate extending approximately 3 feet along the side of the table. -Ground floor bathroom used by residents has a mold like substance behind the toilet and a wall in disrepair under the soap dispenser. On 1/9/19, during tour of the facility, the surveyor confirmed the above findings in an interview with the Director of Environmental Services.

Based on interview, record review, and policy review, the facility failed to adequately store and reconcile a controlled substance ([MEDICATION NAME]) for 1 of 1 facility reported incidents reviewed. Finding: On 5/17/18 at 1:32 p.m. the Division of Licensing & Certification received a faxed reportable incident form from St. Andre's Healthcare indicating missing medication with the date of the incident noted as 5/4/18. On 6/13/18 from 9:45 a.m. through 2:15 p.m. an on-site investigation was conducted by 2 surveyors with the following reviewed: A review of the facility investigation record reveals the Registered Nurse who received the two [MEDICATION NAME] pills from the pharmacy placed them into the locked narcotic box inside one of the medication carts, however; this was to be temporary until the pills could be loaded into the automated medication dispensing system (pyxis), which requires two nurses to load controlled substances. Additionally, the nurse did not log the two [MEDICATION NAME] pills in the bound book for reconciliation count. As a result of the medication not being loaded into the automated medication dispensing system or logged into the bound book for reconciliation it was not noted by nursing staff that the medication was missing until the pharmacy alerted the facility. The facility conducted a full investigation, to include obtaining written statements from any potential staff involved, and reporting the incident to local law enforcement. The whereabouts of the missing [MEDICATION NAME] could not be determined. A review of the written statement of the receiving Registered Nurse dated 5/15/18 indicated that on (MONTH) 3, (YEAR) he/she received from pharmacy personnel narcotic medications of 2 pills of [MEDICATION NAME] sealed in a plastic bag, which he/she placed in the locked narcotic box since he/she cannot enter the Scheduled II medication into pyxis system by him/herself, and further indicates that on (MONTH) 7th a called was received by the Omnicare Pharmacist because 2 [MEDICATION NAME] were missing. Review of the facility's policy titled Controlled Substances - Handling with a revised date of 5/16/16 notes on page 1 that controlled medications will be subject to special receipt, record-keeping, medication assistance, and frequent count verification, storage and disposal procedures. On 6/13/18 at 10:15 a.m. in an interview with the Director of Nursing, the surveyors confirmed that the receiving nurse placed the 2 [MEDICATION NAME] pills inside the narcotic lock box in one of the medication carts but did not log the 2 pills into the Bound Book resulting in the 2 loose medications being in the lock box for several days without notice that they were missing. In addition, in an interview with the Administrator, the surveyors confirmed that the automated medication dispensing system requires 2 licensed nurses to enter Schedule II medications into the system.

Based on observations and interviews, the facility failed to ensure containers of liquids were dated when opened and not used beyond discard dates as indicated on containers per manufacture specifications; and failed to ensure that containers were removed from the refrigerators and unavailable for resident use. In 5 of 5 refrigerators on 1 of 3 days of survey. Finding: On 1/24/18 at 10:30 a.m.during a check of refrigerators located on the three floors of the facility, two surveyors observed the following. The first-floor dining room, the refrigerator contained: One (1) opened(NAME)Thickened water container with discard if not used within seven (7) days of opening on the container. There was no open date noted on the container. Two (2) opened Hormel thick and easy Orange juice containers with discard if not used within ten (10) days. There was no open date noted on the containers. Two (2) opened Hormel thick and easy Apple juice containers with discard if not used within ten (10) days. There was no open date noted on the containers. The second-floor dining room, the refrigerator contained: One (1) opened(NAME)Thickened lemon flavored water container with must be used within seven (7) days of opening. There was no open date noted on the container. The second-floor kitchenette, the refrigerator contained: One (1) opened(NAME)thickened lemon flavored water container with must be used within seven (7) days of opening. There was no open date noted on the container. The third-floor dining room, the refrigerator contained: One (1) opened Hormel thick and easy clear water container with discard if not used within ten (10) days of opening. There was no open date noted on the container. Two (2) opened Hormel thick and easy clear thickened cranberry juice containers with discard if not used within ten (10) days of opening. There were no open dates noted on the containers. One (1) opened [MEDICATION NAME] milk container with consume within seven (7) days. There was no open date noted on the container. The third-floor kitchenette, the refrigerator contained: One (1) Thick and Easy clear thickened Apple juice opened with discard if not used within 10 days of opening on the container. There was no open date noted on the container. One (1) Thick and Easy clear thickened Orange Juice opened with discard if not used within 10 days of opening on the container. There was no open date noted on the container. One (1) Thick and Easy Clear Cranberry juice opened with discard if not used within 10 days of opening on the container. There was no open date noted on the container. On 1/24/18 at 11:00 a.m., The Food Service Director was notified and confirmed the containers were all opened and did not contain an open date on any of the containers. The Food Service Director then removed all unlabeled containers on all three floors and labeled the new containers with open dates. The Food Service Director provided education to all dietary and nursing staff and provided a copy to the Surveyor.

