Every finding on record at St Mark Village

Based on observations, staff interviews and record review, the facility failed to ensure food was stored in a clean, safe and sanitary manner, free from contamination, in one kitchen (Main) of one observed, and in two nourishment pantries (Long-term side - #1 and Rehabilitation side - #2) of two observed. Findings included: On 5/26/2026 at 9:25 a.m. a tour of the main kitchen with the facility's dietician and the kitchen manager revealed following:-The walk-in refrigerator unit was observed with a four-fan housing plate on the back wall and ceiling. The fan housing plate was observed with dust and debris. The refrigerator unit was stocked with food items, some in boxes and some in clear containers. The fans with dust and debris were blowing air inside the unit directly on the food items.- The walk-in freezer unit was observed with various food and paper debris. A shallow metal tray with four clear plastic bags of frozen fish was observed placed on the bare floor of the unit and not on an elevated shelf. The kitchen manager observed the same and confirmed there should not be any food items stored on the bare floor and stated all foods must be stored on the shelves. He observed the debris all over the floor and stated the floor should have been swept clean. An unidentified kitchen staff member was observed to pick up the tray of fish and placed it on top of other boxes of food on the other side of the freezer unit. On 5/28/2026 at 10:00 a.m. a tour of the facility's two nourishment pantries was conducted with the dietician and the assistant dietary manager revealing the following:-Nourishment pantry #1(Long-term side) was observed with three soft ice packs in the freezer. The dietician and assistant dietary manager were not sure why the ice packs were in the freezer, nor did they know what they were used for. The assistant dietary manager thought perhaps it was from the nursing department used for health reasons as the kitchen staff do not use those type of ice packs. The dietician confirmed the kitchen does not utilize those types of ice packs. Pantry #1 was observed with the refrigerator containing two fabric type lunch boxes that belonged to nursing employees, and an unlabeled and undated one box of pizza with several slices of pizza in it. The refrigerator had two Styrofoam plastic containers full of unknown food items which were not labeled with content or date. The dietician confirmed the containers should have been labeled with the contents and date of when they were put in the refrigerator. The assistant dietary manager stated she had to go through the refrigerator and throw away things that are not dated or labeled with contents. She stated these items were from nursing staff and not for the residents consumption. Nourishment pantry #2 located next to the rehabilitation side nurse station was observed with 18 soft ice packs in the freezer. The dietician and assistant dietary manager confirmed they were not sure why those packs were stored in the nourishment freezer and did not know which staff put them there. The assistant dietary manager stated she checks the refrigerator/freezers at least daily and did not remember all those ice packs stored there before. On 5/28/2026 at 10:25 a.m. an interview with the Licensed Practical Nurse (LPN) Staff D, who was working the rehabilitation unit revealed she was not aware of exactly what the ice packs were for and guessed they were from therapy and stated they use them for residents, placing them on their body for therapeutic reasons. Staff D, LPN stated they may also be used to put in the containers on the medication carts to keep liquids cool and stated she did not use them. On 5/28/2026 at 10:30 a.m. an interview with the rehabilitation director revealed all the items in the nourishment pantry refrigerator/freezer were supposed to be resident oriented only and not to be used for employees. In regards to the 18 ice packs found in the nourishment freezers, she said she did not know what they were used for and did not believe therapy staff used them for resident's health care reasons. She stated she never noticed the ice packs before but confirmed they should not be kept in the nourishment pantry freezer. On 5/28/2026 at 10:40 a.m. the main kitchen which was utilized for the Long-Term Care facility meals, the Assisted Living Facility, and the Independent Living facility was toured with the kitchen manager and the dietician. The following was observed:- The walk-in freezer was observed with food items to include two large circular bins of ice cream stored on the bare floor. The kitchen manager confirmed the observation and said they should not be stored on the bare floor for any period of time. Review of the facility policy titled, Food Safety Requirements, Revision date 4/2018, revealed: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared and served in accordance with professional standards for food service safety.Definitions: Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects.Policy Explanation and Compliance Guidelines:1.) Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:B . Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. C . Refrigerator storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storages:iii. Separating raw foods (e.g., beef, fish, lamb, pork and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat food so that meat juices do not drip onto these foods.

Based on record review and interview, the facility failed to provide the representative of the office of the State Long-Term Care (LTC) Ombudsman program with discharge notices for residents transferred to the hospital, to include one resident (#48) of one sampled for hospital discharge transfers. Findings included: An interview on 05/28/2026 at 2:42 PM with Staff E, Social Services Director (SSD) and the Nursing Home Administrator (NHA) revealed nursing staff completes the documentation for unplanned transfers to the hospital from the facility and the role of an SSD included notifying the LTC Ombudsman of planned discharges. Staff E and the NHA stated they were not aware of the facility's responsibility to notify the LTC Ombudsman of transfers to the hospital. Staff E and the NHA said they notified the LTC Ombudsman for planned discharges but not unplanned hospital transfers. They could not verify how many residents were affected. Review of the Agency for Health Care Administration (AHCA) Form 3120-002 revealed the following regarding notifications:Notice given to: Resident, Legal Guardian or Representative ____________ (date)Local Long Term Care Ombudsman Council ____________ (date)Resident Clinical Record ____________ (date)Attachments:Request for Ombudsman Review and Request for Fair Hearing. Record review for Resident #48 revealed an admission date of 01/22/2026. A progress note for Resident #48 dated 03/09/2026 revealed the resident was presenting with worsening dyspnea accompanied with hypoxia and was recommended an immediate transfer to the emergency department for further evaluation and treatment. The Nursing Home Transfer and Discharge Notice for Resident #48 dated 3/9/2026 revealed the resident was transferred to the hospital because, Your needs cannot be met in this facility, with a brief explanation showing the resident required acute care. The transfer notice did not show the required notification had been sent to the LTC Ombudsman. During an interview on 05/28/2026 at 2:42 PM with Staff E, SSD, Staff E stated the resident was transferred for acute care. Staff E, SSD did not provide documentation of the transfer notice sent to the LTC Ombudsman representative related to Resident #48's transfer to the hospital from the facility. An interview conducted on 05/28/2026 at 3:26 PM with the LTC Ombudsman representative revealed the facility would typically send a fax to their office to provide notice of resident's transfers. The LTC Ombudsman said there was no indication their office was notified of Resident #48 being transferred to the hospital from the facility. The LTC Ombudsman said they expected to receive notification for all transfers. The LTC Ombudsman stated for residents transferred to the hospital in March 2026, they expected to receive that facility's monthly log of transfers around April 1st or 2nd. The LTC Ombudsman confirmed not having received any transfer notices from the facility. Review of a facility policy titled Admission, Retention, Transfer and Discharge Policies, revised 12/14/2022, revealed resident transfer to a hospital or other medical facility will only be made with the approval of the Resident and/or responsible party and ordered by the attending physician, or in the event of an acute medical emergency. The policy did not reveal a procedure for notifying the LTC Ombudsman of residents who transferred to a hospital.

