Every finding on record at St Joseph Residence

Based on interview and record review, it was determined that the facility failed to ensure that a Licensed Nurse was on duty for 24 hours a day, 7 days a week, for 8 of 12 days reviewed for Fiscal Year Quarter 4 (July 1, 2025 - September 30, 2025). Findings Include: Review on 12/22/25 of the Payroll Based Journal (PBJ) Staffing Data [NAME] Report for Fiscal Year Quarter 4 2025 revealed that the facility failed to have Licensed Nursing coverage 24 hours a day on the following dates: 7/5/2025, 7/12/2025, 7/19/2025, 7/26/2025, 8/2/2025, 8/9/2025, 8/16/2025, 8/23/2025, 8/30/2025, 9/6/2025, 9/7/2025, and 9/21/2025. Review on 12/23/25 of the facility's schedules and corresponding nursing time punches for the above days revealed that there was not a licensed nurse coverage on duty 24 hour a day on 7/5/2025, 7/12/2025, 7/26/2025, 8/2/2025, 8/9/2025, 8/16/2025, 9/6/2025, and 9/21/2025.Interview on 12/23/25 at approximately 8:30 a.m. with Staff C (Human Resource Manager) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to implement and review, at least annually, the facility's water management plan that has the potential to effect the facility census of 22 residents.Findings include:Review on 12/22/25 of the facility's water management plan dated 11/13/2017 revealed the following: . Areas of greater risk in the nursing home would include the following:Resident showers and whirlpool tubs where droplets and moisture are in the air that resident are breathing while bathing. Plumbing fixtures such as sinks and showers that are located at the end of a dead leg pipping, or in an area that is rarely used allowing hot water to stagnate.Control measures should include the following:. 2. Assess and eliminate dead legs in plumbing system wherever practical. 3. Run hot water for several minutes at least once a week from fixtures in seldom used areas or at the end of dead legs that cannot be easily eliminated. 7. Remove and clean shower heads (including handheld wands) used for resident.Review on 11/22/25 of the facility's legionella checklist, used to document flushing (running of hot and cold water for several minutes) in resident rooms, bathrooms, etc., revealed that flushing was done on 10/29/25 and 11/28/25. Review further revealed that there was no documentation that shower heads were removed and cleaned. Interview on 12/23/25 at approximately 10:00 a.m. with Staff A (Infection Preventionist) and Staff D (Maintenance Assistant) revealed that the water management plan, dated 2017, was the current plan and they did not have documentation that it has been reviewed since 2017. Interview also confirmed that the shower heads had not been removed and cleaned and there was no other documentation for flushing for 2025 except for once in October and once in November 2025.

Based on interview and record review it was determined that the facility failed to submit accurate data for 7 of 92 days reviewed for Fiscal Quarter 4 (July 1, 2025 - September 30, 2025).Findings include:Review on 12/22/25 of the Payroll Based Journal (PBJ) Staffing Data [NAME] Report for Fiscal Year Quarter 4 2025 revealed that the facility failed to have Licensed Nursing coverage 24 hours a day on the following dates: 7/19/25, 8/23/25, 8/30/25, and 9/7/25 and failed to have a Registered Nurse for 8 consecutive hours on 9/6/25, 9/7/25, and 9/21/25.Review on 12/23/25 of the facility's schedules and time punches for the above days revealed that there was a licensed nurse for each 24 hours period and a registered nurse for at least 8 consecutive hours on the above listed dates. Interview on 12/23/25 at approximately 8:30 a.m. with Staff C (Human Resources Manager) confirmed that there were hours worked and not reported for PBJ for the Licensed Nursing Staff on the above four (4) days and the Registered Nurse Staff on the above three (3) days.Review on 12/23/25 of Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.7, effective date June 2025, revealed: .Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline .Review on 12/23/25 of the facility's policy titled, PBJ Compliance and Nurse Admin Compensation Policy, effective 10/27/2016, revealed: .It is the policy of [the facility] to comply with CMS Rules regarding Payroll Based Journal (PBJ) reporting for skilled nursing facilities . The Administrator shall be responsible for validating all information submitted for both employee and contracted/vendor services hours. Upon completion of the monthly submission of payroll data to CMS, the Administrator shall submit a PBJ Submission Attestation . All error reports noted by CMS will be investigated and verified . At least 4 days prior to the quarterly deadline for data submission to CMS, the Administrator will review all data submitted during the quarter with the HR manager .

