Every finding on record at St John's Health Sage Living

Based on observation, staff interview, review of the dishwasher manufacturer's instructions, and facility policy and procedure review, the facility failed to monitor and record the internal temperature of foods and failed to ensure a sanitary environment in 1 of 1 kitchen. The census was 47. The findings were: 1. Regarding recording food temperatures in the food preparation area: a. Observation on 5/7/25 starting at 9:51 AM showed cook #1 took the temperature of mashed potatoes, and did not log the temperature before he placed the food into the holding cart. He then removed the mixed vegetables and split pea soup he had previously cooked out of the holding oven, covered with plastic wrap and foil, labeled with the date, and placed them into the holding cart to be taken to the dining rooms without obtaining the temperature of the food prior to lunch service. b. Interview on 5/7/25 at 10:21 AM with cook #1 revealed he checked the temperature of each dish after he cooked it, but he did not keep a temperature log, and stated we should do that but we don't. Further interview revealed he expected the temperatures of the meats to be from 165 to 167 degrees Fahrenheit (F), and vegetables from 152 to 154 degrees F. c. Interview on 5/7/25 at 10:49 with the CDM confirmed he did not require the staff to keep a log of food temperatures because he was unsure if it would be accurate. Further interview revealed he would do what you want us to do. d. Review of the 12/20/2023 facility policy titled Food Preparation provided by the facility administration on 5/8/25 showed .K. Metal-stem, numerically scaled indicating thermometers, accurate to +2 degrees F are provided and used to ensure proper temperatures of potentially hazardous foods. e. According to Food Code 2022, U.S. Public Health Service . Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the regulator in determining that monitoring and corrective actions have taken place . 2. Regarding temperature logs of the dishwasher: a. Observation on 5/7/25 starting at 9:54 AM showed the facility used a [NAME] AM 15 chemical sanitizing dish machine. Review of the dishwashing machine's manufacturer's instructions showed the minimum temperature of the wash and rinse water was 120 degrees F, with a recommended temperature of 140 degrees F. b. Interview on 5/7/25 at 10:36 AM with cook #1 revealed the staff did not keep a temperature log of the dishwasher or check sanitizer level in the dishwasher or 3-compartment sink, and he stated we should do that. Further interview revealed the temperature of the dish machine should be at least 120 degrees F. c. Interview on 5/7/25 at 10:49 AM with the CDM revealed that the dishwasher chemically sanitized the dishes, and the staff did not need to monitor it, because Ecolab monitored the equipment and dishwasher sanitizer levels once a month and made any adjustments needed. Further interview revealed he would do what you want us to do. d. Interview on 5/8/25 at 10:15 AM with the CDM revealed he was unable to locate the records from Ecolab due to failed communication with them after an employee quit and changed the email without letting the dietary manager know of the change. e. Review of the 8/9/23 facility policy titled Warewashing provided by the administrator on 5/8/25 showed .C. The dish machine temperature and the sanitizer levels will be monitored to assure they maintain the correct temperature and levels. The dish machine shall maintain a temperature of 120 degrees and the sanitizer approximately 50 ppm.G. The dish washers will record the sanitizer levels at least daily to assure accuracy. These records will be kept on file for a minimum of three years. H. Any noted discrepancies are to be brought to the attention of the Food Service Manager or charge person immediately. I. The dish machine will be inspected monthly to assure proper function. These inspection forms will also be kept on file for three years.J. In the advent of any mal functioning [sic], proper steps will be taken to assure the adequacy of sanitation of service ware. f. According to the FDA 20220 Food Code showed 4-703.11 Hot Water and Chemical, Efficacious sanitization depends on warewashing being conducted within certain parameters. Time is a parameter applicable to both chemical and hot water sanitization. The time hot water or chemicals contact utensils or food-contact surfaces must be sufficient to destroy pathogens that may remain on surfaces after cleaning. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization. When surface temperatures of utensils passing through warewashing machines using hot water for sanitizing do not reach the required 71ºC (160ºF), it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in §§ 4-501.112 and 4-501.113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces.

