Every finding on record at St Joseph's Residence

Based on observations of the kitchen and staff interviews, the facility failed to ensure that temperature logs for kitchen refrigerators were consistently completed and failed to ensure clean dishes were stored away from potential contaminants. The findings included: 1. An initial observation of the kitchen with the Food Service Manager on 3/24/2025 at 11:00 AM identified the temperature log for March 2025 for Produce Cooler #1 and Produce Cooler #2 were missing morning temperatures for 3/23/2025. A review of the February 2025 temperature logs identified the morning temperature for 2/28/2025 for Produce Cooler #1 and Produce Cooler #2 were missing. Although requested, the facility was unable to provide a temperature log for January 2025. An interview with the Food Service Manager identified when he started in mid-January 2025, he may have discarded old temperature logs when implementing new forms. After the surveyor inquiry, the Food Service Manager provided copies of the February and January 2025 temperature logs with the missing temperatures. The Food Service Manager indicated that he had called the cook working on 3/23/2025 and 2/28/2025 who indicated to the Food Service Manager that the temperatures were within normal range, but she/he had forgotten to complete the log. An interview with the Administrator on 3/25/2025 at 12:28 PM identified the facility did not have the missing refrigerator temperature logs secondary to the logs may have been discarded or misplaced with the change in management. The Administrator further indicated the older logs should have been maintained. 2. An observation of the dish room with the Food Service Manager on 3/24/2025 at 11:15 AM identified a large fan with a large amount of gray-colored debris and lint blowing over clean dishes, including pots, pans, and utensils. An interview with the Food Service Manager indicated the clean dishes were from breakfast service and the fan was used for keeping staff cool in the dish room. The Food Service Manager further indicated maintenance is responsible for cleaning fans. An interview with Food Service Aide #1 who was working in the dish room on 3/24/2025 at 11:20 AM identified she was told that fans were okay to be blowing on the dishes if far enough away from the dishes. Food Service Aid #1 was unable to recall when and from whom she had received the information. After surveyor inquiry, maintenance cleaned the fan in the dish room. The facility policy for Food Safety Requirements given during the survey notes, the facility must store, prepare, distribute, and serve food in accordance with professional standards for food safety.

Based on observation, review of facility policy and interviews the facility failed to ensure food items were labeled and dated, and that dietary staff in the kitchen wore hairnets and beard guard. The findings include: 1. Observation with the Director of Dietary on 4/17/23 at 9:25 AM in the salad bar refrigerator identified sliced mushrooms were not labeled or dated, and 3 pies had sell by dates of 3/31/23 and use by date 4/2/23. 2. Observation in the produce refrigerator identified 2 bunches of lettuce and 1 bunch of celery in saran wrap not labeled or dated, 1 metal container with a bunch of wilted celery not labeled or dated, and a large metal tray of cooked potato wedges not labeled or dated. 3. Observation of the production refrigerator identified a metal container with 10 cooked turkey thighs not labeled or dated and a tray of potato wedges in saran wrap not dated. Interview with the Director of Dietary, (DOD) indicated all food stored in the refrigerator must be labeled and dated, and it was his/her responsibility to do so. The DOD indicated the 3 pies were frozen prior to being put in the refrigerator and should have been dated when removed from the freezer. The DOD indicated the weekend cook or any dietary staff should have labeled and dated the food items prior to placing the items in the refrigerators. 4. Observation on 4/17/23 at 10:00 AM identified Dietary Aide #1 with a full mustache and beard at least 2 inches in length and was not wearing a beard guard while in the kitchen touching clean and dirty dishes in the dish room. Interview with Dietary Aide #1 on 4/17/23 at 10:02 AM indicated he/she did not have a beard guard to wear as there were no beard guards available. Interview with the DOD on 4/17/23 at 10:05 AM indicated Dietary Aide #1 works 3 days a week and the beard guards were on back order and there were none available in the kitchen. The DOD indicated he/she works with 1 distributor and had not tried to get beard guards anywhere else. Observation of Dietary Aide #2 on 4/18/23 at 1:51 PM in the kitchen failed to reflect he/she was wearing a hairnet or baseball cap. Interview with Dietary Aide #2 indicated he/she started a month and a half ago and was oriented that only the cooks needed to wear hairnets in the kitchen. 5. Observation on 4/18/23 at 2:36 PM identified Cook #1 with facial hair on the checks, neck and part of the [NAME] area not covered by the surgical mask he/she was wearing. Interview with Cook #1 on 4/18/23 at 2:37 PM indicated he/she has worked at the facility on the evening shift full time as the cook for the last 8 months, and indicated everyone in the kitchen must wear a hairnet and a beard guard if they have facial hair. Cook #1 indicated he/she has never worn a beard guard because they are not available. Interview with the DOD on 4/19/23 at 6:42 AM indicated that all dietary employees and anyone entering the kitchen must put on a hair net or hat prior to entering. The DOD indicated it has been months since he was able to get beard guards because the distributor had informed him/her the beard guards were back ordered. The DOD indicated any employee with facial hair is required to wear a beard guard, but they were not available. Review of refrigerated food storage policy directed labeling, dating, and monitoring refrigerator foods, including, but not limited to leftovers so it is used by its use-by date, or frozen (where a applicable) or discarded. Review of food purchase and storage policy identified all refrigerator food is kept covered and labeled with a date. Review of general kitchen sanitation rules policy identified cover all food after chilled and label and date. Review of food and nutrition services dress policy identified hair restraints in the form of hair nets, bandanas, hats or caps or other appropriate coverings are worn while on duty. Beard restraints included.