Based on observation, interview, and record review, it was determined that the facility failed to follow physicians orders for 1 out of 3 residents observed during medication administration (Resident Identifier #20). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 10/29/24 at approximately 9:30 a.m. of Staff B (Medication Nursing Assistant) during medication preparation, revealed that Staff B poured one tablet of Docusate Sodium 50 milligrams (mg)/Sennosides 8.6 mg for Resident #20 into a medication cup. Review on 10/29/24 of Resident #20's physician orders revealed an order dated 10/15/2024: Sennosides 8.6 mg give 1 tablet by mouth one time a day. Interview on 10/29/2024 at approximately 9:35 a.m. with Staff B confirmed that he/she poured the wrong medication. Review on 10/29/2024 of facility policy titled, Medication Administration General Guidelines, dated 1/2021, revealed: .1. Medications are administered in accordance with written orders of the prescriber .

Based on interview and record review, it was determined that the facility failed to ensure a resident was offered and/or provided the Pneumococcal vaccine for 1 of 5 residents reviewed for immunizations (Resident Identifier #18 ). Findings include: Review on 10/30/24 of Resident #18's medical record revealed that Resident #18 was admitted to the facility on [DATE]. Further review revealed that Resident #18 consented to receive the PPSV23 (pneumococcal polysaccharide vaccine) on 9/20/23 and no documentation was available to show Resident #18 received the vaccine. Interview on 10/30/24 at approximately 2:30 p.m. with Staff A (Infection Preventionist) revealed that Resident #18 had not been given the PPSV23 that Resident #18 consented to receive. Review on 10/31/24 of facility policy titled, Immunizations: Pneumococcal Vaccinations of Residents PPSV23, PCV20, PVC15, dated 6/9/22, revealed: . a. All residents age [AGE] years or older will be offered appropriate vaccination, if applicable, based on their prior pneumococcal vaccine status and new 2022 CDC recommendations .

Based on observation, interview, and record review, it was determined that the facility failed to follow physician's orders for a nutritional intervention for 1 of 2 residents reviewed for nutrition in a final sample of 12 residents (Resident Identifier #19). Findings include: Review on 10/30/24 of Resident #19's Weight Summary revealed that the Resident's #19's weight was 104.9 pounds on 9/16/24. Further review revealed that on 10/21/24, Resident #19's weight was 101 pounds. Resident #19's first weight recorded after admission was on 9/1/24 was 109 pounds. Review on 10/30/24 of Resident #19's physician's orders revealed a current order dated 8/31/24 for Ensure three times a day for Ensure high plus protein 3 times a day with meals [sic]. Review on 10/30/24 of Resident #19's Nutritional Assessment, dated 9/3/24, revealed: .Has order for Ensure TID [three times a day], [discussed with] nurse, has not yet received it. Suggested homemade shake if accepted, nurse to review . Plan . Ensure or high calorie shake . This was signed by Staff C (Registered Dietician). Observation on 10/30/24 at 12:36 p.m. of Resident #19 eating lunch in the dining room revealed that there was no Ensure with his/her meal. Interview on 10/30/24 at 12:28 p.m. with Staff D (Licensed Nursing Assistant) revealed that Resident #19 does not ever get Ensure with their meals during the day shift. Interview on 10/30/24 at 12:28 p.m. with Staff E (Licensed Practical Nurse) confirmed that Resident #19 was not getting the Ensure as ordered by the physician and that the resident should be getting it with meals. Staff F revealed the order for the Ensure was not on the Medication Administration Record or on the resident's meal ticket. Interview on 10/30/24 12:36 p.m. with Staff G (Cook) revealed that he/she serves Resident #19 meals and does not get Ensure. Review on 10/30/24 of the facility's policy titled, Supplemental Nourishment Program Policy, effective 9/1/24, revealed: .The following protocol was developed to provide personalized medical nutrition therapy for those residents identified to be at nutritional risk (i.e. weight loss, decreased intake, wounds) . When a resident is added to the Supplemental Nourishment Program . The resident will then be added to the nourishment list that is sent to the unit .

Based on interview and record review it was determined that the facility failed to submit complete and accurate data for 5 of 91 days reviewed for Fiscal Quarter 3 (April 1, 2024 - June 30, 2024). Finding include: Review on 10/31/24 of the Payroll Based Journal (PBJ) Staffing Data [NAME] Report for Fiscal Year Quarter 3 2024 revealed that the facility failed to have Licensed Nursing coverage 24 hours a day on the following dates: 4/23/24, 5/26/24, 6/9/24, 6/21/24 and 6/23/24. Review on 10/31/24 of the facility's schedules for the above days revealed that there was licensed nurse coverage for each 24 hour period for the above listed dates. Interview on 10/31/24 at 11:50 a.m. with Staff H (Human Resources) confirmed that there were missing hours reported for PBJ for the Licensed Nursing Staff on the above 5 days. Review on 10/31/24 of Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, effective date June 2022, revealed: .Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline . Review on 10/31/24 of the facility's policy titled, PBJ Compliance and Nurse Admin Compensation Policy, effective 10/27/2016, revealed: .It is the policy of [the facility] to comply with CMS Rules regarding Payroll Based Journal (PBJ) reporting for skilled nursing facilities . The Administrator shall be responsible for validating all information submitted for both employee and contracted/vendor services hours. Upon completion of the monthly submission of payroll data to CMS, the Administrator shall submit a PBJ Submission Attestation . All error reports noted by CMS will be investigated and verified . At least 4 days prior to the quarterly deadline for data submission to CMS, the Administrator will review all data submitted during the quarter with the HR manager .