Based on facility incident review, staff interview, resident representative interview, and policy and procedure review, the facility failed to ensure residents were free from misappropriation or exploitation for 1 of 3 sample residents (#16) reviewed for allegations of misappropriation. The findings were: 1. Review of the facility incident report showed resident #16 reported on 1/22/25 s/he was missing four checks and $2,000 from his/her bank account. The resident's POA sent images of the cashed checks to the administrator. The checks had phone numbers written in the endorsement area, which the administrator checked against employee records. One of the phone numbers matched a hospital employee who sometimes worked in the facility. The administrator then contacted law enforcement who interviewed and arrested the employee. The hospital terminated the employee. The facility notified all residents and their representatives of the incident and employee's termination via a letter dated 1/24/25. Further review showed no evidence the missing money was returned to the resident. 2. Interview with the facility administrator on 5/7/25 at 3:33 PM confirmed resident #16 reported that s/he was missing some checks on 1/22/25. The administrator investigated the situation and determined that the phone number on some of the checks matched an employee. He revealed he contacted law enforcement and the employee was arrested. He revealed the employee was terminated at that time. The administrator advised resident #16 to keep his/her checkbook in the safe in the resident's room going forward. Interview with administrator on 5/8/25 at 10:07 AM revealed the facility's investigation did not identify any shortcomings on their part, and there was no process improvement plan put in place related to the incident. 3. Interview with resident #16's representative on 5/7/25 at 2:31 PM revealed s/he discovered four $500 checks that had been cashed from the resident's account that s/he did not recognize. S/he revealed s/he called the resident who then discovered that four checks were missing from his/her checkbook. S/he revealed the resident notified the facility administrator who contacted the police. The POA stated, Luckily, I caught it quickly and revealed the theft did not affect the resident's ability to get anything s/he needed. 4. Review of the facility policy titled Residents free from abuse/neglect provided by the facility administrator on 5/7/25 showed .[Resident rights] include freedom from abuse and protection from misappropriation of property. If a resident has been mistreated, we will investigate promptly and report all suspected violations to the proper authorities and Each resident has access to a secure safe inside or connected to their bedroom .

Based on medical record review, staff interview, and review of facility policies and CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 2 of 5 sample residents (#2, #21) reviewed for immunizations. The findings were: 1. Review of the medical record showed resident #2 was [AGE] years old. Further review showed the resident received the following pneumococcal vaccines: pneumococcal 23 polyvalent on 10/18/06 and pneumococcal 13 valent conjugate on 9/24/15. There lacked evidence the resident was offered a pneumococcal immunization since the last administration in 2015. 2. Review of the medical record showed resident #21 was [AGE] years old. Further review showed the resident received the following pneumococcal vaccines: Pneumovax 23 on 9/28/12 and Prevnar 13 on 2/25/15. There lacked evidence the resident was offered a pneumococcal immunization since the last administration in 2015. 3. During an interview on 2/8/24 at 9:57 AM the DON stated the facility followed CDC recommendations for immunizations and confirmed there was no evidence residents #2 or #21 were offered pneumococcal immunizations in accordance with CDC recommendations. 4. Review of the facility's policy Influenza & Pneumococcal Immunization, approved 9/22/21, showed .Eligible residents and patients will be offered the opportunity to receive the vaccines as per CDC guidelines and .The Sage Living will follow the CDC standard for pneumococcal vaccination of adults which includes both the pneumococcal conjugate vaccine (Prevnar-13, PCV13) and the pneumococcal polysaccharide vaccine (Pneumovax 23, PPSV23). 5. Review of Adult Immunization Schedule by Age by CDC located at https://www.cdc.gov/vaccines/schedules/hcp/adult.html (accessed 2/8/24) showed individuals [AGE] years or older who previously received both PCV13 and PPSV23, and the PPSV23 was received at age [AGE] years or older, should receive one dose of PCV20 at least 5 years after the pneumococcal vaccine dose.