Based on observations, record reviews, and interviews, the facility failed to ensure hearing assistive devices were provided for one resident (#3) out of one resident sampled.Findings included: Review of Resident #3's admission record revealed an original admission date of 04/13/2026 and a readmission date of 04/26/2026 with diagnoses to include cognitive communication deficit and unspecified dementia. Review of Resident #3's Minimum Data Set (MDS) dated [DATE], revealed the following: Section B- hearing, speech, and vision revealed the resident has moderate hearing with hearing aids and the speaker must increase volume and speak distinctly. Section C, Brief Interview for Mental Status (BIMS) summary score was 15 out of 15, meaning cognitively intact and section O, Special Treatments, Procedures, and Programs revealed Resident #3 received speech-language pathology and audiology services.Review of Resident #3's care plan revealed a focus:- Communication problem related to impaired hearing, impaired cognition, initiated on 04/16/2026 and interventions to include the following: anticipate and meet needs, ensure hearing aids left, and right are in place, speaking clearly and slower than normal. During an observation and interview on 05/27/2026 at 9:10 a.m. Resident #3 was lying in bed. While greeting, Resident #3 she responded in a loud voice and asked several times to repeat the greeting and the purpose of the visit. The resident stated she was unable to hear and requested to come closer and speak into her right ear. A hearing aid was observed in place. Resident #3 reported that her hearing aid was replaced approximately four years ago, which was also the last time her hearing was evaluated. The resident stated that facility staff have not helped with scheduling a follow up audiology examination. During an observation and interview on 05/28/2026 at 8:59 a.m., Resident #3 was observed lying in bed with hearing aids in both ears. The right hearing aid was mispositioned in the outer upper ear lobe and required staff assistance for proper placement. Interview questions had to be repeated two to three times for the resident to hear and respond appropriately.During an interview on 05/27/2026 at 9:22 a.m., Staff B, Certified Nursing Assistant (CNA), stated she was familiar with Resident #3 and to communicate effectively with the resident she must speak loudly and repeat herself. During an interview on 05/27/2026 at 10:38 a.m., Staff C, Licensed Practical Nurse (LPN), stated that to communicate effectively with Resident #3, she must speak in a loud voice and position herself near the resident. Staff C reported that the social services department was aware of the residents' hearing difficulties. During an interview on 05/27/2026 at 11:57 a.m., the Social Services Director (SSD) stated when staff observe a decline in a resident's hearing, a Certified Nursing Assistant (CNA) or Registered Nurse (RN) notifies the Social Services Department, and the department will assist with scheduling an audiology appointment. She reported Resident #3 had not been referred for a follow up audiology examination. During a follow up interview on 05/27/2026 at 1:25 p.m., the SSD stated she was unsure why Resident #3 had not been referred for an audiology evaluation. During an interview on 05/27/2026 at 3:15 p.m., the Director of Nursing (DON) stated that the Social Services Department is responsible for coordinating audiology appointments for residents. During a follow up interview on 05/28/2026 at 1:56 p.m., the DON stated when residents demonstrate difficulty hearing, facility staff discuss the concern with the resident and/or the Resident Representative (RR) and develop an appropriate plan of care. Review of facility policy titled Hearing and Vision Services, undated revealed the following:Policy: It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated.Policy Explanation and Compliance Guidelines:1. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes:1a.Obtaining history from medical records, the family, and the resident regarding hearing and vision abilities;1b. MDS and care area assessments;1c. Care plan development and implementation2. Staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee.3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources (e.g. Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs.4. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident with appointments and or transportation.5. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision or hearing according to resident needs and/or preferences. Review of facility policy titled Resident Assessment (RAI), undated revealed the following:Policy: This facility makes a comprehensive assessment of each resident's need, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.Policy Explanation and Compliance Guidelines:2. The assessment will include at least the following: d. Communication .3. The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on observations, interviews, and record review the facility failed maintain a clean and sanitary environment for one (Resident #208) out of twenty-one residents in the sample group regarding not deep cleaning and sanitizing a room. Findings included: During the initial tour of the facility, on 12/27/21 at 09:45 a.m. an empty room was entered. No resident names were noted on the door. Resident items were still present in the room. On a shelf in the closet, designated for bed A, there was a bottle of water, a bed pan, and a bedside commode bucket observed. In the closet, designated for bed A, there were clothes labeled with Resident #208's name on them. The dresser, designated for bed A, had wound care supplies in the top drawer. The dresser for bed A had a wrist band with Resident #208's name on it, a [MEDICATION(S)] gauze, 4x4 sponges, two rolls of cloth tape, one roll of gauze bandage, a roll of [CONDITION(S)] wrap, two no stick barrier wipes, and a clear plastic bag labeled wound care supplies which contained a roll of clear tape, and a container of no stick barrier spray. A second plastic bag contained a roll of cloth [CONDITION(S)] wrap and four [MEDICATION(S)] gauzes. In the closet, designated for bed B, were clothes labeled with Resident #209's name on them. Photographic evidence was obtained. A review of the current facility census, dated 12/27/21, indicated Resident #208 and Resident #209 were no longer in the facility. A review of the medical records revealed Resident #208 was discharged on [DATE] to the hospital. A review of the medical records revealed Resident #209 was discharged on [DATE]. Review of a nursing admit/readmit form for Resident #208 dated 12/27/21 at 11:16 p.m. revealed the resident was admitted back to the previous room, in bed B, where the items were discovered on 12/27/21 at 9:45 a.m. in the empty room. Resident #208 had previously been in bed A before discharge. On 12/28/21 at 06:40 AM, in an interview was conducted with the Director of Nursing (DON). The DON stated, The room should have been terminally cleaned by housekeeping before yesterday, and definitely after the resident in the room was discharged a week prior. The DON confirmed the items in the closet were still there, and the photographic evidence taken the day before was the same and the Resident #208 had been admitted back into the room to the other bed prior to the terminal cleaning being completed. On 12/29/21 at 1:23 pm an interview was conducted with the Plant Operations Director (POD), Plant Operations Manager (POM), and Nursing Home Administrator (NHA). The POD stated there is no time frame on when the rooms get terminally cleaned before the next resident moves in, but it is usually within two days of a resident leaving the room. He stated it is the Certified Nursing Assistants (CNA) job to make sure that all the personal items are removed from a room. He stated the clothing, wound care supplies, bedpan, and bed side commode bucket should have been taken care of by the CNAs. The NHA stated the CNAs should have taken the items out of the room. He stated the rooms are to be emptied and cleaned before the resident comes into the room. He makes sure empty rooms are clean before the next resident comes into the room. Review of the policy titled Routine Cleaning and Disinfection, with a copyright date of 2021, revealed the following: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines: 6. Frequency of cleanings will vary a. Patient rooms inspections will be done by the housekeeping staff daily. Cleaning will be done as needed. b. All patient rooms will be deep cleaned after each vacancy and also reinspected prior to a new resident moving in.