Based on interview and record review it was determined that the facility failed to ensure that training and education was provided to staff on abuse, neglect, exploitation, and misappropriation of resident property for 2 of 5 staff reviewed (Staff Identifiers are Staff E and J). Finding include: Review on 11/7/23 of Staff E's (agency Licensed Nursing Assistant) education file revealed no training or education for abuse, neglect, exploitation and misappropriation of resident property. Review on 11/8/23 of Staff J's (agency Licensed Practical Nurse) education file revealed no training or education for abuse, neglect, exploitation, and misappropriation of resident property. Interview on 11/8/23 at approximately 10:30 a.m. with Staff B (Director of Nursing) confirmed that above findings. Staff B stated that they did not have an education process for the agency staff at this time. Review on 11/8/23 of facility policy titled Abuse Prevention and Reporting, revised on 10/24/22, revealed .2. Training- Employees will be educated on abuse prevention and reporting .Employees will be educated at orientation and through on-going programs on issues related to abuse prevention practices .

Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards as is possible regarding storage of chemical cleaning solutions on 3 of 3 units observed (North Hall, East Hall, South Hall). Findings include: Observations on 11/6/23 at 9:30 a.m. and 12:30 p.m. of the North Hall revealed that one of the shared residents bathroom door was open with a bottle of GC2010 chemical cleaning solution hanging on the wall within reach of residents. Observation on 11/6/23 at 12:35 p.m. of the corner of the East and South Halls revealed that the Shower Whirlpool Room door was open with a bottle of GC2010 chemical cleaning solution on a cart and a hot to the touch Hydrocollator that was on within reach of residents. Interview on 11/6/23 at approximately 1:00 p.m. with Staff A (Licensed Practical Nurse) revealed that 4 residents between the 3 halls have been identified to wander and that GC2010 was stored in the shared resident bathrooms. Observations on 11/7/23 at approximately 7:35 a.m. of the North Hall shared bathroom and the South Hall shared bathroom revealed that the doors were open each with a bottle of GC2010 chemical cleaning solution hanging on the wall within reach of residents. Interview on 11/7/23 at 8:38 a.m. with Staff B (Director of Nursing), confirmed the above findings, removed chemical cleaning solutions from bathrooms and locked the Shower Whirlpool Room. Interview on 11/8/23 at 9:45 a.m. with Staff C (Regional Nurse) revealed that the facility did not have a policy to ensure secure storage of chemical cleaning solutions. 43408 Observation on 11/6/23 at approximately 11:52 a.m. of the North Hall bathroom revealed a spray bottle of GC 2010 disinfectant to be hanging on the wall just inside the doorway. Interview on on 11/6/23 at approximately 12:00 p.m. of Staff F (Scheduler/Licensed Medication Nursing Assistant) revealed that there are 2 residents that wander on the North Hall. Review of Safety Data Sheets revealed: GC-2010 Safety Data Sheet - Section 2: Hazard(s) Identification - Acute toxicity (oral) Category 4 - Harmful if swallowed .Serious eye damage/eye irritation Category 1 - Causes serious eye damage.

Based on observation, interview and record review, it was determined that the facility failed to store food in accordance with professional standards for food service safety, to prevent food borne illness for one of one kitchens observed. Findings include: Observation on 11/6/23 at approximately 9:00 a.m. of the kitchen refrigerator revealed the following: 24 raw eggs with a manufacturer's best by date of 10/30/23; 2 raw eggs with a manufacturer's best by date of 10/19/23; 2 unopened sour cream containers with a manufacturer's use by date of 10/28/23. Observation on 11/6/23 at approximately 9:00 a.m. of the kitchen storage room refrigerator revealed a plastic container covered with plastic wrap labeled pumpkin puree 10/10/23 use by 10/31/23. Further observation of plastic container revealed whitish growth like substance on the pumpkin puree. Interview on 11/6/23 at approximately 8:45 a.m. with Staff G (Senior Cook) confirmed the above findings. Review on 11/6/23 of facility policy titled Food Storage and Labeling, revised on 6/29/23, revealed . Refrigerated items: .2. Unopened will be utilized bythe manufacturer's use by or expiration date .4. All opened or left over items must have a visible label that identifies the item, the date it was prepared or opened, and the use by date. This includes (but is not limited to) juice, salad dressing, leftovers, and portioned desserts . Review on 11/6/23 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind .

Based on interview and record review it was determined that the facility failed to submit complete and accurate data for 6 of 92 days reviewed for Fiscal Quarter 3 (April 1, 2023 - June 30,2023). Finding include: Review on 11/7/23 of the Payroll Based Journal (PBJ) Staffing Data [NAME] Report for Fiscal Year Quarter 3 2023 revealed that the facility failed to have Licensed Nursing coverage 24 hours a day on the following dates: 4/8/23, 4/22/23, 5/6/23, 6/3/23, 6/4/23 and 6/24/23. Review on 11/7/23 of the facility's monthly staffing schedule for April 2023 through June 2023 revealed that there was licensed nursing coverage for a 24 hour period for each of the above listed dates. Review on 11/7/23 of the nursing time punches for the above listed dates, revealed that there was appropriate nursing coverage the 24 hour periods listed above. Review on 11/7/23 of the centers PBJ report submissions for the above listed dates revealed the following hours for nursing was submitted: 4/8/23-23.84 nursing hours; 4/22/23-23.75 nursing hours; 5/6/23-23.91 nursing hours; 6/3/23-23.80 nursing hours; 6/4/23- 23.88 nursing hours; 6/24/23- 17.10 nursing hours. Interview on 11/7/23 at approximately 12:45 p.m. with Staff H (Corporate Human Resources) confirmed that above submissions were made on the Fiscal Year Quarter 3 2023 PBJ report. Staff H stated that on 6/24/23 the hours submitted was not accurate and that the total hours should have been 24.23. Interview on 11/7/23 at approximately 12:45 p.m. with Staff I (Administrator) revealed that they do not audit the PBJ submissions for accuracy. Review on 11/7/23 of CMS (Centers for Medicare & Medicaid Services) Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, effective date June 2022, revealed .Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were labeled and disposed of in 1 of 1 medication cart observed. the facility also failed to ensure that narcotics were properly stored in 1 of 1 medication storage room observed (Resident identifiers are #5 and #7). Findings include: Observation on 12/20/22 at approximately 10:44 a.m. of the medication cart with Staff B (Licensed Practical Nurse) revealed an opened Breo Ellipta inhaler for Resident #5 with no open date or open expiration date. Review on 12/20/22 with Staff B of the manufacturer's instructions on the inhaler revealed that once opened, the Breo Ellipta inhaler should be discarded after 6 weeks. Interview on 12/20/22 at approximately 10:45 a.m. with Staff B confirmed that Resident #5's inhaler was opened and had no open date or open expiration date. Staff B also confirmed that the manufacturer's instructions were to discard the inhaler after 6 weeks once opened. Observation on 12/20/22 at approximately 11:05 a.m. of the facility's medication room revealed an unlocked refrigerator. There was a padlock on the refrigerator that was not secured (locked). Inside the refrigerator was 1 vial (2 milligrams (mg) /1 milliliter(ml)) of Lorazepam concentrate (a schedule IV controlled substance) for Resident #7. Interview on 12/20/22 at approximately 11:08 a.m. with Staff B confirmed that the refrigerator was unlocked. Review on 12/21/22 of the facility's policy titled Medication Storage revised on 1/21 revealed, . 4.2 Controlled Medication Storage . 4. Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator.