Based on review of facility documentation, facility policy, and interviews the facility failed to have consistent monthly resident council meetings. The findings include: Review of the resident council meeting minutes between 1/1/22 through 3/31/23 (15 months) identified that meetings were held only 6 months out of the 15-month review period. Review of council meeting documentation dated 3/2022 identified the council meeting was canceled because Resident #6 could not attend. Review of council meeting documentation dated 7/2022 identified due to the hot summer months, there will be no resident council meeting for the months of July and August. Resident council will resume on 9/21/22. Review of council meeting documentation dated 9/21/22 identified the council meeting was canceled because Resident #6 could not attend. Review of council meeting documentation dated 12/2022, 1/25/23 and 2/2023 identified the council meeting was canceled because Resident #6 could not attend. Interviews with members of the resident council, Resident #6, 7, 15, 17, and 21 on 4/18/23 at 9:30 AM indicated the resident council has not consistently met monthly for various reasons. Resident #6 indicated there were many months he/she could not hold/attend the monthly council meetings, but it would have been okay for the other residents to still have the meetings. Resident #7, 15, and 17 indicated despite Resident #6 not being able to attend, they would have still wanted to have the monthly meeting, including during the summer months. Resident #7, 15, 17, and 21 indicated they were not informed by a staff person that the meetings were cancelled and were not offered to have the meetings without Resident #6. Resident #7, 15, 17, and 21 indicated they would have wanted to continue the meetings even if Resident #6 could not attend. Resident #7, 15, 17, and 21 indicated they would like to have the meetings every month to have concerns discussed and addressed and discuss the upcoming events. Interview with the Director of Recreation (DOR) on 4/18/23 at 11:10 AM indicated she was responsible to assist the residents to the meetings, record the minutes for the meetings, and mediate the meetings. The DOR indicated the resident council was to meet every month, but when, at the last minute, Resident #6 indicated he/she would not attend, she would cancel the meeting and announce the cancellation in the dining room. The DOR indicated the facility would normally cancel the resident council monthly meetings during the summer months (July and August). The DOR further indicated she did not ask the residents if they wanted to have a meeting in July and August of 2022 because they have just never had a council meeting during the summer. The DOR indicated she was not aware who directed that the council not meet in the summer. The DOR indicated it was her understanding that if a specific member of the resident council was not going to attend, the meeting would be cancelled. Review of Resident Council Manual identified the resident council is the forum for residents to verbalize any suggestions monthly.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #6 and 274) reviewed for resident to resident altercation, the facility failed to ensure the appropriate agency was notified after an incident. The findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified Resident #6 had severely impaired cognition, required 2 person assistance with bed mobility and transfers, and was totally dependent for locomotion. The care plan dated 5/9/18 identified Resident #6 was unable to walk, and required staff assistance for all transfers. Interventions included to provide assistance of 2 for transfers, and utilize a specialized wheelchair, (Broda chair) for mobility. Additionally, the care plan identified Resident #6 had cognitive and communication deficits with impaired decision making capability. Interventions include to allow Resident #6 rest periods, explain tasks before beginning them, and provide a supportive environment. A physician's order dated 5/30/18 directed the assistance of 2 staff for all transfers, and to use a Broda wheelchair for mobility. Resident #274 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/1/18 identified Resident #274 may attempt to barricade him/herself in rooms in order to hide from staff. Interventions included to anticipate needs, be attentive to Resident #274's whereabouts to ensure safety, maintain Resident #274's safety and the safety of others, and psychiatric follow up as needed. An annual MDS dated [DATE] identified Resident #274 had severely impaired cognition and delusions, was independent with walking, and required supervision for oversight and cueing with locomotion on and off the unit. A physician order dated 5/4/18 directed Resident #274 to have a Wanderguard for safety. A physician order dated 5/8/18 directed Resident #274 to use a rolling walker for ambulation. Although review of facility documentation identified staff checked Resident #274 every 15 minutes on 6/15/18 from 12:00 AM to 2:15 PM, the documentation failed to identify the whereabouts of Resident #274 every 15 minutes on 6/15/18 from 2:30 PM to 11:30 PM, 9 hours. A nurse's note (Resident #6) dated 6/15/18 at 4:49 PM identified that Resident #6 was taken into a resident room by Resident #274, and bombarded in the room. According to the note, Resident #6 sustained no harm from being locked in the room with Resident #274. A nurses notes (Resident #274) dated 6/15/18 at 4:21 PM identified Resident #274 was fixated on Resident #6, and thought that Resident #6 was his/her child. Resident #274 had a behavioral episode and barricaded himself/herself in a room with Resident #6. The SW and DNS were called to intervene, and attempts were made to redirect Resident #274 requiring several staff to separate the 2 residents. Subsequent to notification of the psychiatrist, Resident #274 received Trazadone. Recommendations included to notify the psychiatrist if Resident #274's behavior escalated. Furthermore, the note identified that Resident #274 refused to take the Trazadone, but did calm down when a family member arrived. A reportable event form (Resident #6), dated 6/15/18 at 3:10 PM identified Resident #274 pushed Resident #6, who was in a wheelchair, into a resident room, and closed and barricaded the door shut with a bed. Subsequently, there was no apparent injury to Resident #6, however, after the event Resident #6, was agitated. A reportable event form (Resident #274) dated 6/15/18 identified that on 6/15/18 at 3:10 PM Resident #274 pushed Resident #6 into a resident room and closed and barricaded the door shut with a bed. The report identified that Resident #274 repeatedly stated that Resident #6 was his/ her child, and became combative and aggressive with staff when attempts were made to remove Resident #6 from room. The reportable event form identified no apparent injury to Resident #274, however, it identified that the resident's mental status before the event was alert and quiet and after the event Resident #274 was agitated, delusional, aggressive and physically and verbally abusive. Additionally, the report identified Resident #274 was sent to the emergency department for psychiatric evaluation. Facility documentation dated 6/15/18 identified Resident #274 was swinging his/her arms, yelling out, hitting and pushing and grabbing onto Resident #6's wheelchair during the incident. Interview with RN #2 on 8/15/18 at 4:27 PM identified Resident #6 would become anxious at times, and staff would place the resident in the common area with others because it helped Resident #6. Resident #274 liked to sit in the common area and tried to be near Resident #6, but had never taken Resident #6 away from the common area. RN #2 identified that on 6/15/18 during the evening shift, NA #3 notified RN #2 that Resident #6 had been taken by Resident #274 to a resident room and NA #3 was not able to get into the room because the door was closed with Resident #6 and Resident #274 inside the room. RN #2 indicated that upon notification by NA #3 of Resident #6 and #274 being in the room, he/she went to room to attempt to open the door, but despite tugging and pulling the door handle, RN #2 indicated he/she was not able to enter the room. RN #2 noted that the door had been blocked by either a bed or a chair wedged to hold it closed from inside. RN #2 identified that NA #3 squeezed between the door and doorframe and got into the room. NA #3 moved a bed that was blocking the door, and opened the door. RN #2 noted that once NA #3 was able to enter the room, the residents were not left alone. RN #2 noted he/she contacted both the DNS and SW. RN #2 identified that the SW and DNS came to the room and were able to separate Resident #6 and Resident #274. RN #2 identified he/she completed a reportable event form and gave it to the DNS. RN #2 noted that he/she assessed that Resident #6 was not harmed, and documented the assessment on the reportable event form. Furthermore, RN #2 noted that following the event, the staff monitored Resident #6 because he/she was upset, and staff monitored Resident #274. Interview with DNS on 8/16/18 at 3:23 PM identified that he/she was aware and actively involved with the incident involving Resident #6 and Resident #274 on 6/15/18 and had been called to room. The DNS noted that Resident #274 thought Resident #6 was his her baby, and became very protective when any person was near Resident #6. Resident #274 protected Resident #6 and ran fast from the common area and tried to barricade himself/ herself and Resident #6 from staff. The DNS noted that staff diffused the situation with Resident #274 with persuasion. Although the DNS was unable to provide a time line to establish when Resident #274 and Resident #6 entered the room, the DNS indicated that the incident occurred very quickly. The DNS noted that RN #2 completed a reportable event form and RN #2 did an assessment of the involved residents and concluded that no harm to either resident. Furthermore, the DNS identified that although there were no documented staff interviews, a written summary or conclusion of his/her analysis related to the incident of 6/15/18, the DNS identified that the incident was investigated. The DNS identified he/she determined that there was no harm because of the incident. The DNS noted he/she identified no need to report incident to the state agency, or document the interviews because the incident did not result in harm. Furthermore, the DNS noted that his/her assessment of the incident was that Resident #274 had escalating behaviors related to dementia, and at the time of the incident, Resident #274 believed Resident #6 to be his/ her child, and was protecting Resident #6 from harm. The DNS noted that this was not a case of seclusion because staff did not place the resident in seclusion, and the DNS noted that this was not a resident to resident altercation because Resident #274 was attempting to protect Resident #6. Interview with the SW on 8/16/18 at 3:25 PM in conjunction with the DNS present identified that Resident #274 had moments of confusion and of lucidity. The SW noted that Resident #274 had a history of [REDACTED]. Interview with NA #3 on 8/16/18 at 4:55 PM identified that he/she arrived at work about 2:30 PM on 6/15/18 and although he/she was not assigned to Resident #6 or Resident #274, NA #3 observed Resident #6 and Resident #274 in the common area. NA #3 noted that at approximately 2:50 PM he/she last observed Resident #6 and Resident #274 in common area as NA #3 was in route to answer another resident's call bell. NA #3 identified that at change of shift, 3:00 PM, Resident #6 and Resident #274 were no longer in the common area. NA #3 identified that he/she went to look for these residents and found the door to the room barricaded with the residents inside. NA #3 identified that he/she notified RN #2. Although attempted on 8/16/18 and 8/17/18, interviews with NA #4, NA #5 and NA #6 were not obtained. Although requested from the DNS on 8/16/18 and 8/17/18, documentation of staff interviews related to the incident of 6/15/18 were not provided. Review of the facility policy and procedure for abuse prevention directed to assure that each resident has the right to be free from verbal, physical, mental or sexual abuse, corporal punishment and involuntary seclusion, mistreatment, neglect, misappropriation of resident property or abuse including injuries of unknown origin. Furthermore, the policy defines abuse as the willful (the individual acted deliberatively even no harm was intended) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual including a caretaker of goods or services and psychosocial well-being. The policy refers to the definition of abuse and neglect to define mistreatment. Additionally, it defines involuntary seclusion as separation from other residents or from his or her room or confinement to his or her room against the resident's will, or the will of a resident's legal guardian or representative. The policy identifies that residents with dementia, bedfast and totally dependent on care are at risk for abuse and neglect. The procedure includes investigating all reports of resident abuse, neglect, mistreatment, exploitation, misappropriation of resident property and injuries of an unknown source shall be promptly and thoroughly investigated. Furthermore the policy identifies that the unknown injury/incident investigation form is completed and reviewed by the Administrator/ DNS/or unit supervisor to ensure the safety of the residents has not been jeopardized, and to determine if further investigation is in order. The investigation will consist of a review of the unknown injury/incident report, interviews with persons reporting incident on interview form, interview with any witness to incident, interview with resident, review of resident's medical record, interview with staff members (on all shifts) having contact with resident during period of alleged incident, interview with resident's family members and visitors, interviews with other residents pertinent to incident, review of all circumstances surrounding the incident. Results of the investigation are reported to proper authorities on the state mandated report form. Furthermore, should alleged/suspected violation of unsubstantiated incident of mistreatment, neglect, abuse (including resident to resident altercation/abuse) be reported to home administrator or designee, DPH will be notified verbally and written of such an incident and the administrator will provide appropriate agencies with the report of the findings of the investigation.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #6) reviewed for resident to resident incidents, the facility failed to ensure the highest practicable well-being of the resident after an incident. The findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified Resident #6 had severely impaired cognition, required 2 person assistance with bed mobility and transfers, and was totally dependent for locomotion. The care plan dated 5/9/18 identified Resident #6 was unable to walk, and required staff assistance for all transfers. Interventions included to provide assistance of 2 for transfers, and utilize a specialized wheel chair, (Broda chair) for mobility. Additionally, the care plan identified Resident #6 had cognitive and communication deficits with impaired decision making capability. Interventions include to allow Resident #6 rest periods, explain tasks before beginning them, and provide a supportive environment. A physician's orders [REDACTED]. Resident #274 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/1/18 identified Resident #274 may attempt to barricade him/herself in rooms in order to hide from staff. Interventions included to anticipate needs, be attentive to Resident #274's whereabouts to ensure safety, maintain Resident #274's safety and the safety of others, and psychiatric follow up as needed. An annual MDS dated [DATE] identified Resident #274 had severely impaired cognition and delusions, was independent with walking, and required supervision for oversight and cueing with locomotion on and off the unit. A physician order [REDACTED].#274 to have a Wanderguard for safety. A nurse's note (Resident #6) dated 6/15/18 at 4:49 PM identified that Resident #6 was taken into a resident room by Resident #274, and bombarded in the room. The note indicated Resident #6 sustained no harm from being locked in the room with Resident #274. A reportable event form (Resident #6), dated 6/15/18 at 3:10 PM identified Resident #274 pushed Resident #6, who was in a wheelchair, into a resident room, and closed and barricaded the door shut with a bed. Although Resident #6 was not physically harmed, the report identified Resident # 6's mental status before the event was alert and quiet, and after the event Resident #6 was agitated. Additionally, the report identified both Resident #6's physician and family were notified. A reportable event form (Resident #274) dated 6/15/18 identified that on 6/15/18 at 3:10 PM Resident #274 pushed Resident #6 into a resident room and closed and barricaded the door shut with a bed. The report identified that Resident #274 repeatedly stated that Resident #6 was his/ her child, and became combative and aggressive with staff when attempts were made to remove Resident #6 from room. The reportable event form identified no apparent injury to Resident #274, however, it identified that the Resident #274's mental status before the event was alert and quiet, however, after the event Resident #274 was agitated, delusional, aggressive and physically and verbally abusive. Additionally, the report identified Resident #274 was sent to the emergency department for psychiatric evaluation. Facility documentation dated 6/15/18 identified Resident #274 was swinging his/her arms, yelling out, hitting and pushing and grabbing onto Resident #6's wheelchair during incident. Interview with RN #2 on 8/15/18 at 4:27 PM identified Resident #6 would become anxious at times, and staff would place the resident in the common area with others because it helped Resident #6. Resident #274 liked to sit in the common area and tried to be near Resident #6, but had never taken Resident #6 away from the common area. RN #2 identified that on 6/15/18 during the evening shift, NA #3 notified RN #2 that Resident #6 had been taken by Resident #274 to a resident room and NA #3 was not able to get into the room because the door was closed with Resident #6 and Resident #274 inside the room. RN #2 indicated that upon notification by NA #3 of Resident #6 and #274 being in the room, he/she went to room to attempt to open the door, but despite tugging and pulling the door handle, RN #2 indicated he/she was not able to enter the room. RN #2 noted that the door had been blocked by either a bed or a chair wedged to hold it closed from inside. RN #2 identified that NA # 6 squeezed between the door and doorframe and got into the room. NA #6 moved a bed that was blocking the door, and opened the door. RN #2 noted that once NA #3 was able to enter the room, the residents were not left alone. RN #2 noted he/she contacted both the DNS and SW. RN #2 identified that the SW and DNS came to the room and were able to separate Resident #6 and Resident #274. RN #2 identified he/she completed a reportable event form and gave it to the DNS. RN #2 noted that he/she assessed that Resident #6 was not harmed, and documented the assessment on the reportable event form. Furthermore, RN #2 noted that following the event, the staff monitored Resident #6 because he/she was upset, and staff monitored Resident #274. Interview with DNS on 8/16/18 at 3:23 PM identified that he/she was aware and actively involved with the incident involving Resident #6 and Resident #274 on 6/15/18 and had been called to room. The DNS noted that Resident #274 thought Resident #6 was his her baby, and became very protective when any person was near Resident #6. Resident #274 protected Resident #6 and ran fast from the common area and tried to barricade himself/ herself and Resident #6 from staff. The DNS noted that staff diffused the situation with Resident #274 with persuasion. Although the DNS was unable to provide a time line to establish when Resident #274 and Resident #6 entered the room, the DNS indicated that the incident occurred very quickly. The DNS noted that RN #2 completed a reportable event form and RN #2 did an assessment of the involved residents and concluded that no harm to either resident. Furthermore, the DNS identified that although there were no documented staff interviews, a written summary or conclusion of his/her analysis related to the incident of 6/15/18, the DNS identified that the incident was investigated. The DNS identified he/she determined that there was no harm because of the incident. Furthermore, the DNS noted that his/her assessment of the incident was that Resident #274 had escalating behaviors related to dementia, and at the time of the incident, Resident #274 believed Resident #6 to be his/ her child, and was protecting Resident #6 from harm. The DNS noted that this was not a case of seclusion because staff did not place the resident in seclusion, and the DNS noted that this was not a resident to resident altercation because Resident #274 was attempting to protect Resident #6. Interview with the SW on 8/16/18 at 3:25 PM and DNS identified that Resident #274 had moments of confusion and of lucidity. The SW noted that Resident #274 had a history of [REDACTED]. Interview with NA #3 on 8/16/18 at 4:55 PM identified that he/she arrived at work about 2:30 PM on 6/15/18 and although he/she was not assigned to neither Resident #6 nor Resident #274, NA #3 observed Resident #6 and Resident #274 in the common area. NA #3 noted that at approximately 2:50 PM he/she last observed Resident #6 and Resident #274 in common area as NA #3 was in route to answer another resident's call bell. NA #3 identified that at change of shift, 3:00 PM, Resident #6 and Resident #274 were no longer in the common area. NA #3 identified that he/she went to look for these residents and found the door to the room barricaded with the residents inside. NA #3 identified that he/she notified RN #2. Review of Resident #6's care plan on 8/15/18 failed to identify updated deficits or interventions related to the incident of 6/15/18. Interview with DNS on 8/17/18 at 8:55 AM identified DNS did not have documentation of nor additional information about interventions added to Resident #6's care plan following the incident of 6/15/18. Review of facility policy on care plan identified every resident will have a comprehensive care plan. The facility failed to document ongoing assessments and/or monitoring of Resident #6 and/or revise the care plan after the incident on 6/15/18 at 3:10 PM when Resident #274 pushed Resident #6 into a resident room and closed and barricaded the door shut with a bed. Subsequent to the incident, documentation identified Resident #6 was agitated.

Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #10), reviewed for accidents, the facility failed to ensure the plan of care was followed to prevent an accident. The findings include: Resident #10's [DIAGNOSES REDACTED]. A fall assessment dated [DATE] identified Resident #10 was at high risk for falls. The significant change MDS dated [DATE] identified Resident #10 was severely cognitively impaired and required extensive assistance of 2 staff with bed mobility, transfers and toilet use and extensive assistance of 1 staff with dressing, grooming and locomotion on unit. The MDS identified Resident #10 was not steady with moving from seated to standing position, moving on and off the toilet and/or transferring between bed and chair or wheelchair. Additionally, Resident #10 had a limitation of lower extremity range of motion on one side and used wheelchair for mobility. Further, Resident #10 had one fall with major injury since the last assessment. The care plan dated 6/20/18 identified Resident #10 was at risk for falls and had a fractured malleolus and poor balance. Interventions included to anticipate and meet needs promptly, assure proper footwear and utilize a chair alarm while in the recliner/wheelchair, and a bed alarm while in bed. The physician's orders [REDACTED]. Additionally, the physician's orders [REDACTED]. a. A reportable event form dated 7/7/18 identified that at 4:00 AM while RN #1 was responding to call light, Resident #10 was found in his/her room lying on the bathroom floor. Additionally, the floor was wet, and Resident #10 had been incontinent of urine. Further, the report identified the bed alarm had not been turned back after staff last toileted Resident #10. The reportable event form identified Resident #10 sustained a hematoma on the forehead with a 1.5cm linear skin split, and faint bruising of bilateral knees. Review of the facility's post-fall risk investigation identified that Resident #10 was last toileted at 1:30AM. Per the investigation, NA #2 indicated he/she was not aware the alarm had a remote on/off switch, and subsequently was educated on proper use/application of bed alarm. The investigation concluded the fall was likely due to misuse of the bed alarm. Interview with NA #2 on 8/16/18 at 10:00 AM identified that he/she had assisted Resident #10 to the bedside commode earlier in the shift. NA #2 indicated that prior to Resident #10 being transferred to the commode, one of the nurse's turned the alarm off (alarm box is located in the common area, not in the resident's room). After using the commode, NA #2 transferred Resident #10 back to bed and placed the call bell within reach. NA #2 further identified that he/she assumed the nurse would have turned the alarm back on afterwards. Interview with RN #1 on 8/16/18 at 10:45AM identified that on 7/7/18 at 4:00 AM he/she responded to Resident #10's call bell which was ringing. Resident #10 was found in bathroom lying on the floor in urine. RN #1 identified that the bed alarm was not sounding and upon further investigation found that the alarm switch was in the off position. RN #1 identified that when a resident is assisted out of bed, the nurse aide either asks someone to turn the alarm off prior to getting the resident up, or they turn it off themselves. Once the resident is safely back to bed, the nurse aide should ensure the alarm is turned back on. RN #1 further identified that it was NA #2's responsibility to ensure the alarm was turned back on after he/she finished toileting Resident #10. b. Observation on 8/16/18 at 9:00AM identified Resident #10 was sitting in a custom wheelchair in the common area of the unit. A chair alarm was not visible. Upon surveyor inquiry, NA #1 went to the Resident #10's room, retrieved the chair alarm, and brought it out to the common area. Resident #10 was then assisted to an armed chair with alarm pad placed beneath resident and the alarm box turned on and fastened to the arm of the chair. Interview with RN #4 at the time of observation identified that Resident #10 should be sitting in a regular chair when out on the unit, but still requires the use of a chair alarm for safety. RN #4 could not explain why the chair alarm was not in place as per the physician order. Interview with NA #1 at the time of observation identified that it was his/her responsibility to ensure the chair alarm was being used. NA #1 indicated that Resident #10 was attempting to get up unassisted earlier and because they had to respond, and transfer the resident quickly to the wheelchair, he/she forgot to put the chair alarm on. Review of the facility's alarm policy identified that alarms are used to provide the least restrictive environment for the resident while optimizing safety. Additionally, the bed alarm can be put on hold when care is being provided. Once the provision of care is complete, and the resident is remaining in bed, the alarm must be reset before staff leaves the resident's room.