Based on observations, interviews, facility policy and record reviews the facility failed to ensure the interventions on the resident centered care plan were revised, related to wound care for one (Resident #3) of twenty-one residents in the sample group. Findings included: On 12/28/2021 at 1:37 p.m. a wound care observation was conducted for Resident #3. The wound was located on the left lower lateral calf and was diagnosed as a venous stasis wound related to [CONDITION(S)] (PVD). A review of the medical record for Resident #3 indicated he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Order Summary Report for Resident #3 revealed an active order for wound care started on 2/28/2021 to Cleanse area to left lateral lower extremity with normal saline and apply oil [MEDICATION(S)] and cover with Collagen and dry dressing and change every day and as needed (PRN), for PVD. A review of the Comprehensive Care Plan for Resident #3 was conducted on 12/28/21, a focus area for Resident #3 was listed as follows: Focus: He is at risk for further skin alterations related to unavoidable risk due to decreased mobility, fragile skin, PVD, bowel and bladder incontinence, scratches self. He was admitted with multiple skin alterations (date initiated: 9/2/20) Goals: He will not sustain further skin alterations of unknown origin thru next review date (revision on: 10/13/21). Skin alteration to RLE (right lower extremity) will heal without complications by next review date (revision on: 2/17/21) Skin tear to RLE will resolve by next review date (revision on: 12/17/21) Skin tear to right upper arm will heal without complications by next review date (revision on 12/17/21) Skin alterations to left heel will heal without complications by next review date (revision on 12/17/21) Skin tear to left forearm will heal without complications by next review date (revision on: 12/17/21) Skin tear to left upper arm will heal without complication by next review date (revision on 12/17/21) Review of the Care Plan showed no goal related to the left lateral lower extremity associated with the wound care observations conducted on 12/28/21. Interventions related to specific wound area included:: Treatment to right upper arm per orders see TAR (treatment administration record) (date initiated 9/7/21) Treatment to left forearm per orders see TAR (date initiated 11/28/21) Treatment to left heel per orders see TAR (date initiated 9/28/21) Treatment to left upper arm per orders see TAR (date initiated 12/27/21) Treatment to right lower extremity per order see TAR (date initiated 11/23/21) An interview was conducted on 12/29/2021 at 9:00 a.m., with the Clinical Manager for MDS, who is responsible for updating care plans. During the interview she confirmed a goal and intervention for Resident #3's left lower leg Venous Stasis wound was not listed on the current care plan. She stated I pulled his care plan yesterday (12/28/2021) and noticed I had resolved it accidentally, by completing the intervention on 10/13/2021, and it is my fault that it's not there right now on the care plan. The wound should have been on his care plan the whole time. Immediately after the interview, the Clinical Manager revised Resident #3's care plan and showed the survey team she added the intervention. The intervention read Treatment to left lateral lower extremity per orders see TAR. (date initiated 12/27/21). A review of the facility policy titled Comprehensive Care Plans, with revision made in September 2021, Pages 01-02 read as follows: POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines: 2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR (Preadmission Screening and Resident Review) recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and record review the facility failed to demonstrate responsiveness to resident council concerns regarding nursing care when voiced grievances were not addressed and acted upon for three out of three months reviewed. The facility did not provide the resident council with responses, actions, and rationale taken regarding their concerns. Findings: An interview was conducted with the facility Life Enrichment Director on 11/23/20 at 1:45 p.m. She confirmed that she was the appointed facility staff facilitator for the resident council. She reported that there was no council president in accordance with the residents' wishes. She reported that the council met monthly but that during the coronavirus disease (COVID-19) pandemic the group format had been stopped and replaced with a monthly survey format. She explained that the survey was conducted individually by life enrichment staff with each resident as an opportunity for residents to voice any concerns. She reported that concerns voiced in the survey were taken to appropriate department heads, and minutes were compiled from the survey and distributed back to the residents. Resident council minutes were reviewed for September 2020, October 2020, and November 2020. At the top of each document was the following: The meeting of the Resident Association was unable to be held due to restrictions related to COVID, however Residents were visited by (staff name) to allow them to voice their opinions by filling out a questionnaire where resident answers were kept anonymous. The minutes for each month revealed No concerns under the heading Old Business. The minutes for September, dated 09/17/20, revealed the following under the heading New Business .Nursing: Some residents shared they get the help and care they need without waiting, and some shared that sometimes there is a wait, and it depends on the staff member. Life Enrichment met with (name), the Director of Nursing (DON). (DON) is going to write up a grievance and do retraining with the staff. The minutes for October, dated 10/15/20, revealed the following under the heading New Business .Nursing: Some residents shared they get the help and care they need without waiting, and some shared that sometimes there is a wait, and it depends on the staff member. One resident expressed needing to use the restroom every 30 minutes due to a diuretic, which is more than what her scheduled bathroom times are, so she sometimes has to wait to get help. The minutes for November, dated 11/18/20, revealed the following under the heading New Business .Nursing: Most residents think that Staff give the help that the Residents need without waiting a long time, and others shared that they wait a long time at night and think that more Staff are needed during that time. (Life Enrichment Director) asked Residents what makes them think more Staff are needed. It was shared that they hear the Aide's (sic) conversations outside their rooms, and 'why else would they be waiting so long.' (Life Enrichment Director) shared that we have the State required staff needed at night and the long wait would be looked into. Facility grievance logs were reviewed for September, October, and November 2020. There were no entries on behalf of the resident council. During a review of facility grievances with the facility Social Services Director on 11/24/20 at 1:30 p.m., it was confirmed that there were no grievances filed on behalf of the resident council. On 11/24/20 at 3:30 p.m. a small group meeting with three regular resident council members was conducted. Attendees were Residents # 4, # 6, and # 32. A review of the Minimum Data Set (MDS) for each resident was conducted and revealed the following Brief Inventory of Mental Status (BIMS) for each: Resident # 4 had a BIMS of 14 which meant that she cognitively intact; Resident #6 had a BIMS of 14 which meant that she was cognitively intact; Resident #32 had a BIMS of 12 which meant that the resident had moderate cognitive impairment (score range 8-12). The residents confirmed that they were regular council members, confirmed that there had been no group council meetings due to precautions related to COVID, confirmed they participated in the replacement survey format, and reported that they did receive the minutes but that it doesn't say the outcome of the concern. Regarding concerns about nursing care, long wait times, and staffing revealed in the September, October, and November council minutes, all three residents confirmed the concerns and that they were ongoing. Resident # 6 stated that there had been occurrences twice in the last two weeks where the facility was short nurses on the night shift and the facility Director of Nursing (DON) had to come in and cover. Resident # 4 stated that there was often just one nurse and one aide on each hallway at night and said, takes a long time for them to come to my room and answer my light .sometimes as long as calling four times. The residents could not identify specifics about the facility grievance process and council concerns. The residents stated they did not know what happened with the concerns they expressed in council meetings. On 11/24/20 at 4:30 p.m. a follow-up interview to the council meeting was conducted with the Life Enrichment Director. Regarding the nursing care concerns revealed in the minutes for [DATE] - November 2020 she stated that her role was to report the concern to the appropriate department which she identified as nursing but that beyond that she couldn't comment. On 11/25/20 at 9:10 a.m. an interview was conducted with the facility Administrator, the DON, and the Life Enrichment Director. The Life Enrichment Director re-confirmed that her role was to take concerns expressed by the resident council to the relevant department head. She confirmed that she had brought the concerns expressed about nursing care, long wait times, and staffing to the DON for the months of September and October. The Administrator, DON, and Life Enrichment Director all confirmed that there was not a facility process/practice for grievances/concerns voiced by the resident council. The DON stated the nursing care/wait times/staffing concerns voiced by the resident council had been brought to her attention. Regarding the concerns expressed in September 2020 she stated that the concerns were addressed in the Certified Nursing Assistant (CNA) meeting stating she, would have to double check on a nurses meeting if I addressed with nurses .but did address with the CNAs .addressed about answering call lights promptly, making sure residents got their needs met appropriately. She stated that the CNAs had not provided any feedback as to why long wait times were happening and that no further root cause analyses had been conducted. Regarding the concerns expressed in October 2020 she said, I haven't addressed it yet .was going to at the next CNA meeting again . The Administrator said, it sounds like we need to do a root cause analysis for the facility related to this area. Review of the facility policy titled, Resident and Family Grievances with a revision date of October 2019 revealed: Policy Explanation and Compliance Guidelines: .8. Grievances may be voiced in the following forums: .d. Verbal complaint during resident or family council meetings .; 10. Procedure: .b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form .c. Forward the grievance form to the Grievance Official as soon as practicable .The Grievance Official will take steps to resolve the grievance, and record information about the grievance .The Grievance Official, or designee, will keep the resident or family member appraised of progress towards resolution of grievances