Based on observation, staff interview, and review of facility policies and the 2022 Food Code, the facility failed to ensure hand hygiene and gloving was done in accordance with accepted standards to minimize cross contamination during 1 of 1 observations of meal preparation in the kitchen. The findings were: 1. Observation in the kitchen on 1/11/23 from 3:45 PM until 4:22 PM showed cook #1 was preparing food for the evening meal. The cook wore the same pair of gloves for the duration of the observation (no hand hygiene or changing of gloves). During the observation, the cook was observed to touch potentially contaminated surfaces, such as a cardboard box, the handles of the refrigerator, the handles of the fryer baskets and handles to drawers with his gloved hands. Then the cook used his hands, with the same gloves on, to hold down cooked breaded chicken breasts while he cut them in half with a knife. He then used the same gloved hands to put the chicken in pans on the steam table. 2. During an interview on 1/12/23 at 8:59 AM the dietary manager stated cook #1 was a newer employee. He stated staff were instructed to wash their hands frequently during meal preparation and they followed any state guidelines regarding gloves and hand hygiene. He confirmed cook #1 should have removed the gloves and performed hand hygiene after touching potentially contaminated surfaces. 3. Review of the facility's policy Maintenance of Sanitation and Infection Control (approved 10/1/2020) showed .The manager is responsible for supervising sanitation, housecleaning procedures and personnel in such a manner to create and maintain an environment that is safe for the storage, preparation and serving of food and which meets the standards established by federal, state and local regulations .The Food Service department is inspected annually by the CMS to assure compliance with US FDA Food Code and federal OBRA regulations. 4. Review of the 2022 Food Code by the U.S. Food and Drug Administration showed 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .(H) Before donning gloves to initiation a task that involves working with food; and (I) After engaging in other activities that contaminate the hands.

Based on observation, staff interview and review of facility policies, the facility failed to ensure medications were kept secure for 1 of 3 medication carts. The findings were: 1. Observation of the medication cart used for Paintbrush Place on 1/9/23 at 6 PM showed the medication cart was located in the hall with one of the drawers open approximately three inches. There were no staff in the area. There was a resident ambulating with a walker in the hall near the cart. 2. An interview with the Director of Nursing (DON) on 1/12/23 at 9:29 AM revealed the expectation of the facility was the medication cart would not be unlocked unless the nurse was in the immediate vicinity. The drawer being left open was not an acceptable condition. 3. Review of the facility policy titled Medication Management - Storage & Security dated 11/28/22 showed Medication carts must be locked or stored in a manner that prevents unauthorized access (i.e. directly supervised/monitored by authorized personnel with legal access to the medications) when not in use.

Based on observation, staff interview, and review of the Food Code, the facility failed to ensure staff preparing and assembling food wore hair restraints during 1 of 2 meals observed, in 2 of the 3 units (Wildflower Way and Larkspur Lane). The findings were: 1. Observation on 10/19/21 at 8:20 AM in Larkspur Lane revealed RN #2 was at the steam table in the dining room dishing up food for residents #21 and #24. The RN was not wearing a hair restraint. 2. Observation on 10/19/21 at 9:28 AM in Wildflower Way revealed RN #3 was at the steam table in the dining room dishing up food for resident #1. The RN was not wearing a hair restraint. 3. During an interview on 10/20/21 at 2 PM the certified dietary manager (CDM) stated nursing staff helped serve food from the steam tables when there wasn't enough dietary staff to do that. He stated he had not discussed with nursing staff the need to wear hair restraints because he had not thought of that. 4. Review of the Food Code, 2017, by the U.S. Food and Drug Administration, showed .(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (B) This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal risk of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on medical record review and staff interview, the facility failed to ensure 2 of 5 sample residents (#19, #20) reviewed were free from unnecessary medications. The findings were: 1. Review of the 8/5/21 quarterly MDS assessment showed resident #19 admitted to the facility on [DATE] with diagnoses that included depression and [CONDITION(S)]. Review of the current physician orders showed a 9/9/21 order for 0.25 mg of [MEDICATION(S)] (an anti-anxiety medication) to be administered BID [twice daily] for 90 days, PRN [as needed] anxiety, with a stop date of 12/8/21. This order was documented as reviewed by both an RN and pharmacy on 9/9/21. The following concerns were identified: a. Review of the medical record showed no documentation justifying the PRN medication order extending beyond the 14-day time limitation period. b. Review of the 9/28/21 monthly medication regimen review showed documentation by the pharmacist noting No irregularities noted at review. c. Interview with FNP #1 on 10/20/21 at 11:36 AM revealed she was unaware she needed documentation supporting the order, and confirmed there was no documentation supporting the 90-day order. She further confirmed the order should have been limited to 14 days, and then re-evaluated. 2. Review of the 8/5/21 quarterly MDS assessment showed resident #20 had diagnoses including dementia and anxiety disorder. Review of the October 2021 medication administration record (MAR) showed the resident received [MEDICATION(S)] (anti-anxiety medication) 0.5 mg on 10/3 and 10/12. The following concerns were identified: a. Review of medication orders showed on 1/6/21 [MEDICATION(S)] 0.5 mg was ordered everyday PRN (as needed) for anxiety. The order was not limited to 14 days. b. Review of the medical record showed no rationale for extending the PRN order beyond 14 days by the prescribing practitioner. c. During an interview on 10/21/21 at 9:13 AM FNP #1 confirmed the PRN [MEDICATION(S)] order on 1/6/21 did not have a stop date, and there was no rationale for extending the PRN order beyond 14 days documented. She stated there were some progress notes from the physician that she found, but they weren't dated until 6/29/21, 8/24/21, and 10/19/21. d. Review of the physician progress notes dated 6/29/21, 8/24/21 and 10/19/21 showed they mentioned hallucinations and stated the resident was stable on his/her current medication regimen, but there was nothing specific to the PRN [MEDICATION(S)].