Based on observations, clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #5), the facility failed to follow the resident's plan of care when applying zippered compression stockings. The findings include: Resident #5's [DIAGNOSES REDACTED]. Resident #5's Quarterly MDS assessment dated [DATE] identified Resident # 5 was without cognitive impairment and required extensive assistance with one person for all dressing which included doning of stockings. The Resident Care Plan (RCP) dated 7/5/17 identified variable assistance with adult daily living skills (ADL) due to his/her physical limitations related to chronic pain and [MEDICAL CONDITION]. Interventions directed to complete all ADL's Resident #5 is unable to complete. A physician's orders [REDACTED]. Review of the Resident's Grievance log dated 7/11/17 identified that Resident #5 had a concern with NA #1 on 7/7/17 when applying the bilateral zipper stockings after morning care. Resident #5 stated that on the morning of 7/7/17, NA #1 was attempting to apply the zipper compression stockings and did not unzip the stockings prior to putting the stockings on his/her legs. Resident #5 instructed NA #1 to unzip the stockings before the application but NA #1 continued to put on the stockings already zipped. Resident #5 stated that his/her knee was in pain and that he/she told NA #1 to stop. Resident #5 stated that he/she was upset over the incident and reported a grievance to the Social Worker on 7/11/17. Further review of the grievance identified that the Social Worker and the Director of Nursing Services met with Resident #5 and NA #1 on 7/11/17 and that NA #1 was re-educated on 7/11/17 on the importance of following the proper procedure on putting on the compression stockings with zippers. In an interview on 8/31/17 at 10:00 AM, Resident #5 was able to recall the incident and further stated that he/she felt that NA #1 was rushing to get the zippered compression stockings on that morning and did not unzip them prior to putting them on the resident. Resident #5 further stated that he/she told NA #1 to unzip them before applying the stockings but that NA #1 continued to apply them already zipped. Resident #5 further stated that he/she was in pain and told NA #1 to stop putting them on him/her. Resident #5 met with the Social Worker and yhe DNS and was pleased with the facility's outcome. Interview with NA #1 on 8/30/17 at 10:20 AM identified that he/she was Resident #5's aide on 7/7/17 and did put on the zippered compression stockings while still zipped but was not familiar with them and was never inserviced on how to use the stockings. NA #1 further stated that Resident #5 has chronic pain and that morning of 7/7/17 complained of pain to him/her. NA #1 told the resident's nurse before continuing with care and returned to continue with care for Resident #5 after the nurse medicated the resident. NA #1 stated that the resident did not complain of anymore pain to him/her. Interview the DNS on 8/29/17 at 3:00 PM stated that he/she met with Resident #5 on 7/11/17 and that the resident felt that NA #1 was trying to do his/her job quickly and did not follow the proper way of putting on the compression stockings. The DNS immediately on that day did an inservice with NA #1 on how to apply zippered compression stockings and to be more attentive and listen to resident's requests carefully.