Based on observation, interview and record review, it was determined that the facility failed to follow physician's order for documenting wound measurement for 1 of 1 pressure ulcer reviewed in a final sample of 12 residents (Resident identifier is #11). Findings include: Professional reference: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 12/21/22 of Resident #11's clinical note dated 10/26/22 revealed that Resident #11 had a recurrent right outer ankle abrasion. The right outer ankle area was cleaned and dressed with previous orders to the site. Review on 12/21/22 of Resident #11's initial alteration in skin integrity assessment dated [DATE] revealed a facility acquired right ankle bone abrasion and wound type of recurrent. Further review revealed no description of the right ankle bone abrasion such as appearance, measurements, shape, or drainage. Review on 12/21/22 of Resident #11's orders revealed a telephone order on 10/26/22 for a treatment to cleanse right ankle abrasion with normal saline, skin prep the edges, and add a small piece of Xeroform (cut to fit) to center redness, cover with dry dressing every day, measure, and document on Tuesdays. Review on 12/21/22 of Resident #11's medical records revealed no documentation of measurement for Resident #11's right outer ankle abrasion for 11/1/22, 11/8/22, 11/15/22, and 11/20/22 (Tuesday dates on November 2022). Review on 12/21/22 of Resident #11's clinical note dated 11/2/22 revealed that the right ankle was assessed, cleaned, and dressing changed as ordered. Further review revealed that the right ankle area had a small open, superficial break, partial skin loss. Review also revealed no measurements of the right ankle open area. Review on 12/21/22 of Resident #11's clinical note dated 11/20/22 revealed that Resident #11 was walking from the bathroom limping and he/she had pain to their right ankle where the open wound was located. Review of the clinical note dated 11/20/22 also revealed that the right ankle area was red and painful to touch. Review on 12/21/22 of Resident #11's clinical note dated 11/21/22 revealed that Resident #11 had a re-opened area on their right outer ankle measuring 0.1 centimeter (cm) in length by 0.1 cm in width by 0.1 cm depth with redness around the perimeter of the wound, tender to touch, possible infection. There was a new order obtained from the nurse practitioner for Doxycycline 100 milligram (mg) twice a day for 7 days for possible cellulitis. Review on 12/21/22 of Resident #11's initial alteration in skin integrity assessment dated [DATE] revealed Resident #11 had a facility acquired stage 2 pressure ulcer to their right outer ankle with granulation tissues/red, length of 0.1 cm, width of 0.1 cm, depth of 0.1 cm, no drainage, no tunneling, no undermining, peri-wound skin inflamed/indurated, wound edges was symmetrical, and round wound shape. Further review revealed that Resident #11 was started on antibiotic for possible infection. Interview on 12/21/22 at approximately 10:45 a.m. with Staff C (Registered Nurse) revealed that in September 2022 Resident #11 had developed an unstageable pressure ulcer on the right outer ankle, the pressure ulcer healed, and re-opened as an abrasion on 10/26/22. Interview on 12/21/22 at approximately 10:47 a.m. with Staff D (Director of Nursing) confirmed the above findings. Staff D also confirmed that Resident #11 had a right outer ankle abrasion on 10/26/22 and on 11/21/22 on the same location developed into a stage 2 pressure ulcer. Staff D also stated that on 10/26/22 there should have been a non-pressure ulcer skin assessment flow sheet initiated in regards to Resident #11's right outer ankle abrasion. Staff D was unable to provide further documentation of measurements and tracking of Resident #11's right ankle bone abrasion after 10/26/22 and before 11/21/22. Observation on 12/21/22 at approximately 11:11 a.m. with Staff B (Licensed Practical Nurse) revealed that Resident #11 had an open area to their right outer ankle at the bony prominence, round in shape and redness to the surrounding perimeter. Interview on 12/21/22 at approximately 11:11 a.m. with Staff B confirmed the above observation. Review on 12/21/22 of facility policy titled, skin care, with no date, revealed .SKIN CARE AND TREATMENTS .10. Document upon identification of potential or actual skin issues in the resident summary template and Chat. 11. Wound rounds are done weekly for all residents with wounds. Staging and measurement of wounds should be done at this time by a designated and consistent nurse. Ideally, a wound care team would be established that includes the charge nurse and LNA. The wound care team would meet weekly to assess skin care issues and preventative strategies. Wound rounds are not to exceed 7 days from the last rounds .14. Pressure ulcer and wound assessments will be performed by a consistent licensed nurse for treatment care selection. Wound characteristics will assist the physician and nurse in a treatment choice .SKIN CARE GUIDELINES PROCEDURE .6. When a skin issues is observed: redness, rash, skin tear, blister, or actual breakdown, open the skin process in Vision. The process will cue the nurse of the nest steps needed. This includes completing the Initial Alteration in Skin Integrity Assessment for min Vision Initiation of the process, will enable the DNS [Director of Nursing Services] and R.D. [Registered Dietician] to be notified of the wound .9 .During rounds, the wound nurse, and/or wound team will complete the Weekly Pressure Ulcer Assessment Form or the Non-Pressure Ulcer Skin Condition Report .