Based on medical record review, staff interview, and review of facility protocols, the facility failed to ensure interventions were implemented to prevent constipation for 1 of 1 sample resident (#30) reviewed for constipation. The findings were: 1. Review of the 8/31/21 significant change MDS assessment showed resident #30 scored a 3 out of 15 on the brief interview for mental status (BIMS) (indicated severe cognitive impairment), required supervision for toilet use, was always continent of bowel, and did not have constipation. Review of a 9/15/21 bowel and bladder note showed the resident was continent of bowel and .bowels regular with only PRN [as needed] use of senna and MOM [milk of magnesia- a [MEDICATION(S)]]. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of bowel movement (BM) documentation from 9/1/21 through 10/19/21 showed only nine documented bowel movements for the residents during that timeframe on the following dates: 9/10, 9/11, 9/15, 9/20, 9/24, 10/2, 10/16, and 10/18. b. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Review of nursing notes showed on 10/6/21 the resident .required disimpaction. The note showed the resident had passed some of the stool, but was not able to push it all out. The nurse stated he was going to ask the nurse practitioner for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the BM documentation and MAR for October 2021 showed the resident's last BM was on 10/2 (3 days with no BM) and no PRN medications for constipation were given. d. Review of nursing notes showed a note dated 10/16/21 which read .[resident] has pattern of not being able to push some of [his/her] BMs out. [His/Her] muscles down there are not able to receive or follow directions from [his/her] brain. Senekot twice a day at least is needed for the short term. will ask NP [nurse practitioner] for order. Review of nursing notes showed on 10/6/21 the nurse disimpacted stool from the resident, so that was the date of the last documented BM. Review of the MAR for October 2021 showed no PRN medications for constipation were given during that timeframe. e. During an interview on 10/20/21 at 2:30 PM, RN #1, who wrote the progress notes on 10/6/21 and 10/16/21, stated the constipation with the resident was new. He stated the resident might have had some episodes before, but requiring disimpaction twice in one month was different. He stated the resident was recently started on routine medications for constipation. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated staff assisted the resident to the bathroom about 75% of the time, but s/he did sometimes go the bathroom independently. He also stated the facility did have a bowel protocol to manage constipation. f. Review of the facility's LTC Bowel Protocol (updated 11/4/17) showed .If a resident has not had at least a moderate-large BM by the 2nd day after the previous moderate-large BM, the nurse will administer Milk of Magnesia 30 ml po [by mouth] per routine orders. If this if not effective by the 3rd day, the nurse may also administer a [MEDICATION(S)] suppository per rectum per routine orders. If no BM by the 4th day, the nurse may also administer Fleets saline rectal enema. The nurse will follow-up with physician as necessary . g. During an interview on 10/21/21 at 8:52 AM the DON stated her expectation was that the bowel program should be followed. She stated if a resident refused medication for constipation, then the resident should be educated and it should be documented.