Based on clinical record review and interviews, for one sample resident (Resident #21) reviewed for special services, the facility failed to ensure there was written communication and/or documentation of hospice visits and/or for one of five residents reviewed for pain management (Resident #25), the facility failed to ensure that when a resident verbalized pain that the pain concern was addressed according to the facility's policy. The findings include: a. Resident #21's [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified Resident #21 was without cognitive impairment and required extensive assistance of one staff with ADLs. physician's orders [REDACTED]. Review of the hospice documentation indicated hospice services commenced on 7/26/17, and the hospice nurse would visit Resident #21 twice per week. Computerized comprehensive assessment and plan of care update reports were completed on 7/28/17 and 8/11/17. Hospice suggestions were written on communication notes on 7/26/17 and 8/1/17. Although the record contained a blank interdisciplinary visit sheet, the record failed to contain any narrative notes written by the hospice nurse from 7/26/17 to present. Interview with RN #1 on 8/31/17 at 10:20 AM indicated though the resident was seen twice per week, the hospice nurse usually writes notes on the interdisciplinary visit sheet and questioned whether notes are now written in the hospice nurse's computer. Interview with the DNS on 8/31/17 at 11:15 AM indicated the DNS was unaware if notes are kept by the hospice nurse but the nurse does not document notes from the visits in the resident's chart. Interview with RN #3, (hospice nurse), indicated Resident #21 is seen twice per week, visit notes are written in a tablet computer, and a copy of the note is not made for the facility or resident's chart. RN #3 further indicated the nurse verbally communicates with the nursing supervisor or DNS after the visit if he/she is available and this is the process that has always been followed. The facility lacked a consistent communication mechanism between the facility and the hospice nurse. b. Resident #25's [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE] reflected that Resident #25 did not have any cognitive impairment and that he/she needed one to two staff persons to provide extensive physical assistance with activities of daily living. The resident's care plan dated 4/26/17 and last revised 6/7/17 identified that Resident #25 had chronic pain in his/her knees related to the [DIAGNOSES REDACTED].e. resting splint to knee). A review of the physician's orders [REDACTED]. A review of the nursing notes dated 7/20/17 identified that Resident #25 was seen by psych APRN #1. Review of the behavioral health assessment dated [DATE] indicated that Resident #25 had been demonstrating anxiety. Further review of the assessment indicated that Resident #25 denied anxiety however, expressed concerns with knee pain. Review of the assessment directed the staff to continue current medication regime and to monitor the resident for pain. A review of the nursing notes from 7/20/17 thru 8/30/17 failed to reflect whether Resident #25 was asked about pain consistently and/or the effectiveness of the [MEDICATION NAME]. A review of the resident's vital sign sheet indicated that Resident #25 verbalized to the staff 7 times (from 7/20/17- 8/30/17) that he/she had pain. Although review of the Medication Administration Record [REDACTED]. A review of the facility's policy indicated that the licensed nurse on duty is responsible to take immediate action to effectively treat the pain, a pain assessment flowsheet will monitor complaints and intensity of pain and documentation of the date, time, pain site, pain level, medication offered or declined and medication given with dose and route, staff observation and the outcome. The staff is expected to document after one (1) hour the effectiveness and or ineffectiveness of the intervention. Interview with the Director of Nurse on 8/31/17 at 11:00 AM indicated that he/she expects the staff to document on the resident's pain per policy but he/she believed that the computer program failed the facility because it didn't link the routine pain medication administration with a follow-up link to document the medication effectiveness.

Based on observation, review of the clinical record, review of facility policy, and interviews, for one of three residents (Resident #2) reviewed for dental services, the facility failed to provide dental services in a timely manner. The findings include: Resident #2's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified that Resident #2 had no cognitive impairment and required extensive assistance of one person for personal hygiene. The Resident Care Plan dated 5/10/17 identified Resident #2 was at risk for weight change and dehydration due to some difficulty chewing and at times requests ground or pureed meats. Interventions directed to provide a dental consult as needed, to provide an oral assessment annually and to provide a softer ground and pureed food as desired. An oral assessment dated [DATE] identified that Resident #2 had 4 lower gum teeth and that dentures were being made. A physician's orders [REDACTED].#2 may have meats modified (ground/puree) as requested. A nursing note dated 5/19/17 at 10:38 AM identified that Resident #2 was seen by Dentist # 1 for fitting for new dentures and that impressions were taken for a better fit with a plan to dispense new denture at next visit. Interview with Resident #2 on 8/28/17 at 1:30 PM identified that he/she would like dentures but earlier this year some time before the summer months was told it would cost him/her $1,300.00 for dentures and he/she is unable to pay that amount of money. Interview with LPN #1 on 8/30/17 at 12:15 PM identified that Resident #2 does not have dentures. Interview with LPN #2 on 8/31/17 at 1:40 PM identified that he/she is responsible to arrange for dental visits and/or dental follow up visits. Further interview with LPN #2 identified that he/she was with Dentist #1 on 5/19/17 when Resident #2 was seen by Dentist #1. LPN #2 identified the new denture did not fit well and that Dentist #1 took a new impression and took back the denture to make an adjustment. Further interview with LPN #2 identified that she put a check mark next to Resident # 2's name for the month of June 2017 indicating Resident #2 required a follow up dental visit. Review of the clinical record failed to failed to reflect that Resident #2 had been seen by the dentist since May of 2017. The facility lacked documentation that Resident #2 had been seen by the dentist since May of 2017.