Based on observations, record reviews, and interviews the facility failed to immediately monitor and document the status of the resident upon returning from the [MEDICAL TREATMENT] treatment for one (Resident #153) of one [MEDICAL TREATMENT] resident reviewed. This failure had the potential to result in delayed management of changes in condition and complications arising from [MEDICAL TREATMENT]. Findings: Resident #153 was admitted on [DATE]. The Admission Record included [DIAGNOSES REDACTED]. A review of the Order Summary Report indicated Resident #153 had [MEDICAL TREATMENT] at 10:15 a.m. on Tuesdays, Thursdays, and Saturdays with an offsite vendor. The care plan for Resident #153 identified that the resident needed [MEDICAL TREATMENT] related to [MEDICAL CONDITION] and staff were to monitor/document/report as needed (prn) any signs/symptoms (s/sx) of infection to access site: redness, swelling, warmth or drainage and monitor/document/report prn new/worsening [MEDICAL CONDITION]. An observation and interview was conducted with Resident #153 on 11/23/20 at 4:21 p.m., as she sat in her wheelchair in her room after returning from [MEDICAL TREATMENT]. At 2:03 p.m. on 11/23/20, Staff Member C, Licensed Practical Nurse (LPN) stated she sent a communication form with the resident, which was completed by the [MEDICAL TREATMENT] Center and returned to the facility. On 11/25/20 at 12:24 p.m., Staff Member C stated Resident #153 did not return to the facility until after her shift ended. A review of the [MEDICAL TREATMENT] Communication Reports and progress notes related to Resident #153 was conducted with Staff Member C. The reports indicated Facility Nursing staff to document the following in the Resident's Medical Record when the resident returns to the facility: - a. Vital signs; - b. Skin integrity; - c. any bleeding or concern with [MEDICAL TREATMENT] (Notify the [MEDICAL TREATMENT] center also); - d. Any other issue with the Resident regarding [MEDICAL TREATMENT]. Review of the communication reports and progress notes in the resident's medical record indicated that on 11/7/2020 and 11/13/2020 two out of seven opportunities (from 11/7/2020 through 11/23/2020), there was no documentation of the resident's status including vital signs and skin integrity immediately after return. There was also no documentation if there had been any bleeding or concerns with the [MEDICAL TREATMENT] site and any other issue regarding [MEDICAL TREATMENT]. There had been no documentation as instructed in the resident's medical record. The staff member confirmed these findings and stated they (nursing) were suppose to document her return with the items listed on the communication report. The Service Agreement between the facility and the [MEDICAL TREATMENT] Center indicated that both parties were to ensure there was documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. On 11/25/20 at 4:51 p.m., the Director of Nursing stated the facility audited the [MEDICAL TREATMENT] forms and would be implementing a new one. She added that there should have been at least a progress note on the resident's status when returning from [MEDICAL TREATMENT].

Based on interview and record review the facility failed to notify residents and their representatives and families of any occurrence of a single confirmed infection of COVID-19 for 1 of 14 (Staff A) staff persons identified on the facility's staff COVID-19 Master -Positive list. Findings included: Review of the facility's listing of COVID-19 positive staff revealed that the facility had 1 staff person, Certified Nursing Assistant A (CNAA) with a first day of absence on 6/9/20, and has not yet returned to work. There was no documentation related to notification of residents, representatives or family members of the positive staff member. On 6/30/20 at 11:05 AM, Resident #1 was observed in the hallway with a staff person waiting to enter the shower room. The resident was wearing a surgical face mask. Resident #1 reported that as far as she knows there were no staff or patients who have COVID-19 and that she had not been informed of anything like that. Interview on 6/30/2020 at 2:30 PM with the Assistant Director of Nursing (ADON) revealed that Staff A worked as the staff screener for her entire shift on 6/8/20. Staff A reported to the facility that she hung out with family on the night of 6/8/20 and that the family member tested positive on 6/9/20. The ADON reported the facility was notified of the exposure on 6/9/20 and that Staff A was directed to get tested for COVID-19 and self quarantine at home for 14 days. The ADON reported that she believed that the staff person was tested on [DATE] and had positive results on 6/10/20 or 6/11/20. Continued interview with the ADON at this time revealed that this COVID-19 positive case was reported to the federal and local government agencies, but that she did not notify residents or their representatives and families of the positive case. The ADON reported that they did not think that it was necessary to report this positive case to residents and families as they believed that Staff A's exposure occurred after her last shift worked and on that last shift she screened staff and had no resident contact. When asked if the staff person had contact with anyone whom she may have screened, the ADON replied I guess she did. Review of the facility policy titled COVID-19 Reporting with an implementation date of April 2017 and a revised dated of May 2020 revealed the following: St. Mark Village staff will notify the proper agencies, staff, residents and resident family/resident representatives upon all confirmed cases of COVID-19, whether staff or resident, and 3 or more staff/residents with new-onset of respiratory symptoms that occur within 72 hours of each other. 1. St. Mark Village social workers or designee will notify residents and their representatives within 12 hours of the occurrence of a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours.

Based on observations, interviews, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility did not maintain an effective infection prevention and control program as evidenced by: 1) one of one housekeeper that delivers laundry not transporting residents personal laundry in a safe and sanitary manner, 2) two of five direct care staff not washing hands after handling soiled linen appropriately, 3) one of housekeeping staff observed not maintaining proper infection control by placing a trash can on a resident's seated walker, 4) two or two laundry staff not maintaining proper infection control by storing personal items in the area of clean resident linen and using soiled metal carts to hold and transport linen. Findings included: 1. On 6/30/2020 at 11:00 a.m., a Laundry Staff Member I (LSMI) was observed pushing a large linen cart through the closed doors on to the north unit. As he passed the nursing station, the cart was observed to contain clean personal clothing on hangers for the residents. The cart was not covered as it was transported down the corridor. LSMI was asked why the linen cart was not covered. He stated, It's getting washed right now (referring to the cover). He confirmed that the facility only had one cover for this cart. On 6/30/20 at approximately 12:05 p.m., the Housekeeping Coordinator stated, The staff have been looking for the cover but have not been able to find it. She confirmed that the cart needed to be covered when out on the units. 2. On 6/30/20 at 11:15 a.m., Certified Nursing Assistant D (CNAD) was observed as she left a resident bedroom with two bags of soiled linen. She walked to the soiled room where she disposed of the two bags into a large container. CNAD then washed her hands in the sink for a total of nine seconds. She was informed at that time of the nine seconds of hand hygiene. She stated, Oh, I'm sorry and walked away. On 6/30/20 at approximately 1:30 p.m., the north unit bathroom was entered as Certified Nursing Assistant F (CNAF) was carrying a bag with a soiled brief inside of it. The brief was observed to contain a moderate amount of stool. CNAF placed the bag inside of a garbage container and then removed her gloves. She was observed as she washed her hands for a total of five seconds. After she completed the hand hygiene, she was asked if there was a recommended process time. She stated, I know it's supposed to be for 20 seconds and walked out of the bathroom. Hand Hygiene HCP (healthcare personnel) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE (personal protective equipment), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHS (alcohol based hand sanitizer) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 3. On 6/30/20 at 11:30 a.m., Housekeeping Staff Member B (HSMB) was observed in resident room [ROOM NUMBER] as she was lining the trash can with multiple clear trash liners. While completing this task, the housekeeper used the resident's seated rolling walker to rest the trash can. The Housekeeping Coordinator appeared at that time and was asked about the process of lining trash cans. She said that the trash cans should never touch the resident's belongings and should not be used to rest trash cans on. Interview with HSMB at the time of the observation confirmed that she used the resident's personal walker to rest the trash can on while she lined the trash cans. She reported that there was not enough room and that she should not have put the trash can on the walker. She reported that the outside of the trash can was clean because she cleans it sometimes. The Housekeeper said that the last time she cleaned it was on Sunday (2 days prior). 4. On 6/30/20 at 12:05 p.m., a tour of the clean laundry room was conducted with the Housekeeping Coordinator. Upon entrance to the clean linen room, a staff member's personal backpack was observed sitting on top of a metal rack. Just below the metal rack contained folded clean resident towels. A plastic beverage bottle that was half full with a pink liquid was observed inside of a portable linen cart that contained clean folded towels. A second beverage bottle with pink liquid was observed on the shelving unit touching clean resident's personal lap blankets. Above the clean folding area an air vent with a large amount of thick gray debris was observed. A fan was also observed and contained a large amount of thick gray colored debris. The Housekeeping Coordinator was asked about the placement of bottled drinks on the clean linen carts and she did not respond. Continued observation revealed a metal wheeled cart that was full of linen. The laundry aid confirmed that the linen inside of the cart was clean. On closer observation, the vast majority of the metal cart surface contained a reddish to orange colored brittle coating. The Housekeeping Coordinator confirmed the metal cart was no longer a cleanable surface as the metal coating was no longer intact. The soiled laundry room was observed and found to contain three more metal carts with wheels. All the carts contained the same reddish to orange colored brittle surface. The Housekeeping Coordinator confirmed that the carts were still in use.