Based on review of facility documentation and staff interview, the facility failed to provide the required forms for 1 of 1 sample resident (#30) who was discharged from Medicare part A in the past six months with benefit days remaining. The findings were: 1. Review of the SNF Beneficiary Protection Notification Review form completed by the facility showed resident #30 started Medicare Part A on 5/26/21. The form indicated the last day of covered Medicare Part A services was on 6/23/21. Further review of the form showed the NOMNC [Notice to Medicare Provider Non-Coverage] ( Form CMS ) was provided, and a copy of the notice was attached. However, there was no copy of the SNF ABN [Skilled Nursing Facility Advanced Beneficiary Notice] (Form CMS ). A handwritten note on the review form indicated the SNF ABN was not provided because not aware was needed in this scenario. 2. During an interview on 10/20/21 at 2:11 PM the DON confirmed that the SNF ABN form should have been issued for this resident. She stated she had not realized it was needed.

Based on medical record review, staff interview, and review of facility documentation, the facility failed to ensure neurological assessments were completed as required for 1 of 4 residents (#1) reviewed for falls. The findings were: 1. Review of the 4/22/21 quarterly Minimum Data Set (MDS) assessment showed resident #1 had two or more falls with injury since the last assessment. Review of the 4/22/21 Morse Fall Scale showed a score of 75, which indicated the resident was at high risk for falls. 2. During an interview on 6/17/21 at 3:45 PM the director of nursing (DON) stated the facility's policy on neurological assessments was not included in their policy for falls, but provided the surveyor with a typed sheet of paper. Review of the documentation showed POLICY- If suspected head injury, chart VS [vital signs] and neuro assessment q [every] 6 hours x 24 hours, then q shift x 48 hours. 3. Review of a nursing note dated 6/4/21 showed the resident was found on the floor at 9 AM. The resident stated s/he hit his/her head. Review of neurological assessments in the electronic medical record showed neurological assessments were not completed as required. On 6/18/21 at 9:26 AM the DON provided the surveyor with additional documentation from the medical record pertaining to the 6/4/21 fall. Interview at that time with the DON revealed after looking at all of the documentation, there were four times when neurological assessments should have been completed, but were not documented. She stated the missing neurological assessments were on 6/4/21 at 7:30 PM, 6/5/21 at 7:30 AM, 6/6/21 on the night shift, and 6/7/21 on the day shift. 4. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated s/he bumped his/her head. Review of neurological assessments in the electronic medical record showed neurological assessments were not completed as required. On 6/18/21 at 9:26 AM the DON provided the surveyor with additional documentation from the medical record pertaining to the 6/14/21 fall. Interview at that time with the DON revealed after looking at all of the documentation, there were four times when neurological assessments were missing or were late. She stated the 6/15/21 2:45 PM assessment was late, and not completed until 4 PM. She stated the missing neurological assessments were on 6/15/21 at 8:45 AM, 6/16/21 on the day shift, and 6/17/21 on the night shift.

Based on medical record review and staff interview, the facility failed to ensure the discharge summary contained all required items for 1 of 1 sample residents (#46) who was discharged . The findings were: Review of the physician's discharge summary showed resident #46 was discharged home on[DATE]. The physician's discharge summary included a recapitulation of the resident's stay, but did not include a final summary of the resident's status as required. Review of the Your Discharge Plan of Care/Instructions form dated 8/16/18 showed it did not contain a final summary of the resident's status as required. There lacked information on: cognition, communication, vision, mood/behavior patterns, continence, physical functioning, dental status, skin condition, and activity pursuit. During an interview on 10/31/18 at 2:34 PM the DON stated the facility was using the Your Discharge Plan of Care/Instructions form for the discharge summary and confirmed it did not contain all the required information for the final summary of the resident's status.