Based on observation, interview and record review, it was determined that the facility failed to ensure that food was stored in accordance to professional standards for food safety related to expired food and beverages in 1 of 1 kitchen observed. Findings include: Review on [DATE] of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. Observation on [DATE] at approximately 9:20 a.m. of the kitchen prep area revealed the following: -One re-sealable zipper storage bag containing loose small pasta (not in original packaging). Hand written on the bag was Acini (a small pasta), [DATE] and use by [DATE]; -One bottle of Kitchen Bouquet (a browning and seasoning sauce), hand written on the label was [DATE] and use by [DATE]. Observation on [DATE] at approximately 9:25 a.m. of the bakery room revealed the following: -One re-sealable plastic container that had a handwritten label that read creamy rice and use by of [DATE]; -One pint of almond extract that had a handwritten label that read opened [DATE] and a use by [DATE]; -One container of cupcake icing with a manufacturer's best by date of [DATE]. Further review of the bakery room in the refrigerator revealed the following: -One re-sealable zipper storage bag of coconut flakes with a written use by date of [DATE]; -Three bags of fudge with a handwritten date of ,d+[DATE]; Observation on [DATE] at approximately 9:45 a.m. of the basement dry storage room revealed the following: -Eight 1 quart cans of pineapple juice with a manufacturer's best by date of [DATE]; -Twenty-two containers of beef flavor cup of noodles, 1 with a manufacturer's best by date of [DATE], 3 with a manufacturer's best by date of [DATE], 6 with a manufacturer's best by date of [DATE], 6 with a manufacturer's best by date of [DATE] and 6 with a best by date of [DATE]; -Twenty-five packets of beef flavored ramen noodles, 1 with a manufacturer's best by date of [DATE], 24 with a manufacturer's best by date of [DATE]; -Eight 16 ounce bags of pearl barley with a manufacturer's best by date of [DATE]; -Eleven cans of chicken a la king, 7 with a manufacturer's best by date of [DATE] and 4 with a manufacturer's best by date of [DATE]; -One pint of coffee syrup with a sell by date of [DATE]; -One container of chocolate syrup with a manufacturer's best by date of [DATE]; -Twenty 12 ounce cans of evaporated milk with a manufacturer's best by date of [DATE]; -Eight cans of coconut milk with a manufacturer's best by date of [DATE]; -Three containers of mayonnaise with a manufacturer's use by date of [DATE]. -Twelve 10 ounce packages of Trio Alfredo mix, 8 with a manufacturer's best by date of ,d+[DATE] and 4 with a manufacturer's best by date of ,d+[DATE]; Observation on [DATE] at approximately 10:15 a.m. of the basement walk-in refrigerator revealed the following: -One container of 16 ounces of cottage cheese with a manufacturer's date of [DATE]; -Three re-sealable gallon size bag hand labeled peanut butter cups for baking and [DATE]. use by [DATE]; -Four re-sealable gallon size bags hand labeled graham crackers and [DATE]. use by [DATE]; -Four re-sealable gallon size bags with a handwritten label butterscotch chips best by [DATE]; -One 11 ounce sealed bag of butterscotch morsels with a manufacturer's best by date of ,d+[DATE]; -One container that had 3 re-sealable and unlabeled bags containing small morsel chips, with a handwritten label that said peanut butter chips dated [DATE]. In the above observations on [DATE] of the re-sealable plastic containers/bags, there was no original packaging with a manufacturers expiration/best by/use by date. Interview on [DATE] at approximately 10:30 a.m. with Staff B (Food Service Manager) confirmed the above foods were past the dates (the use by, best by, and sell by dates) and should have been removed from the storage room/refrigerators. Staff B stated none of the above foods were or would be served to the residents. Review on [DATE] of the facility's policy date [DATE] read, in part, . Purpose: To ensure that all refrigerated, frozen and dry goods items are used or disposed of in a timely manner Dry Good Storage: . 3. Canned goods will be used within 2 years of the received date or the manufacturer's recommended use by or expiration date, whichever is sooner. 4. Above also applies to items in the Emergency Supply area, which will be rotated yearly. 5. All other dry goods i.e. cookies, crackers, cereals, mixes, etc. will be utilized by the manufacturer's use by date Refrigerated items: 1. Unopened items will be utilized by the manufacturer's use by or expiration date. 2. All opened or leftover items must have a visible label that identifies the item, the date it was prepared or opened on, and the use by date .

Based on interview and record review it was determined that the facility failed to investigate bruising of unknown origin for 1 out of 2 residents reviewed for injury of unknown orgin out of a final sample size of 11 residents. (Resident identifiers is #19.) Findings include: Review on 12/21/21 of Resident #19's nurses notes dated 11/23/21 revealed LNA [Licensed Nursing Assistant] asked this writer to look at bruise on resident's back. It was noticed while getting resident ready for bed. This writer went in and resident does have a medium size bruise on the upper right side of [pronoun omitted] back. Resident denies pain and does not know how it got there. This writer informed nurse coming on 11-7. Review on 12/22/21 of Resident #19's medical record including clinical notes and skin assessments revealed no additional notes about the above mentioned bruise. Interview on 12/22/21 at 10:29 a.m. with Staff A (Director of Nursing) confirmed that Resident #19's bruise had been reported to him/her the following day (on 11/24/21) and had been discussed at the facility's morning meeting. Interview on 12/22/21 at 10:56 a.m. with Staff A confirmed that there was no investigation into how the bruise occurred. Review on 12/22/21 at approximately 3:00 p.m. of the facility policy titled Abuse Prevention and Reporting (undated) revealed .3. All alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately after the incident is discovered and observed by the employee to the employee's supervisor on duty . 4. Initial Report The administrator or designee will report the alleged violation involving abuse, neglect, or mistreatment, including injuries of unknown source and misappropriation of resident property to the Ombudsman's Office immediately. 5. All alleged violations will be thoroughly investigated, and the facility will take measures to prevent further potential abuse while the investigation is in progress.