Based on observation, interview, medical record review and standard precautions for infection control the facility failed to ensure that one out of one certified nurse assistant (CNA A) was able to provide appropriate hand hygiene while wearing an uncleanable hand brace; 2. did not ensure that yearly infection control training was conducted and 3. did not provide education to staff during the time of confirmed head lice related to 3 (#4, #5 and #6) of 9 sampled residents. Findings Included: On 9/23/2019, at 8:10 a.m., Certified Nursing Assistant A (CNA A) was observed in a resident bedroom making the bed. She was noted not wearing any gloves during the process. She removed dirty linen from the bed with her right hand then shifted it to her left hand as she placed it inside of a clear colored plastic bag. CNA A went to the head of the bed, removed the pillow case covers, and then replaced them with clean covers. CNA A walked over to the clear plastic bag that was located at the foot of the bed, bent down and picked up a small throw pillow that was lying on the floor. She placed small pillow on top of the clean pillows. At that time she confirmed she had picked the pillow up off the floor. She then removed the small pillow from the bed with her right hand and placed it side of the clear plastic bag. She was asked if she works the rehabilitation unit. She stated, I can't I have a lifting restriction on my left arm. The CNA A showed the surveyor her left hand that was noted with a soft gray in color hand splint with a white compression stocking extended up to her elbow. CNA A was asked how she cleans her brace and the white compression stocking from her hand in-between residents. CNA A said that she washes her hands in-between residents. She then demonstrated this by removed the brace from her hand that revealed the lower portion of her hand incased in the compression stocking. She then pushed the stocking in an upward motion to her forearm. She stated, than I wash my hands. She was asked if the cloth splint and stocking portion that was on her hand is being washed. She said no. She indicated that the splint and the compression stocking was not dirty because she washed her hands. CNA A confirmed that was caring for seven residents today. And that had included resident #4, 5 and 6. CNA A additionally confirmed she had cared for the three last month when they were on isolation precautions. She stated I wore the hand brace during that time. The facility identified four residents starting on 7/29/2019 of having head lice in the facility. The last treatment for [REDACTED]. Resident # 4 was [DIAGNOSES REDACTED].#5 was [DIAGNOSES REDACTED]. Resident #6 was diagnosed with [REDACTED]. She was asked if anyone had spoken to her about or instructed her on maintaining infection control? She stated, they know I wear it when I work. She confirmed that that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON had entered the conference room during the interview as she indicated she was aware of the cloth hand brace and compression stocking to her hand and arm. She also indicated she was aware it was being used as the she provided care and services to the residents. At 10:23 a.m. the DON confirmed that last time CNA A had Infection Control Training was on 8/31/2018. An interview with Employee C at 5:40 a.m., on the date of the survey at 5:50 a.m., that there had been 4 cases of lice on two halls in skilled nursing. She knew that the facility dealt with the lice but was unaware of details. She confirmed that she had no in-services related to lice or pests and had not seen any bedbugs or roaches in the skilled nursing facility. An interview was conducted with Employee B on 9/23/19 at 8:32 a.m., who confirmed that he had heard there was an outbreak of lice in the facility in passing from another staff member. He also confirmed that he did not have an in service regarding infection control related to lice, but his head was checked for lice. An interview with Employee D on 9/23/19 at 552 a.m., confirmed there had been an outbreak of lice in the skilled nursing facility a while ago but had not heard of any follow up. An interview with Employee E. was conducted on the date of the survey at 10:02 a.m. She confirmed that she was the laundry and housekeeping coordinator and had been employed at the facility for approximately [AGE] years. She stated that the ADON ( infection control preventionist) told her about a month ago in the morning meeting that there had been multiple cases of lice in the skilled and rehab facility, was informed of room numbers and was told to wash the personal linen, bed linens, privacy curtains from those rooms and hold them until nursing told her to return to resident and/or rooms. She was also told to provide deep cleaning to those rooms. She confirmed at that time that she did not receive any training in how to wash the linens, nor did she give any training to the laundry/housekeeping staff. She dried the linens, washed them in hot water, dried them again and then bagged them until nursing told her to return to the residents and/or rooms. She stated that over the years she knew how to treat linens exposed to lice. When asked for further explanation she stated that a lice outbreak did not happen often, and she received no guidance from the nursing department on how specifically to clean linens exposed to lice. She also confirmed that there was no written training given to laundry aides, housekeepers or floor technicians on how to clean floors, rooms and linens affected by lice since (YEAR). Continued interview with Employee [NAME] at 12:32 p.m., on 9/23/19 confirmed that the last education of attendance record for head lice control and prevention was last given to the laundry/ housekeeping staff on 7/8/15. Record review confirmed that an Inservice had been given on 7/9/15 for lice control and prevention. The facility provided a copy of their Infection Prevention and Control Program dated on (MONTH) (YEAR). Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Policy explanation and compliance guidelines: Contact precautions are measure that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact or indirect with the resident or the residents environment.

Based on record review and interview the facility failed to ensure that grievances were resolved to the satisfaction of Resident #1 relating to medications being administered appropriately for one of two residents reviewed ( Resident #1). Findings included: During an interview with the representative for Resident #1 it was determined that he filed a grievance with the assistant director of nursing related to timely medication administration on 8/26/19. The grievance log confirmed that the grievance was resolved on 8/27/19 with the word Resolved and with no documentation that a written decision had been issued to the resident or representative after the conclusion of the investigation. Review of the current facility policy dated (MONTH) (YEAR) revealed on Page 2 (g) : g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concerns(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. An interview with Employee F on 9/23/19 at 12:30 p.m., confirmed that she was the Grievance Official and not aware of the current policy for issuing a written response at the conclusion of a grievance. She stated that she had not been the staff member to investigate the grievance, and only knew what the staff member had written as the resolution. The staff member who had completed the grievance investigation was not available for interview. A follow up interview with the administrator at 2:22 p.m., on the date of the survey confirmed that they were going to review the policy and make sure that it was followed, or amended to reflect desired practice for investigating a grievance.