Based on observation, staff interview, and review of manufacturer's instructions, the facility failed to ensure medications available for use were not expired in 1 of 3 medication carts (Team 1 medication cart). The findings were: 1. Observation during medication pass on [DATE] at 9:15 AM showed one opened Basaglar insulin [MEDICATION NAME] injection pen with no written open date. Interview at that time with RN #1 confirmed there was no written open date, and the medication was available for use. 2. Interview with the DON on [DATE] 9:24 AM confirmed the facility expectation would be to label the insulin pen with the 28 day expiration. 3. Review of manufacturer's instruction found at www.basaglar.com/using-basaglar/insulin-storage-expiration (retrieved [DATE]) showed open Basaglar insulin [MEDICATION NAME] injection pens could be used for up to 28 days.

Based on medical record review, staff interview, and review of facility protocols, the facility failed to ensure the bowel protocol was followed for 2 of 12 sample residents (#20, #45). The findings were: 1. Review of the facility's Bowel Protocol (updated 6/11) showed: If a resident has not had at least a moderate-large BM (bowel movement) by the 2nd day after the previous BM, the nurse will administer an oral laxative per routine or individual orders. If this is not effective by the 3rd day, the nurse will administer a [MEDICATION NAME] suppository per routine orders. Further administration of a [MEDICATION NAME] suppository or Fleets enema per routine orders will be done as needed, with follow-up with individual physician orders [REDACTED]. 2. Review of the bowel assessment for resident #45 showed a note dated 9/11/17 which indicated [MEDICATION NAME] was changed from administration every other day to every day due to constipation. Review of physician's orders [REDACTED]. If no BM by 3rd day, may also give [MEDICATION NAME] 10 mg suppository per rectum daily PRN. If no BM by 4th day, may also give Fleets saline enema per rectum daily PRN. The following concerns were identified: a. Review of the Nurse Assistant Care Record for September 2017 showed no documented bowel movements on 9/15/17, 9/16/17, or 9/17/17. Review of the MAR for that timeframe showed no PRN medications were given to treat the constipation. b. Review of the Nurse Assistant Care Record for October 2017 showed no documented bowel movements on 10/1/17, 10/2/17, or 10/3/17. Review of the MAR for that timeframe showed no PRN medications were given for constipation. 3. Review of the care plan for resident #20 showed potential constipation was initiated on 8/4/14. Review of routine orders (signed 7/18/16) showed Constipation: on 2nd day after last BM give Milk of Magnesia 30 ml everyday PRN (as needed). If no BM by 3rd day, may also give [MEDICATION NAME] 10 mg suppository per rectum daily PRN. If no BM by 4th day, may also give Fleets saline enema per rectum daily PRN. Review of the Nurse Assistant Care Record for October 2017 showed no documented bowel movements on 10/6/17, 10/7/17 or 10/8/17. Review of the MAR for that timeframe showed no PRN medications were given for constipation. 4. During an interview on 10/12/17 at 8:16 AM the DON stated the bowel protocol had not been followed for residents #20 and #45.