Based on observations, review of the clinical record, review of facility policy and staff interviews for one of one sampled resident (Resident # 6) the facility failed to ensure licensed staff administered a prescribed oral solution. The findings include: Resident # 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely cognitively impaired (BIMS score of 07) and required assistance of one staff for personal hygiene. The care plan dated 7/20/16 identified that R# 6 required assistance with care due to visual impairment and cognitive deficit. Interventions included to provide assistance with oral mouth wash as needed. Physician orders [REDACTED]. Swish for 30 seconds and spit out. (CNA flow sheet). Observation on 9/26/16 at 11:00 AM identified a full unopened bottle and an opened bottle of [MEDICATION NAME] CHG oral rinse on a shelf in R # 6 ' s bathroom. Observation on 9/29/16 at 9:30 AM identified one opened bottle of [MEDICATION NAME] CHG oral rinse on a shelf in R#6 ' s bathroom. Interview with RN # 1 on 9/29/16 at 9:30 AM indicated the [MEDICATION NAME] should not be left in the room and indicated that the nurse aides give the resident the [MEDICATION NAME] as part of oral care daily. Subsequently, the [MEDICATION NAME] was removed from R # 6 ' s bathroom. Additionally, RN # 1 indicated that the 11-7 shift provides the [MEDICATION NAME] with oral care in the morning. Interview with the DNS on 9/29/16 at 10:11 AM identified that the facility implemented a policy related to oral care after having been provided education on oral care. The DNS identified that nurse aides are doing the [MEDICATION NAME] rinse as he/she thought that [MEDICATION NAME] was a rinse and could be provided by the nurse aides according to the education. The DNS indicated he/she was unaware that the [MEDICATION NAME] was being left in the resident ' s room. The DNS indicated that the facility policy on oral care did not specifically address [MEDICATION NAME], he/she thought it was appropriate that the nurse aides provide it. Review of nurse aide documentation dated 9/01/16 through 9/28/16 identified that [MEDICATION NAME] was administered by nurse aide twice daily. Facility's policy on oral care indicates to dip toothbrush into cleaning paste or rinse, removing excess. Brush the teeth, clean the toothbrush periodically by wiping with a towel or to remove debris, dip brush into cleaning paste or rinse before continuing. The policy did not address [MEDICATION NAME]. The medication, self-administration policy identified in part, that for the resident who self-administers medications, the medication is kept in a locked container in the resident ' s room to safe-guard it from others.

Based on observations, review of the clinical record, review of facility policy, and staff interviews for one of one sampled resident (Resident # 6), the facility failed to ensure medication was secured to ensure the safety of residents. The findings include: Resident # 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified R# 6 as severely cognitively impaired (BIMS score of 07) and required the assistance of one staff for personal hygiene. The care plan dated 7/20/16 identified that R # 6 required assistance with care due to visual impairment and cognitive deficit. Interventions included to provide assistance with oral mouth wash as needed. Physician orders [REDACTED]. Swish for 30 seconds and spit out. (CNA flow sheet). Observation on 9/26/16 at 11:00 AM identified a full unopened bottle and an opened bottle of Peridex CHG oral rinse on a shelf in R # 6 ' s bathroom. Observation on 9/29/16 at 9:30 AM identified one opened bottle of Peridex CHG oral rinse on a shelf in R # 6 ' s bathroom. Interview with RN # 1 on 9/29/16 at 9:30 AM indicated the Peridex should not be left in the room and indicated that the nurse aides give the resident the Peridex as part of oral care daily. Subsequently, the Peridex was removed from R#6 ' s bathroom. Additionally, RN# 1 indicated that the 11-7 shift provides the Peridex with oral care in the morning. Interview with the DNS on 9/29/16 at 10:11 AM identified that the facility implemented a policy related to oral care after having been provided education on oral care. The DNS identified that nurse aides are doing the Peridex rinse as he/she thought that Peridex was a rinse and could be provided by the nurse aides according to the education. The DNS indicated he/she was unaware that the Peridex was being left in the resident ' s room. The DNS indicated that the facility policy on oral care did not specifically address Peridex; he/she thought it was appropriate that the nurse aides provide it. The medication, self-administration policy identified in part, that for the resident who self-administers medications, the medication is kept in a locked container in the resident's room to safe-guard it from others.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents reviewed for Activities of Daily Living (Resident # 8) the facility failed to ensure the clinical record was complete and accurate, and/or the facility failed to ensure a physician's orders [REDACTED]. The findings include: Resident # 8 ' s [DIAGNOSES REDACTED]. The Resident Care Plan (RCP) dated 7/27/16 identified comfort care and advanced directives in place. Interventions included to respect comfort care (DNR, no feeding tube, no lab work, no weights, no finger sticks, no IV fluids and no hospitalization ), and to review advanced directives quarterly and with any significant change. A physician's order [REDACTED]. The significant change MDS assessment dated [DATE] identified Resident # 8 had severely impaired cognitive skills for daily decision making, and required extensive assistance with personal hygiene. Nurse's note dated 8/27/16 at 14:24 identified that at 11:45 AM R#8 had no pulse, no respirations and was unresponsive to verbal/physical stimuli, and RN pronounced R# 8 at 11:46 AM. Additional review of the clinical record failed to identify a physician's order [REDACTED]. Review of the death certificate dated 8/27/16 identified death was pronounced by RN # 1 at 11:46 AM. In an interview and clinical record review with the DON and RN # 1 on 9/29/16 at 10:40 AM, RN # 1 stated he/she had pronounced R # 8 ' s death, and he/she did not look for a physician's order [REDACTED].# 8 ' s death. Although a review of the clinical record identified physician progress notes [REDACTED].# 1 were unable to provide documentation to reflect that a physician's order [REDACTED]. Interview with Physician # 1 on 9/29/16 at 1:04 PM identified there should have been a physician's order [REDACTED]. Review of facility Death Pronouncement Policy, Pronouncement of Death by a Registered Nurse identified in part, the Physician writes a progress note including that death is likely to occur within six months, the determination shall be valid for a period of time not to exceed 120 days, and the Physician writes an order that the Registered Nurse May Pronounce a death of a Resident with a DNR status.