Based on interview and record review, it was determined that the facility failed to address recommendations from the pharmacist for 1 resident out 5 resident reviewed for unnecessary medications in a final sample of 11 residents. (Resident identifier is #12.) Findings include: Review on 12/21/21 of Resident #12's MRR's (Medication Regimen Reviews) revealed the following: -A recommendation dated 9/14/21 Resident has a PRN [as needed] [MEDICATION(S)]/[MEDICATION(S)] [bronchodilator] for Nebulizer with directions of 3 times a day PRN. Please obtain the minimum number of hours between doses (suggest at least every 4 hours between doses). -A recommendation dated 10/13/21: Resident has a PRN [MEDICATION(S)]/[MEDICATION(S)] for Nebulizer with directions of 3 times a day PRN. Please obtain the minimum number of hours between doses (suggest at least every 4 hours between doses). -A recommendation dated 11/14/21: Resident has a PRN [MEDICATION(S)]/[MEDICATION(S)] for Nebulizer with directions of 3 times a day PRN. Please obtain the minimum number of hours between doses (suggest at least every 4 hours between doses). -A recommendation dated 12/16/21: Resident has a PRN [MEDICATION(S)]/[MEDICATION(S)] for Nebulizer with directions of 3 times a day PRN. Please obtain the minimum number of hours between doses (suggest at least every 4 hours between doses). Review on 12/21/21 of Resident #12's November Medication Administration Record (MAR) revealed the following physicain order: [MEDICATION(S)] 0.5 mg (milligrams)/[MEDICATION(S)] 3 mg solution (one unit dose) for nebulization inhalation as needed three times daily starting on 8/19/21. Further review of the MAR revealed that Resident #12 recieved the above medication on 11/10/21 at 3:39 p.m with no effect and on 11/10/21 at 3:41 p.m. with no effect, which was less than 4 hours between doses. Interview on 12/21/21 at approximately 2:45 p.m. with Staff A (Director of Nursing) confirmed the above findings. Further interview revealed that the above MRR's were not addressed by the physician. Review of facility policy titled, Medication Monitoring, Medication Regimen Review and Reporting, dated 9/18 revealed .8. The nursing center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days.

Based on interview and record review it was determined that the facility failed to report bruising of unknown origin to the State Survey Agency for 1 out of 2 residents reviewed for injuries of unknown orgin out of a final sample size of 11 residents. (Resident identifiers is #19.) Findings include: Review on 12/21/21 of Resident #19's nurses' notes dated 11/23/21 revealed LNA [Licensed Nursing Assistant] asked this writer to look at bruise on resident's back. It was noticed while getting resident ready for bed. This writer went in and resident does have a medium size bruise on the upper right side of [pronoun omitted] back. Resident denies pain and does not know how it got there. This writer informed nurse coming on 11-7. Interview on 12/22/21 at 10:29 a.m. with Staff A (Director of Nursing) confirmed that Resident #19's above bruise had been reported to him/her the following day (on 11/24/21) and had been discussed at the facility's morning meeting. Interview on 12/22/21 at 10:56 a.m. with Staff A confirmed that it had not been reported to the State Survey Agency. Review on 12/22/21 at approximately 3:00 p.m. of the facility policy titled Abuse Prevention and Reporting (undated) revealed .3. All alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately after the incident is discovered and observed by the employee to the employee's supervisor on duty . 4. Initial Report The administrator or designee will report the alleged violation involving abuse, neglect, or mistreatment, including injuries of unknown source and misappropriation of resident property to the Ombudsman's Office immediately. 5. All alleged violations will be thoroughly investigated, and the facility will take measures to prevent further potential abuse while the investigation is in progress.