Based on observation and staff interview, the facility failed to ensure items did not remain available for use after expiration in 2 of 3 observed storage areas (spice rack, baker's area) of the kitchen. Further, the facility failed to ensure machinery was clean and sanitary in 1 of 2 areas (baker's area) used to cook food items. In addition, the facility failed to ensure cleanable surfaces in 3 of 4 food preparation areas. The findings were: 1. Observation of the baker's area on 7/20/15 at 7:32 PM showed there were muffins, bread, and nuts that were stored on a shelf and had no dates to determine when the items were prepared or when they should be taken out of use. Further observation at that time showed a cabinet that contained marshmallows, flax seed, and powdered sugar that did not have an expiration date on the storage packaging. The cabinet also contained, gel paste dated 7/03, Kroger color cones that were best if used by 7/16/13, and premium carnival sprinkles dated 10/11/12. 2. Observation of the spice rack on 7/20/15 at 7:40 PM showed a bottle of fennel seed was undated and a second bottle of fennel seed was dated 5/22/11. 3. Observation of the baker's area on 7/20/15 at 7:32 PM showed there were 3 ovens that had bowls and mixing utensils stored on top of them. Further observation showed all the items, including the tops of the ovens were dirty with grease and visible dust. 4. Interview with the dietary manager on 7/22/15 at 4:45 PM confirmed the items were expired and should not have been available for use. Further interview confirmed the ovens and the items stored on top of them should have been cleaned. 5. Observation of the central dining room on 7/23/15 at 9:50 AM showed the countertop had a chip that measured 3 inches by 1/2 inch that exposed the underlying wood resulting in an uncleanable surface. Further observation at this time showed the top drawer had a damaged corner that measured 1 1/2 inches by 1/2 inch that exposed the underlying wood, resulting in an uncleanable surface. 6. Observation of the nourishment room on 7/23/15 at 9:53 AM showed the countertop had a chip that measured 4 1/2 inches by 1/2 inch on the corner that exposed the underlying wood, resulting in an uncleanable surface. 7. Observation of the kitchen on 7/20/15 at 7:32 AM showed the sink counter in the baker's area had a chip on the front that measured 16 inches by 1/2 inch that exposed the underlying wood, resulting in an uncleanable surface. Continued observation at that time showed the right backsplash had a chip that measured 6 inches by 1/2 inch that exposed the underlying wood, resulting in an uncleanable surface. 8. Interview with the maintenance director on 7/23/15 at 10:02 AM revealed the areas had not been previously identified, and the exposed wood could not be cleaned properly.

Based on observation and staff interview, the facility failed to ensure the facility was clean and well maintained in 3 of 3 resident hallways. The findings were: 1. Observation of the bathroom floor in room 419 on 7/23/15 at 9:40 AM showed an unsealed crack in the flooring that measured 16 inches in length resulting in an uncleanable surface. 2. Observation of the bathroom floor in room 432 on 7/23/15 at 9:42 AM showed an unsealed crack in the flooring that measured 8 inches in length resulting in an uncleanable surface. 3. Observation of the bathroom floor in room 401 on 7/23/15 at 9:45 AM showed an unsealed crack in the flooring that measured 12 inches in length resulting in an uncleanable surface. 4. Observation of the bathroom floor in room 407 on 7/23/15 at 9:46 AM showed an unsealed crack in the flooring that measured 12 inches in length resulting in an uncleanable surface. 5. Observation of the bathroom floor in room 421 on 7/23/15 at 9:47 AM showed an unsealed crack in the flooring that measured 24 inches in length resulting in an uncleanable surface. 6. Observation of the bathroom floor in room 413 on 7/23/15 at 9:48 AM showed an unsealed crack in the flooring that measured 24 inches in length resulting in an uncleanable surface. 7. Interview with the nursing home administrator on 7/23/15 at 9:40 AM revealed there was no formal written plan to replace or fix the floors in the resident bathrooms. 8. Interview with the maintenance director on 7/23/15 at 9:48 AM confirmed the cracks in the bathrooms could allow water in them and the facility would be unable to completely sanitize the surface.

Based on observation, staff interview, and policy and procedure review the facility failed to ensure infection prevention practices were followed by staff for 1 of 3 sample residents (#46) with a urinary catheter. The findings were: 1. Observation of transfer for resident #46 on 7/21/15 at 2:56 PM showed CNA #1 and CNA #2 placed a sling behind the resident and then positioned the lift in front of the resident. The sling was then attached to the mechanical lift. CNA #1 lifted the resident's urinary drainage bag and secured it to the lift bar. Continued observation showed there was urine in the tubing of the urinary drainage bag. As the resident was raised with the mechanical lift, the urinary drainage bag was above the level of the resident's bladder. 2. Review of the facility policy entitled Urinary Catheter-Associated Infection Prevention with an approval date of 10/11/12 showed .Purpose: To provide healthcare workers regimens and practices related to urinary catheters that may decrease the incidence of urinary tract infections.Procedure:.D. Maintenance of urinary catheter.4. Keep the drainage bag lower that (sic) patient's bladder at all times, including during transport. 3. Interview with the DON on 7/23/15 at 5:33 PM revealed staff should keep the urinary drainage bag below the bladder and it should not be hung on the bar of the lift because it can cause the drainage bag to be raised above the level of the resident's bladder.