Based on interview, policy, and record review the facility failed to ensure that [MEDICAL CONDITION] medication that was ordered on an as needed basis had a stop date for one resident (#34) out of 5 sampled residents for unnecessary medications. Findings included: Resident #34 was admitted to the facility in (MONTH) of 2019 from an acute care hospital with [DIAGNOSES REDACTED]. Review of Resident #34's Medication Administration Record [REDACTED]. The resident was administered the [MEDICATION NAME] on 2/10/19, 2/12/19, 2/14/19, 2/16/19, 2/17/19, 2/18/19, 2/19/19,2/21/19,2/23/19,2/24/19, and 2/26/19. Review of the pharmacy review form dated for the month of (MONTH) there was no recommendations made from the pharmacist. During an interview with the Director of Nursing (DON) on 02/28/19 at 01:32 p.m. the DON said the [MEDICATION NAME] was prescribed as needed for more than 14 days and it should not have. During a phone interview with the facility's consulting pharmacist on 3/1/19 at 2:06 p.m. she stated [MEDICATION NAME] should be ordered for 14 days then the physician needs to readdress the order. Review of the facility's Use of [MEDICAL CONDITION] Drugs policy last revised on (MONTH) of (YEAR) revealed Residents are not given [MEDICAL CONDITION] drugs unless the medications necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the residents, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 8. PRN (as needed) ordered for [MEDICAL CONDITION] drugs shall be used only when the medication is necessary to treat a [DIAGNOSES REDACTED].e. 14 days).

Based on observation, interview and medical record review, the facility failed to ensure medical records were maintained that ensured end of life wishes of residents were implemented correctly in three (#15, 56 & 209) out of twenty three sampled Residents as evidenced by the Electronic Medical Record (EMR) and medical paper record did not reflect corresponding and requested code status. Findings Included on: 1. Electronic medical record review was conducted for Resident #15 that indicated on the Admission Record she was admitted from an acute care hospital stay on [DATE]. She was said in her nineties with a [DIAGNOSES REDACTED]. On [DATE] at 9:20 a.m. Resident # 15 was in her bedroom and was confused when approached. She was unable to remember what she had for breakfast. Nor was she able to remember why and how long she had been at the facility. She stated it itches as she rubbed her right arm in an up and downward motion. Further review of the EMR revealed no current Physician orders [REDACTED]. For either 'Do Not Resuscitate (DNR) or Cardiopulmonary Resuscitation (CPR)'. The EMR chart page had a designated area for code status. The code status area was blank. Resident #15's paper record was reviewed that revealed a yellow copy of a DO NOT RESUSCITATE ORDER that contained the date on [DATE]. On [DATE] at 1:40 p.m. an interview was conducted with the Director of Nursing (DON) as she stated absolutely the EMR and resident paper record should match. She confirmed at that time she had not been aware of the discrepancy between the two medical records. 2. Resident #209 was admitted to the facility in (MONTH) of 2019 from an acute care hospital, per the Admission Record. Review of Resident #209's medical record revealed no indication of code status for the resident. Whether he was a full code or if he had do not resuscitate (DNR) directives in order. During an interview with Resident #209 on [DATE] at 04:04 p.m. he stated he did not know what a DNR or a do not resuscitate is but he would want them to save his life if anything were to happen to him. 3. Resident #56 was admitted to the facility in (MONTH) of 2019, per the Admission Record. Review of Resident #56's medical record revealed no indication of code status for the resident, whether she was a full code or if she had do not resuscitate (DNR) directives in order. During an interview with Resident #56 on [DATE] at 03:36 p.m. the resident stated she would want the staff to perform CPR on her if she needed it. 4. During an interview with the Director of Nursing on [DATE] at 01:45 p.m. she stated if there is no yellow sheet in the chart then the default is full code. Typically no we don't have an order for [REDACTED].>5. Review of the facility's Communication of Code Status last revised on (MONTH) of (YEAR), revealed It is the policy of the facility to adhere to residents rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. 2. When an order is written pertaining to a resident's presence or absence of an advance directive, the directions will be clearly documented in the designated sections of the medical record. Examples of directions to be documented include, but are not limited to: a. full code b. Do Not Resuscitate c. Do Not hospitalized 3. the nurse who notates the physician order [REDACTED]. 4. the designated sections of the medical record are: front of chart 5. additional means of communication of code status include: PCC on chart page 6. in the absence of an advanced directive or further direction front he physician, the default direction will be full code. the presence of an advanced directive or any physician directives related to the absence or presence of an advanced directive shall be communicated with social services. 8. the social services director shall maintain a list of resident who have an advanced directive on file. 9. the residents code status will be reviewed at least quarterly and documented in the medical record.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, failed to maintain the dish washing machine and sanitization sink logs in one out of one kitchens, and to serve meals in a sanitary manner in the rehabilitation dining room. Findings included: 1. On 11/13/017 at 9:00 a.m., during the initial tour of the kitchen several undated and opened containers in the dry storage room were observed. These items included several twelve-gallon plastic containers of lemon juice, liquid flavorings, and coconut [MEDICATION NAME]. Additionally, there was a one-quart container of blueberry flavoring that had been opened and was undated. Present during the tour was Executive Chef A. Several of the plastic containers were covered with a sticky dark substance and a white powder. The Chef said that the white powder was probably powdered sugar. An opened one-gallon plastic container of imitation butter was sitting on a shelf outside of dry storage room and was undated. Inside of the walk-in refrigerator was an opened one-gallon container of soy sauce and a one-gallon container of Worcestershire sauce that were undated. The walk-in produce cooler had eight undated gallon containers of opened salad dressing. It was observed during the initial tour that the door leading from the kitchen to a dining room was propped open. Chef A said that the door was kept open during food service because staff were running trays out. A second door to the kitchen was also propped open during the meal preparation. There were two ice cream freezers that were observed to be unsanitary and neither had a thermometer. The glass sliding door on top of the unit and the groves of the sliding doors had a dark substance on them. There was a build-up of ice on the inside walls of the freezers ranging from approximately quarter of an inch to approximately one-half of an inch thick. The lids to three of the gallon containers of ice cream were not put on properly exposing the ice cream. Lying at the bottom of both freezers were small pieces of ice cream scattered throughout and also round scoops of ice cream lying in the bottom. Seventeen opened three-gallon containers of ice cream were undated. Present in the reach in refrigerator was a half empty jar of grape jelly that was not dated. More undated items were found in the two-door refrigerator that were also uncovered and included: 15 plates of salad, 10 bowls of applesauce, and 15 bowls of peaches. There was a substance resembling food particles in the groves of the doors of the refrigerator. The Chef was shown the build-up of the substance. The glass doors were dirty and greasy with food stuck on the glass and frame of the doors. At 10:00 a.m., on 11/13/2017, Dietary aid/dishwasher B, stated that the dish washing machine was a high temperature machine. The three compartment sink was tested by the dishwasher where the test strip read 300 parts per million. He was asked to see the logs for review. Dietary aid B stated that he had not seen the log to the three-compartment sink in about three weeks. He then produced the clipboard for the dishwasher log. No entry had been made on the clipboard for the dishwasher since September 2017. He acknowledged that he had not been recording temperatures for the dishwasher. Chef A then produced a new log from another area, but it had no entries. Copies of dishwasher temperature logs were provided and included: 06/23/2017, 06/13/2017, and 09/15/2017. On 11/14/2017 at 10:55 a.m., an observation was made in the kitchen where Certified Dietary Manager (CDM) C for the Long Term Care Unit was present. There was a tall open cart that contained chicken pot pies that was only covered half way down with plastic exposing the pies to the surrounding. The CDM was shown the cart and pulled the plastic down. At 11:02 a.m., on 11/14/2017, a door leading to a dining room was observed propped open with a wooden door wedge and was located near the food tray line. Observed in the reach in refrigerator near the opened door were 26 uncovered cheesecakes. At the other end of the room was a second door that was also being held open by a wooden door wedge. At that time a staff member, who identified herself as a server (D), was observed walking through the open door and through the kitchen without wearing a hairnet or washing her hands. A moment later another server (E) entered the kitchen without a hairnet. Server E stated said she didn't think she needed a hairnet if she stayed to one side of the kitchen, which was where utensils and a refrigerator were located. Then server F also entered the kitchen without hairnet. Present during the observation was the CDM and Chef A. On 11/14/2017 at 11:11 a.m., dietary aid/dishwasher B stated that he had now started the logs for the dishwasher and the three-compartment sink. He provided copies of the new logs. The dish machine log was resumed on 11/13/2017 and contained the temperatures for the lunch and evening meals and the temperatures for the breakfast meal on 11/14/2017. Prior to 11/13/2017 the last temperatures recorded on the log were on 09/15/2017 for the breakfast and lunch meals only. The three-compartment sink log was resumed on 11/14/2017. The last log provided for the sink was dated October 2017. Dietary aid B confirmed that they just resumed the log for the dishwasher on the previous day (11/13/2017) and the log for the three compartment sink on 11/14/2017. When starting the new log on 11/14/2017 for the November three compartment sink dietary aid B completed the log on the lines for the 1st and the 2nd instead of the 14th. The CDM provided a corrected new log for November 2017 at 2:55 pm on 11/15/2017 where the log was started on 11/13/2017. On 11/13/17 at 12:08 p.m., observed staff member G, dietary aide, serving lunch in 1100 hallway dining room. While gloved staff member sorted through paper dietary slips for residents, utilizing both hands, turned to cart behind steam table, held bread with left hand and cut it with right hand. Staff member ungloved and washed hands prior to re-gloving. Staff member looked through paper slips, opened wooden cupboard beside refrigerator, opened a bag of potato chips, extracted a handful of chips, and placed them on resident plate. Continued observation revealed staff member sifting through dietary requests, remove a couple pieces of bread from bag, plated a handful potato chips then took lettuce and tomato off a plate and place on resident plate. Staff member ungloved and washed hands then re-gloved prior to looking at paper slips again. Staff member was observed, while gloved, to open refrigerator, return to cart, remove bread slices from bag, held sandwich with left hand cutting it with right, reach into potato chip bag and place chips on resident plate. An interview was conducted with staff member G immediately following meal service. She stated that the slips of paper she was looking at during service was dietary slips with resident requests. Staff member G stated that handwashing should be done after touching inanimate items. She stated that she washed her hands so much they were chapped. An interview was conducted with staff member K, Chief Culinary Officer, on 11/16/17 at 10:00 a.m., during which staff member stated staff member indicated that every time staff serves a plate they are to wash hands and re-glove. He indicated that during meal service staff are not to open a cupboard without washing hands and changing gloves before returning to plate food. On 11/16/17 at 11:40 a.m., an interview with the staff member I, ADON was conducted. Staff member I stated the observation of dietary aide going from refrigerator to chip bag then to the lettuce was a huge infection control issue. She confirmed anyone has access to the refrigerator in the rehabilitation dining room. She stated she was going to speak with the DON and department managers, figure out a plan of action, and educate every staff member including manager on handwashing and gloving. She stated she was going to find out what the managers were informing their staff regarding handwashing and gloving. The policy titled Handwashing Guidelines-Dietary Employees, implemented and revised July 2017, stated under the heading Frequency of handwashing: Hands should be washed in the following situations: after hands have touched anything unsanitary i.e., garbage, soiled utensils or equipment, dirty dishes, etc., When switching between working with raw food and working with ready to eat food, and After engaging in any activity that may contaminate the hands.