Based on observation, interview, record review and policy review, the facility failed to ensure medication error rate was not greater than 5% during 38 medication pass opportunities (Resident identifiers are Resident #1 and #7.) Findings include: Resident #7 Observation on 1/20/21 at approximately 7:30 a.m. of Staff A (Licensed Practical Nurse) during medication pass revealed Staff A poured 15 mls (milliliters) of [MEDICATION NAME] for Resident #7. Review on 1/20/21 at approximately 7:30 a.m. of Resident #7's MAR (Medication Administration Record) revealed the following [MEDICATION NAME] order: [MEDICATION NAME] 10 grams/15 ml oral solution (30 ml) one time daily, starting 5/9/19. Interview on 1/20/21 at approximately 7:30 a.m. with Staff A confirmed that Staff A poured only half of the ordered dose and was going to administer half of the ordered dose. Resident #1 Observation on 1/20/21 at approximately 8:00 a.m. of Staff A during medication pass revealed Staff A dial dose on the basaglar kwikpen (insulin) to 7 units. Staff A did not prime the Basaglar Kwikpen prior to dialing the dose. Review on 1/20/21 at approximately 8:00 a.m. of Resident #1's MAR indicated [REDACTED]. Interview on 1/20/21 with Staff A confirmed that he/she did not prime the kwikpen prior to dialing to ordered dose. Observation on 1/20/21 at approximately 8:05 a.m. of Staff A administering Resident #1's insulin with Resident #1's Basaglar Kwikpen revealed that Staff A did not leave the Basaglar Kwikpen inserted in Resident #1 for 5 seconds after the dose was administered. Review on 1/20/21 of the manufacturer's instructions for the Basaglar Kwikpen, dated 2019 revealed: .Priming your Pen Prime before each injection Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6 To prime your pen, turn the dose knob to select 2 units. .Step 7 Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. .Step 8 Continue holding your pen with needle pointing up. Push the dose knob in until it stops, adn 0 is seen in the dose window. Hold the dose know in and count to 5 slowly. .Step 11 Insert the needle into your skin. Push the knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the needle. Observation on 1/20/21 at approximately 8:10 a.m. of Staff A during medication pass revealed Staff A removed 1 Potassium Chloride 20 meq (milliequivalents) ER (Extended Release) tablet for Resident #1. Review on 1/20/21 at approximately 8:10 a.m. of Resident #1's MAR indicated [REDACTED]. Interview on 1/20/21 at approximately 8:10 a.m. with Staff A confirmed that Staff A was going to administer half of the ordered dose of Potassium Chloride 20 meq ER. Review on 1/20/21 of the facility policy titled, Medication Administration General Guidelines, dated 2007 revealed the following: Policy Medications are administered as prescribed in accordance with manufacturers' specifications, . .Procedures .3. Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED] .Medication Administration 1. Medications are administered in accordance with written orders of the prescriber In total there were 3 medication errors out of 38 medication administration opportunites resulting in a 7.89% error rate.

Based on interview, grievance log review and policy review, the facility failed to report 4 allegations of abuse over a period of 3 month period of grievances reviewed. Resident identifiers are #1, #10 and #15. Findings include: Review on [DATE] of the facility grievance log revealed the following: [DATE] Resident #1 stated during resident council that night staff were very rough with her/him. [DATE] Resident #15 reported to staff that he/she observed 2 staff members coming out a deceased residents room with personal items. [DATE] Resident #10 reported to staff that a staff member assisted Resident #10 with putting on a sweater roughly and in a rude manner. [DATE] Resident #1 reported missing money and items. Interview on [DATE] at approximately 1:00 p.m. with Staff B (Administrator) revealed that these allegations were all investigated but not reported to the state agency. Review on [DATE] of the facility policy titled, Abuse Prevention and Reporting; revision date [DATE] revealed: Requirements .3. All alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately after the incident is discovered or observed by the employee to the employee's supervisor on duty. The supervisor on duty has the responsibility to report same immediately to the facility administrator (or designee). The facility will investigate and report all allegations of abusive conduct to the state agency. .Procedures for Prevention of Resident Abuse .7) Reporting/Response The center will report all alleged instances of abuse to appropriate state agencies. a. The center will report all alleged instances of abuse to the Ombudsman's Office and all other agencies as required. Other agencies may include: i. Police; ii. Attorney General; iii. BON (Board of Nursing); iv. Other professional licensing agencies; and v. BEAS (Bureau of Elderly and Adult Services)

Based on observation, interview and policy review, the facility failed to safely dispose of medications in a secured receptacle on 1 out of 1 units observed. Findings include: Observation on 1/20/21 at approximately 7:20 a.m. with Staff A (Licensed Practical Nurse) during medication administration, Staff A spilled the medication cup onto the medication cart with the following medications: [REDACTED] Aspirin 81 mg (milligrams) 1 tablet Calcium with Vitamin D 600mg/200mg 1 tablet Carvedilol 6.25mg 1 tablet [MEDICATION NAME] 40mg 1 tablet Staff A picked up the medications off of the medication cart and disposed of the above medications in a uncovered trash receptacle attached to the medication cart. Interview on 1/20/21 at approximately 8:15 a.m. with Staff A revealed that Staff A did not know the facility's policy for disposal of medications. Interview on 1/20/21 at approximately 2:30 p.m. with Staff C (Director of Nursing) revealed that there are residents on the unit with Dementia and that medications should not be disposed of in the trash receptacles. Review on 1/20/21 of the facility policy titled, Disposal of Medications, Syringes and Needles, Disposal of Medications, dated; 12/12 revealed: 5.5 Disposal of Medications .Procedures 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. a. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. .4. Medications not listed in Schedule II, III, IV and V (non controlled medications) shall be destroyed by the nursing care center in the presence of a pharmacist or nurse, and one other witness as per state regulation a.Transfer medication to trash receptacle following destruction to unusuable consistency .