Based on observation and staff interview, the facility failed to ensure staff wore hair restraints during trayline service for 2 of 3 meals observed. The findings were: Observation on 6/17/14 from 7:45 AM until 8 AM in the central dining room showed CNA #1 behind the steam table dishing food onto plates. The CNA did not have a hair restraint on. Observation on 6/18/14 at 8:35 AM revealed CNA #2 behind the steam table, dishing food onto plates. The CNA was not wearing a hair restraint. During an interview on 6/18/14 at 2:10 PM the RD stated dietary staff wore hair restraints, but she didn't think hair restraints had been discussed for CNAs. She acknowledged the CNAs who were working behind the steam table were different than hostesses or waitresses, who would be excluded from the hair restraint requirement. According to the Food Code 2013, U.S. Public Health Service, 2-402.11 (A) Except as provided in ? (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (B) This section does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on observation, medical record review and staff interview, the facility failed to provide necessary services to maintain good personal hygiene for 1 of 2 sample residents (#37) observed for incontinence care. The findings were: Review of the 2/24/14 quarterly MDS assessment for resident #37 revealed s/he was frequently incontinent of urine, and required extensive assistance with transfers and toilet use. Observation on 6/16/14 at 5 PM showed the resident was transferred from a recliner in his/her room to the toilet by CNA #1 and CNA #3. The resident's pants were visibly wet across the lap, with the wetness extending down the front of the thighs, and across the buttocks, with the wetness extending down the back of the thighs. Following toilet use, the CNAs cleansed the resident's genital and peri-anal areas, but failed to cleanse the resident's skin in all of the areas where the resident had been wet before dressing the resident in clean clothing. During interview on 6/19/14 at 3:50 PM, DON #2 stated facility CNAs were trained to clean the entire area, wherever a resident was wet, not just the "peri-area," and confirmed the aides should have cleaned the resident thoroughly.

Based on observation, review of menus, and staff interview, the facility failed to ensure the planned menu for pureed diets was followed during 1 of 2 meals observed. The findings were: Review of the planned menu provided by the RD showed residents with a pureed diet order were supposed to receive pureed Turkey Divan and winter squash for dinner on 6/17/14. However, observation of trayline service on 6/17/14 at 5:40 PM revealed the residents with pureed diets did not receive pureed Turkey Divan. Instead, dietary aide #1 used commercially-packaged plain pureed turkey, and put turkey gravy on top when serving residents #24 and #46. Interview with the dietary aide at the time confirmed the gravy was not the Divan sauce, but was turkey gravy. During an interview on 6/18/14 at 2:10 PM the RD confirmed the Turkey Divan should have been pureed, and staff should not have used the commercially-packaged pureed turkey.

Based on observation, menu review, and staff interview, the facility failed to maintain dignity during meals for 1 of 1 resident (#21) who received a pureed diet. The findings were: Review of the menu for lunch on 9/25/13 revealed chicken enchiladas and a Baja vegetable mix was to be served. The following concerns were identified: a. Observation in the kitchen during meal preparation on 9/25/13 from 10:50 AM until 11:40 AM revealed the vegetables were pureed for resident #21. However, the main meal (chicken enchiladas) was not prepared for the resident. Instead, cook #1 heated up a commercially packaged pre-formed plain chicken puree for the resident. During interviews on 9/25/13 at 11:25 AM and 11:26 AM cook #1 and dietary aide #1 both stated the facility usually used the commercially packaged pre-formed pureed meat for the main meal for resident #21. b. Observation during the meal in the Central dining room on 9/25/13 at 11:55 AM revealed plates were dished up from the steam table in the dining room. There was a strong smell of enchiladas in the room. At 12:11 PM resident #21 was served his/her plate, which included the plain chicken puree with gravy on top. c. During interviews on 9/25/13 at 3:25 PM and 9/26/13 at 8:30 AM the RD stated residents on a pureed diet should have a similar meal as residents on a regular diet. She stated the facility used to puree the main dish, but lately staff were using the commercially packaged pureed meats. She agreed the resident was missing out on the flavors and variety when the plain commercially packaged meat was routinely used.