Based on observations and interviews, the facility failed to maintain a sanitary environment related to the use of urine collection devices during 2 of 3 survey days. Finding: -On 1/23/18 at 6:28 a.m., a surveyor observed in a shared bathroom between rooms [ROOM NUMBERS], 2 soiled urinals labeled with Resident #17 and #58 names and a urine collection device (catheter bag) hanging on the hand rail with no identification on catheter bag with a cap on the tubing and visible sediment in tubing. At this time the Licensed Practical Nurse (LPN) confirmed both Residents #17 and #58 have an indwelling catheter and use catheter bags. -On 1/24/18 at 8:52 a.m., a surveyor observed in a shared bathroom between rooms [ROOM NUMBERS], a catheter bag capped and hanging on the hand rail beside the toilet next to 2 urinals. On 1/24/17 at 9:35 a.m., in an interview with a Certified Nurses Aide (CNA), he/she confirmed that only Resident #17's catheter bag is changed over to a leg bag during the day. The catheter is drained, recapped and hung on the hand rail in the bathroom. He/she also confirmed there was no identification on the catheter bag, however Resident #17 is the only resident whose catheter bag is changed over to leg bag during the day. He/she then labeled the catheter bag with Resident #17's name. On 1/25/18 at 8:00 a.m., in an interview with a surveyor, the Director of Nurses (DON) stated that the proper procedure of changing a catheter bag to a leg bag consists of rinsing out the catheter bag, capping it and placing it in a clean plastic bag then store it in the residents room. At this time the DON confirmed the above observations did not support good infection control practice.

Based on record review and interviews, the facility failed to ensure 1 of 18 sampled residents was free of a significant medication error (#51). Finding: On 1/23/18, during record review, Resident #51 who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The Nurse Manager stated the medication did not properly carry forward in the electronic system, therefore information did not translate properly to the Medication Administration Record [REDACTED].

Based on observations and interview, the facility failed to ensure that chemicals were properly secured in the shower room chemical storage closet on 1 of 3 units on 1 of 2 days of survey. Finding: 5/9/2017 at 1:35 p.m., a surveyor observed the chemical storage closet in the main shower room on the 3rd floor to be closed, but unlocked. There was a sign on the door that indicated the closet contained chemicals and should be kept closed and locked at all times. After securing the door, the surveyor notified the charge nurse who observed and confirmed the chemicals in the chemical closet to contain: -One (1) bottle of Comet Bathroom Cleaning Solution, approximately ¼ of the solution remained in the bottle, and with a caution statement on the back. -One (1) bottle of Air Lift chemical, approximately 2/3 of the solution remained in the bottle, with a caution statement on the back label stating eye and skin irritation. Review of the Material Safety Data Sheets (MSDS) for the Comet Disinfecting Sanitizing Bathroom Cleaner-Ready solution indicated the solution causes eye irritation and is harmful if swallowed. Review of the Material Safety Data Sheets (MSDS) for the Air Lift Fresh Scent, an air freshener, indicated the solution may be harmful if swallowed, may cause eye/skin irritation, and to keep it out of the reach of children. On 5/9/17, at 2:00 p.m., the finding was confirmed in an interview with the Administrator.