failed to maintain kitchen equipment in a clean and/or sanitary manner and/or failed to maintain dishwasher temperatures. Based on observation and interview facility failed maintain kitchen equipment in a clean and sanitary manner, and /or maintain dishwasher temperature log and/or to follow appropriate hand washing practices: The findings included: During a tour and observation of the dietary department with the FSD present on 9/2/14 at 10:10 AM the following was identified : 1. Two walk in freezers were noted to contain large accumulation of ice stemming from the freezing unit on top of food products,shelving and the floors. 2. The primary freezer was noted with large accumulation of ice at the door seal, and on the threshold of the door. 3. Two large fans were noted soiled with build up of grease, dirt and dust. 4. Dishwasher temperature log was not documented for the day and the dishwasher washing temperature gauge was noted to not be functioning. Subsequent observation on 9/3/14 identified that the log lacked any temperature entry. 5. DA #1 was observed alone in the dishwashing room washing utensils, dishware, pots and pan and other kitchen ware. DA#1 was noted to multiple times clean /rinse soiled ware and without the benefit of washing hands,donning gloves and/or any other infection control measure, crossed to the clean dishware and proceeded to handle the various kitchen ware. Interview and observation with the FSD at 10:15 AM indicated that staff are to wash hands and replace gloves when moving from soiled to clean. Interview with the FSD on 9/3/14 at 12:30 PM indicated that although the gauge continued to not function, temperatures were tested yesterday. Interview with the maintenance director on 9/3/14 at 12:35 PM indicated that temperature test strips were to be utilized as a interim measure until the gauge was replaced. Subsequent interview with the FSD and DA#2 on 9/3/14 indicated that they were unaware of the need for temperature test strips. Facility hand washing policy and procedure identfied in part that dishwashers should always was their hands before handling clean dishes.

Based on observation and interview, the facility failed to follow appropriate sanitary dish washing practices: The findings included: During a tour and observation of the dietary department with the FSD present on 9/2/14 at 10:10 AM, DA #1 was observed in the dishwashing room. DA#1 was observed moving back and forth from handling dirty dishes to clean dishes without the benefit of handwashing between tasks. Interview and observation with the FSD at 10:15 AM indicated that staff are to wash hands and replace gloves when moving from soiled to clean. Facility hand washing policy and procedure identfied in part that dishwashers should always wash their hands before handling clean dishes.

Based on review of the clinical record, facility policy and procedures and interviews for the only sampled resident reviewed for urinary incontinence (R #14), the facility failed to provide care/services to improve and/or prevent a decline in normal bladder function. The findings included: Resident#14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident without cognitive impairment, independent for activities of daily living and always continent in terms of his/her bladder status. The RCP updated on 5/7/14 identified urinary urgency incontinence. Interventions included nurse aides to encourage bladder exercises and the resident is to inform nurse aides of the number of times he/she has an episode of incontinence every shift. On 9/4/14 at 11:00 A.M., an interview and review of the admission incontinence management assessment form dated 5/1/14 with RN #1 indicated that the resident was admitted to the skilled floor from the fourth floor (Residential unit) due to occasional urinary incontinence and that s/he has been seen by an APRN since 2011 for the problem. The APRN assessment dated [DATE] identified urinary incontinence, urgency, nocturia of the bladder for one + (plus) years, stable in quality and moderate in terms of severity. The APRN plan included to continue [MEDICATION NAME] 10mg (milligrams) every day (for overactive bladder), scheduled toileting and review and maintain plan of care. A review of a most recent quarterly MDS assessment dated [DATE] identified the resident ' s bladder function declined from always being continent to frequently incontinent of urine. A review of the nurse aide flow sheets identified that although the resident was noted as continent of urine from the period of 4/22 to 4/30/14; the resident was identified as having 1-2 episodes of urinary incontinence per shift (i.e. 7A.M.-3P.M., 3P.M.-11P.M. and 11P.M.-7A.M.) during the period of 5/1 -7/31/14. On 9/4/14 at 11:47 A.M. an interview and review of the clinical record with the DON and the MDS Coordinator (LPN#1) identified that although the APRN identified the resident was on a scheduled toileting plan, the resident remained independent with toileting, refused the toileting schedule and therefore it is care planned for the resident to report to the aides if and/or when he/she experiences urinary incontinence per shift. LPN#1 further indicated that during the admission assessment period (7-days) the resident was continent which was why he/she was coded as being "always continent" and that although it was identified by the facility that the resident had a change in his/her bladder status from "always in continent of urine" to "frequently incontinent of urine", documentation was lacking to reflect that the facility re-assessed the resident's bladder status when a further decline was noted. According to the facility policy and procedure which identified in part that the incontinence management assessment must be completed on or before the 7th day upon admission, change of continence/condition and annually.

Based on initial tour of kitchen, the facility failed to ensure outdated foods were disposed of in a timely manner. The findings include: Initial tour of the kitchen completed on 7/30/13 at 9:30 AM identified the following prepared items in the walk-in refrigerator: green beans, beef stroganoff, egg salad, diced tomatoes, and tomato sauce documented as prepared on 7/26/13 and/or to be discarded on 7/29/13. In addition, prepared tartar sauce was dated as prepared 7/19/13. Salami and liverwurst were both dated 7/19/13. All of the above food items were removed and discarded by the Director of Dietary. Interview with the Director of Dietary at the time indicated facility policy is that prepared foods should be used within or discarded in three days.

Based on observation of medication administration for 1 of 3 sampled residents (Resident #26), the facility failed to ensure the resident received medication as directed by the physician. The findings include: Resident #29's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as cognitively intact. Physician orders [REDACTED]. On 7/30/13 at 9:53 AM, observation of medication administration with LPN#1 identified LPN#1 administered the resident her/his oral medication, gave the resident the handihaler with the Spirvia cap already in place and instructed the resident to breathe in. Resident #26 inhaled the medication once and gave the handihaler back to LPN#1. LPN#1 then emptied the used contents from the handihaler into the trash without having the resident complete the second inhalation. Interview with LPN#1 on 7/30/13 at 9:54 identified that she had not had R#26 complete 2 inhalations because she thought the order was for one inhalation per capsule.

Based on observations of the kitchen and interviews, the facility failed to ensure that expired food items were removed from the current inventory and discarded. The findings include: During observations of the kitchen on 9/24/12 at 10:15 AM with the Food Service Director several expired food items were noted in the dry storage area. The expired food items included sixteen boxes of baking soda with expiration dates of 7/10, 6/11 and 7/11; two gallons of apple cider vinegar with an expiration date of 9/09, twelve gallons of apple juice with expiration dates of 12/11 and nine gallons of water with expiration dates of 6/12. Interview on 9/24/12 at 10:30 AM the Food Service Director stated he was responsible for stocking and rotating the food supplies and must have missed the expired items. Review of the facility's policy indicated that food items should be stored so that first foods in will be first food out for use in production.