Based on observation, review and interview the facility failed to discard medications and label medications in one (long-term care) of two medication preparation rooms. Findings included: An observation with staff member H, Licensed Practical Nurse (LPN), on 11/15/17 at 3:03 p.m., in the long-term care medication preparation room revealed a pink bath basin in unlocked cupboard. Laying in the pink basin were multiple medication cards with medications, a disposable enema and a clear bag with multiple loose capsules and tablets. The bag containing loose medications was not labeled with type of medications or resident name. Staff member H stated she did not know why medications were there. Photographic evidence of pink basin obtained. At 3:07 p.m., on 11/15/17 staff member I, Assistant Director of Nursing (ADON), observed the pink basin in medication preparation room, she sighed and shook head, stated she had no explanation for the medications in the pink basin. She stated she wanted to ask the Director of Nursing (DON) if she knew anything about it. AT 3:14 p.m., the DON observed the pink basin, stated that she had asked the 11-7 shift supervisor to destroy medications and that the medication destroyer bottle was full so she expected that the supervisor had put them in the basin. She stated that she had asked for the destruction of medications the end of October. The DON stated that medications are not stored liked that in the facility and it was an anomaly. Review of the facility policy titled, Medication Storage, implemented and reviewed on October 2017; found Medications housed on our premises are stored in the medication rooms according to the manufacturer's recommendations. The policy titled, Disposal of Medications, copyrighted 2007, stated 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. Continued review revealed for the State of Florida, the appropriate method non-controlled medication destruction was as follows: transfer medication to trash receptacle following destruction to unusable consistency. Mixing medications with an undesirable substance, such as used coffee grounds or kitty litter, and putting them in impermeable, non-descript containers, such as empty cans or sealable bags; will further ensure the drugs are not diverted.

Based on record review and interview the facility failed to review and revise a care plan for an elopement device for one (#91) of 25 residents. Findings included: Resident #91 was admitted on [DATE] with readmissions on 2/23/17 and 9/29/17. Resident #91's Admission Record reflected medical [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE], indicated Brief Interview of Mental Status (BIMS) of 6, severely impaired. Review of Resident #91's physician orders for September indicated order for wanderguard: check placement and function every shift - poor safety awareness. The physician orders for October did not reveal an order for [REDACTED]. The quarterly Resident elopement risk evaluation dated 11/1/17, found a score of 5. The readmission Resident Elopement risk evaluation dated 9/30/17, indicated a score of 7. The forms stated elopement risk if score is 10 or greater. During an interview with staff member I, Assistant Director of Nursing (ADON) on 11/14/17 at 4:35 p.m., the ADON stated staff checks for functioning and placement of wanderguard every shift. The ADON reviewed the facility wanderguard binder, which indicated the resident had a wanderguard. Staff member I reviewed the clinical record and confirmed there was no physician order to discontinue the wanderguard. She stated Resident #91 did not wander and, when resident was transferred to the hospital on [DATE], the wanderguard did not alarm. Review of the care plan, initiated 2/24/17, found Resident #91's is an elopement risk related to disoriented to place; History of attempts to leave facility unattended and impaired safety awareness related to dementia. The interventions included wanderguard to alert staff of attempts to leave facility without assistance. Check placement and functioning every shift/prn, (Initiated 2/24/17). On 11/15/17 at 8:38 a.m., the ADON stated that she was the one who sent Resident #91 to the hospital on [DATE]. She was in the room with the paramedics, did not cut wanderguard off resident #91 and the wanderguard alarm did not sound when the resident left facility. She stated, in fact I know she (resident #91) did not have a wanderguard bracelet on yesterday. The change of therapy Minimum Data Set (MDS), dated [DATE], indicated a behavior of wandering not exhibited. The quarterly MDS, dated [DATE], indicated behavior wandering not exhibited. During an interview on 11/15/17 at 11:26 a.m., staff member J, Clinical Process Manager, stated when resident #91 came back from hospital on [DATE] the wanderguard was resolved. She stated the wanderguard was discontinued on 9/29/17 and she should have resolved the wanderguard on 9/29/17. Staff member J stated she went through the resident chart on 11/14/17 at 5:30 p.m. and she noticed that Resident #91 did not have an order for [REDACTED]. Review of policy, dated July 2017, and titled, Reviewing and Revising the Care Plan, stated, a person-centered comprehensive care plan will be developed in accordance with facility procedures and will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessments.

Based on interview and record review the facility failed to provide activity of daily living care related to showering as requested for one(#82) out of 25 sampled residents. Findings included: On 11/14/2017 at 11:52 a.m., Resident #82 was interviewed and asked if he was able to choose how many times a week he takes a bath or shower. The resident responded no, that it was supposed to be twice a week, but they don't always hit the mark. Results of the brief interview for mental status (BIMS) of 10/31/2017 reflected a score of 13, indicating cognitively intact. On 11/15/2017 the resident's shower schedule and shower sheets, indicating when he had received a shower or bath were requested, and provided by the Assistant Director of Nursing (ADON). At 1:00 p.m., an interview was conducted with the ADON. She stated that, per the documentation, the resident had received only two showers for the month of October 2017 (10th and 20th) and only one shower for the month of November 2017 (8th). She was asked how they would know if he refused a shower, was given a bed bath, or staff just did not give the shower. She said that she had reviewed nursing progress notes for October and November and that there was no written documentation regarding refusals or bed baths. She said that they would not know since they were not documenting the information. There was one refusal on a shower sheet, dated 10/24/2017, due to the resident not feeling well. The resident was scheduled for showers two times a week on Wednesdays and Saturdays on the 3:00 pm to 11:00 pm evening shift. Shower sheets provided: 10/10/2017: Shower provided. Comment: No new concerns. 10/20/2017: Shower provided. Comment: No new concerns. 10/24/2017: Refused shower due to not feeling well. 11/8/2017: Shower provided. Comment: All clear. Resident #82's [DIAGNOSES REDACTED]. The Care Plan was reviewed and included the focus area that he had a fall and had pain in his abdominal and lower extremities; had a pelvic fracture; and his pain will interfere at times with his activity of daily living (ADL).(date initiated 10/12/2017). Interventions included: He prefers his showers in the am (morning). Shower him twice weekly unless other wise indicated or per his preference (date imitated 10/12/2017); He requires extensive assistance of one for lower body dressing with pulling his pants up, socks and shoes (date imitated 10/12/2017); and he requires extensive assistance of two with bed mobility, transfers, bathing, and toileting (date imitated 10/12/2017). On 11/16/2017 at 10:20 am the Minimum Data Set Coordinator provided a copy of the Care Plan and stated that the intervention of requiring extensive assistance of 2 for bed mobility, transfers, bathing, and toileting had been revised/changed to assistance of 1 on 10/20/2017. The Minimum Data Set, dated dated [DATE], included: Section G, Functional Status: Personal Hygiene: Extensive assistance and one person physical assist. Bathing: Physical help in part of bathing activity and one person physical assist. Section C, Cognitive Status: Brief Interview for Mental Status: Score of 13 (15 being the highest achievable for cognition).

Based on observations, interview and photographic evidence, the facility failed to ensure one of ice machine used for resident ' s consumption in one of two units, and main dining was thoroughly cleaned and free of bio-growth. Findings Include: While conducting a comprehensive tour of food preparation and storage areas on 09/29/2016 at 2:09 PM, the ice machine located in the Health Care Center (HCC) nourishment room was observed with black/gray layer of bio-growth in the inner portion of the ice machine (directly under lid hinges and above ice). Water droplets observed leaking directly from bio-growth to ice. When wiped with paper towel, the layer of bio-growth was easily removed from ice machine unto paper the towel. Certified Dietary Manager (CDM), who accompanied surveyor on tour witnessed observation and confirmed sighting of bio-growth. CDM notified maintenance and Director or Nursing who confirmed that Ice in the machine are used for residents ' consumption. On 09/29/2016 at 2:13 PM, The Care Center Environmental Manager stated that maintenance cleans the ice machines on a monthly basis, not dietary. He did not know the cause of the bio-growth, but speculated that it could be from condensation. On 9/29/2016 4:08 PM, The Care Center Environmental Manager provided in-service records, cleaning log, and manufacture's guide for the ice machine. He stated that the ice machine is cleaned twice a month, to manufactured specifications, and that the bio-growth was an oversight by staff. He also stated that last cleaning was conducted on 8/22/2016 Last documented cleaning of ice machine on log located on the side of the ice machine HD supply, and Monthly Water Filtration Service was 8/22/2016.

Based on observations, interviews, and photographic evidence the facility failed to ensure that the grout area between tiles in the East wing shower room were free of bio-growth in one out of three shower rooms. Findings: On 9/27/16 at 9:41 a.m. in the East wing shower room, surveyor observed that the grout between wall tiles was gray to black with bio- growth. The area was below the shower handle and approximately twenty-four inches long in the grout line. The surface was rubbed with paper towel and nothing came off with pressure. Wall was observed again on 9/30/16 at 10:20 a.m. and the bio-growth remained on the grout line. This observation was confirmed by interview with staff B on 9/30/16 at 10:23 a.m. After attempting to rub area clean with paper towel Staff B stated, I will get housekeeping to come and clean that right now. An interview was conducted at 10:35 a.m. on 9/30/16 with the Housekeeping Coordinator. She stated, Housekeeping checks and cleans the bathrooms daily. The floors are scrubbed two times a week. At 10:37 a.m. upon reaching the shower room with the housekeeping coordinator the bio-growth was being cleaned by housekeeping staff and most of the bio-growth was gone.

Based on observation, interview, photographic evidence, and record review, the facility failed to (1) securely dispose of protected health information on physician orders [REDACTED].#144 and #64) out of 24 sampled residents, and; (2) failing to provide privacy during the administration of an injection for one resident (#99) out of two residents observed as evidenced by not closing the privacy curtain nor closing the bed room door. Findings Include: 1. On 09/27/2016 at 2:37 PM, Physician order [REDACTED]. Upon further investigation, it was revealed that the physician order [REDACTED].#144 that included name, social security number and orders for two current medications. An additional clear bag, labeled with Resident #64 ' s picture, name and room number, was also found in the trash can. The bag contained 10 individually packaged [MEDICATION NAME] suppository. Observation was witnessed and confirmed by the Director of Nursing (DON). She stated that the physician order [REDACTED]. She stated that those documents are supposed to be placed in the gray shred locked container. Facility ' s policy and Procedure for Resident Right - Privacy and Confidentiality (Revised February 2015) establishes that residents have the right to personal privacy and confidentiality of his or her personal clinical record. Pharmacy policy IE5: Medication Destruction (effective date April 2016), instructs that no resident identifiers should be on the labels when disposing of drug packaging in the trash. 2. On 09/29/2016 at 11:09 a.m. Licensed Practical Nurse A (LPN A) stated that Resident #99's blood sugar had been 217 and that she had required 3 units of Humalog insulin per the sliding scale orders. The nurse entered the bedroom with the insulin and informed the resident of the procedure that was about to be performed. The nurse at that time pulled up Resident #99 shirt thus exposing her abdomen and injected the insulin. While the insulin injection had been performed the privacy curtain and bedroom door had remained open and residents were observed passing by in the hallway way with visual access to the procedure. At 11:11 a.m. LPN A confirmed that she had not closed the bedroom door or the privacy curtain during the insulin injection procedure for Resident #99. She said that she had forgotten. On 09/29/2016 at 4:00 p.m. an interview was conducted with the Director of Nursing. She said that she had been informed by LPN A that she had forgotten to close the bedroom door during the administration of insulin for Resident #99. She at that time confirmed the door should have been closed.