Based on observation, interviews, review of facility documentation and/or facility policy and procedures, the facility failed to prepare, store and/or serve food under sanitary condition and/or failed to maintain a sanitary environment. The findings included: On 9/13/11 at 9:45 A.M., observation of the kitchen area with the Chef Manager (CM) identified the following: 1. Dirt, dust particles, debris and/or old food were scattered in various areas on the floors of the kitchen (i.e. near the stove, refrigerators, underneath the three compartment sink and prep tables). An interview with the CM at the time indicated that although breakfast service was completed at 8:00 A.M. on that morning, the floors were to have been mopped and swept daily and as often as needed. 2. A prep table positioned in front of a stove was noted to have particles of rice, seasonings, dried mashed potato powder and flour scattered on the lower shelf of the table utilized to store food items. 3. A wall mounted air vent that was in operation and positioned near an industrial size mixer was identified as having clumps of dust, cobwebs, dirt, and debris along the blades and/or fins covering the air vent. An interview with the Chef Manager at the time indicated that the vents were to have been cleaned on a monthly basis via maintenance and could not attest to when the most recent cleaning had occurred. The CM further indicated that he would contact maintenance and request that the vent be cleaned. 4. Observation of food items in a refrigerator utilized for the storage of salad fixings (i.e. lettuce, sliced tomatoes, onions and bell peppers, cottage cheese, tuna and coleslaw) and desserts noted the items being stored with foods and beverages belonging to staff, in the lower half of the refrigerator. It was further noted that although the salad fixings were being stored in their own separate containers, dates were lacking to reflect the age and/or shelf life of each of the food items. 5. A tray containing 9 bowls of chocolate e-claires and a bowl containing a gelatin mold with fruit, were being stored in a refrigerator shared by staff without the benefit of being properly covered and/or labeled with dates to mark the age and/or shelf-life of each food item. On 9/13/11 at 9:45 A.M. an interview with the Chef Manager indicated that the items were to be covered and/or dated. Subsequent to surveyor inquiry, the Chef Manager was observed throwing the uncovered and/or undated food items out. 6. Observation of the walk-in freezer identified heavy patches of ice and/or thick patches of frost on the freezer racks, walls, and ceiling, on several boxes of food stored on the freezer racks and on the floor of the freezer. It was further noted that old food was identified as being frozen and stuck to the floor (i.e. meatballs). An interview with the Chef Manager at the time indicated that the freezer was to have been defrosted on a monthly basis. On 9/14/11 and 9/15/11 at 9:00 A.M. and 1:40 P.M. an interview with the Chef Manager and the Director of Dining Services indicated that the seal was broken around the door and that a repairman had arrived on 9/14/11 to re-enforce the seal. The Director of Dining Services further indicated that as of 8/3/11, the facility was in the process of replacing the doors on two of the walk-in freezers and that the freezer with the patches of ice was related to a water leak. Although the Director was aware of the water leak, the facility failed to devise a plan to manage the leaking water to prevent it from turning into large patches of frost and/or ice. Subsequent to surveyor ' s inquiry, on 9/14/11 the facility was noted utilizing a crowbar to break up the large patches of ice that were stuck to floor and walls of the walk-in freezer. 7. On 9/13/11 at 9:40 A.M., during observation of the dishwasher's rinse cycle, it was noted that it took three attempts for the dishwasher to reach the appropriate temperature for its rinse cycle (i.e. 180 degrees Fahrenheit). An interview with the Chef Manager at the time indicated that there had been problems with the dishwasher meeting the appropriate temperature in the past and when that happens, the staff would utilize a thermometer to check the temperature of the dishes and if the temps were 180 degrees and/or above, then the dishes considered sanitized. On 9/15/11 at 1:40 P.M. a review of the dishwasher's temperature log with the Director of Dining Services, lacked documentation to reflect that the temps were being monitored and/or logged on a consistent basis for 6/18/11, to 6/21/11, 6/23/11, 6/24/11, 6/28/11; 7/6/11, 7/9/11, 7/26/11, 8/1/11, 8/18/11, 8/22/11 to 8/24/11, 8/26/11 to 8/27/11 and for 9/12/11 through the morning of 9/14/11. The Director indicated that although the temps weren't logged for at least three events in August of 2011 due to a picnic and paper products were utilized, the temps for the dishwasher were to have been obtained at a minimum, of twice daily. 8. On 9/15/11 at 9:30 A.M. an observation of the facility's emergency food supply and a review of its three day menu with the Director of Dining Services identified that documentation was lacking to reflect that a menu had been developed for use in an emergency. The Director further indicated that although he had an emergency food supply set up for use, he didn't have a formalized menu in place. 9. On 9/15/11 at 9:30 A.M. upon review of the facility emergency food supply, it was identified that the facility was storing several food items that were outdated and damaged as part of their emergency food supply. The outdated food items consisted of 6 bottles of 14 ounces (oz.) of grape juices dated for best use by 2/3/11; 2 cases of 12, 13.5 oz. cans of spinach dated for best use by 2/28/10; 9 containers of 12 oz. of dry coffee creamers dated for best use by 7/06; one-6 lbs. (pound) can of pineapple bits dated for best use by 1/25/11; 2-8 oz. canisters of dry coffee grounds dated for best use by 6/11. The damaged food items consisted of several dented cans (i.e. 6 lbs. cans of applesauce and chili (undated); peaches, sauerkraut and pears and six-46 oz. cans of pineapple juice). It was further noted that dust and cobwebs were noted on the bottom of the second shelf housing the aforementioned food items. An interview with the Dining Service Director at the time indicated that although the emergency stock was to have been rotated each month, and that all food items were to have been dated and the dented cans were to be placed in a bin and returned to the food supplier for credit, he could not explain why the facility failed to do so. 10. Observation of a refrigerator storing the facility bread supply identified a bag containing a staff persons items (i.e. 3 bottles of Gatorade, 2 bottles of spring water and one small juice box). On 9 /15/11 at 1:40 P.M. an interview with the Director of Dining Services indicated that the kitchen staff were to have stored their person food items and beverages in a staff refrigerator outside of the kitchen area. 11. Observation of a walk-in refrigerator identified 6 blocks of cheese though which although wrapped, were not dated to indicate the age and/or the shelf-life of the item. It was further noted that one of the blocks of cheese was growing a greenish/gray colored substance and was subsequently throw away by the Chef Manager upon observation.

Based on clinical record review and interview for 1 of 2 sampled residents (Resident #24) reviewed for missing property, the facility failed to ensure that the resident's behavior of having frequent complaints of missing property was including in the resident's care plan. The findings include: Resident #24's [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was without cognitive or memory impairments, had no behaviors or mood disorders and required a varied amount of assistance with all activities of daily living. In an interview with the resident on 09/14/11, the resident identified that there were various clothing items as well as other personal items that were missing. The resident identified that this had been reported to facility personnel. A social service note dated 7/26/11 noted that the resident continued to state that things have been taken from the room and noted that the resident also referred to items that were missing prior to the resident's admission to the skilled unit from the assisted living unit, and that many of the items that the resident referred to as "stolen" were found shortly after it was reported they were missing. The note further identified that all accusations were investigated but that there was no evidence that certain items were removed by staff. Review of the grievance records and the incident records failed to note that either had been completed in relation to the resident's allegations. Interview with the social worker on 09/15/11 at 1:00 PM identified that the resident had a history of [REDACTED]. Review of the resident's care plan failed to indicate the problem of accusatory behavior and/or interventions to address the behavior.