Every finding on record at Stonebridge Chillicothe

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when staff stored two clear plastic bags of raw chicken on the second from the top shelf of the freezer with two boxes of garlic bread stored on the shelf underneath the raw chicken, failed to identify seven packages of hamburger and four bags of hotdog buns that contained mold and failed to maintain the ice machine to avoid condensation and ice buildup. The facility census was 57.Review of the facility policy titled Food Receiving and Storage, dated July 2014, showed uncooked and raw animal products and fish would be stored separately in drip-proof containers and below fruits, vegetables, and other ready to eat foods; When food was delivered to the facility it would be inspected for safe transport and quality before being accepted. Review of the facilities Refrigerators and Freezers policy, dated December 2014, showed supervisors were responsible for ensuring food in pantry, refrigerators, and freezers were not expired or past perish dates. Supervisors should contact vendors or manufactures when expiration dates were in question or to decipher codes. Observation on 04/21/2026 at 5:25 A.M. showed:-Two clear plastic bags of raw chicken stored on the second from the top shelf of the freezer with two boxes of garlic bread stored on the shelf underneath the raw chicken;-Seven packages of hamburger buns stored on a wire rack shelf that had mold on the hamburger buns;-Three packages of hotdog buns stored on a wire rack shelf that had mold on them;-One package of hotdog buns stored on a wire rack shelf that was open and had the hot dog buns had mold on them. During an interview on 04/21/2026 at 5:35 A.M. [NAME] A said:-Raw chicken should be stored on the bottom shelf of the freezer to prevent contamination;-He/she had not noticed the mold on the hamburger and hotdog buns, he/she tried to throw out moldy bread as it was noticed but the bread usually did not stay fresh for very long.During an interview on 04/21/2026 at 7:40 A.M. the Dietary Manager said: Have had issues with the bread since it had been delivered on a cold truck and when stored in dry storage it made the bread spoil quicker.During an interview on 04/24/2026 at 11:19 A.M. the Administrator said:-Moldy bread should have been identified and not have been kept in the dry storage area;-Raw chicken should be stored in a separate food bin on the bottom shelf of the freezer with no other food stored below it to prevent contamination.2. Review of the facility policy titled Refrigerators and Freezers, dated December 2014, showed:-Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs.-Necessary repairs would be initiated immediately.Observation of the kitchen on 04/21/2026 at 5:25 A.M. showed the Victory Freezer had condensation and ice buildup on the outside of the freezer between two of the freezer doors. During an interview on 04/23/2026 at 9:45 A.M. the Dietary Manager said the freezer had condensation and ice build-up on the outside occasionally when staff did not ensure the door was closed all the way.During an interview on 04/23/2026 at 9:50 A.M. [NAME] A said: The freezer occasionally had condensation and ice buildup on the outside between the doors.Observation of the kitchen on 04/23/2026 at 10:00 A.M. showed the Victory Freezer remained unchanged with condensation and ice buildup on the outside of the freezer between two of the freezer doors. During an interview on 04/24/2026 at 11:19 A.M. the Administrator said:-The freezer should not have condensation and ice buildup on the outside of it;-She would expect the condensation and ice buildup to be addressed immediately and if unable fix the problem in house a call would need to be made to the local heating, ventilation, and air conditioning (HVAC) contractor to repair the freezer.

Based on interview and record review, the facility failed to protect one resident's right to be free from physical abuse when Resident #1 swatted (hit swiftly with a sharp slap or blow) Resident #2 on the arm. Resident #2 sustained a red mark on his/her left arm. The facility census was 55. Review of the facility policy titled, Abuse, Neglect, and Exploitation, Program Responsibilities, dated September 2022, showed: -Each resident has the right to be free from abuse; - Abuse means the willful infliction of injury and intimidation resulting in physical harm, pain or mental anguish; - Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish; - Willful means the individual deliberately, not that the individual must have intended, to inflict injury or harm; -Residents must not be subject to abuse by anyone including facility staff and other residents; -The facility will ensure each resident has the right to be free from abuse. Review of the facility's policy titled, Resident to Resident Altercations, revised October 2022, showed: -All altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the nursing supervisor, Director of Nursing and the Administrator; -Resident to resident altercations may include mental/verbal conflicts and physical altercations; -Examples of reportable resident to resident altercations include: Threats of violence; any willful action that results in physical injury, metal anguish and/or pain. 1. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/19/25 showed: - Severe cognitive impairment; - Physical and verbal behaviors directed towards others; -Medications taken include antipsychotics (a type of psychiatric medication used to treat mental health problems) and are taken on a routine basis; - Diagnoses included, dementia, anxiety and depression. Review of the resident's nurses notes showed: -03/15/25 at 8:27 P.M., Resident states he/she feels anxious and regretful for keeping his/her spouse and others awake last night; -03/21/25 at 8:12 A.M., Resident having behaviors this morning. The resident sat himself/herself down on the floor in the weight room twice. Resident is yelling at staff and throwing walker at staff. Resident does not take direction or redirection from staff. Review the resident's care plan dated, 03/21/25 showed: -The resident will have fewer episodes of yelling and hitting at staff; - The reisdent has cognitive and memory problems related to dementia. - Staff directed to intervene as necessary to protect the rights of others. Review of the resident's nurses notes showed: -03/25/25 at 6:18 P.M., Resident is having increased behaviors, yelling out into the hall and yelling for his/her mother. The resident is yelling at staff. Resident sat on the floor; -03/29/25 at 1:21 P.M., The resident continues to yell for help when he/she does not need anything. The resident has been arguing with his/her spouse. The resident slams his/her walker up and down when yelling for help. The resident also attempts to throw the walker; -03/30/25 at 4:08 P.M., The resident is having behaviors. The resident is yelling and walking up and down the hall. The resident was hitting himself/herself in the head and calling himself/herself a dummy; -03/31/25 at 4:48 P.M., Resident #1 was walking past Resident #2's room. Resident #2 went to shut his/her door without speaking to the resident, the resident yelled at Resident #2 and threatened to hit Resident #2. The resident did not strike anyone but threatened; -03/31/25 at 6:46 P.M., Resident is yelling down the hall and at his/her spouse; -04/01/25 at 11:08 A.M., Resident #1 was heard with raised voice. Resident #1 and Resident #2 were in the hallway verbally fighting. Resident #1 being the aggressor. Resident #1 moved toward Resident #2 with threatening implications; Resident #2 tried to protect himself/herself while Resident #1 was coming at him/her. Resident #1 raised his/her hand back and hit Resident #2 on the left arm leaving a red mark; -04/02/25 at 9:35 P.M., The resident continuously yells for help from staff and is placing self on the floor; -04/02/25 at 2:51 P.M., The physician was notified regarding the resident's ongoing behaviors. An incident occurred yesterday involving resident to resident contact. Resident #1 struck another resident; -04/03/25 at 7:00 A.M., Resident attempted to hit staff and was pulling his/her own hair out. The resident said, I do not feel good and I am mentally ill; -04/03/25 at 8:43 A.M., Resident having extreme behaviors and has raised fists at staff and other residents; -04/03/25 at 11:00 A.M., Resident has been having behaviors for multiple weeks now. 2. Review of Resident #2's Quarterly MDS, dated [DATE] showed: -Severe cognitive impairment; -Independent with Activities of Daily Living (ADLs); -Diagnoses included Alzheimer's Disease, dementia and depression. Review of the Resident's care plan dated 03/28/25, showed: -Has chronic pain. -At risk for falls. Review of the resident's nurses notes showed: -04/02/25 at 2:50 P.M., Physician notified. The resident was involved in a resident to resident contact situation where he/she was struck by another resident exhibiting behavioral issues. The resident defended himself/herself during the encounter. Review of the facility investigation dated 04/01/25 at 10:30 A.M., showed: -Resident #1 was frustrated with Resident #2; -Resident #1 said he/she attempted to go into Resident #2's room; -Resident #1 said Resident #2 said something smart to him/her; -Resident #1 said he/she swatted Resident #2 on the arm; -Resident #1 said he/she was having trouble managing his/her emotions. Review the facility investigation dated 04/01/25 at 11:00 A.M., showed: -Resident #2 said Resident #1 kept bitching at me and I told him/her to cut it out; -Resident #2 said Resident #1 put his/her hand on him/her. Review of the facility investigation dated 4/01/25 at 11:30 A.M., showed: -Licensed Practical Nurse (LPN) B heard resident #1 raise his/her voice at Resident #2; -LPN B said Resident #1 was near Resident #2's room; -LPN B said Resident #1 was stepping toward Resident #2; -LPN B said Resident #2 raised his/her hand as if protecting himself/herself; -LPN B said Resident #1 put his/her hand to Resident #2's arm; -LPN B said Resident #2 had a red mark on his/her left arm. Review of the facility investigation dated 4/01/25, at 12:20 P.M., showed: -Conclusion: o Resident #1 went to Resident #2's room; o Resident #1 was confronted by Resident #2; o Resident #1 and Resident #2 got into a verbal altercation; o Resident #1 lashed out physically and swatted Resident #2 on the arm; o Resident #1 said he/she had been having trouble managing his/her emotions and could benefit from an inpatient psychiatric stay; o Resident #1 was accepted for an in-patient stay at a psychiatric stay. During an interview on 4/14/25 at 1:14 P.M. LPN A said: -Abuse can be both deliberate and non deliberate; -He/She was aware that Resident #1 hit Resident #2; -All residents have the right to be free from abuse. During an interview on 04/14/25 at 1:18 P.M., the Director of Nursing (DON) said: -Resident #1 went to Resident #2's room; -Resident #1 and Resident #2 began yelling at each other; -Resident #1 swatted Resident #2 on the arm; -The residents were separated and monitored by staff; -All residents have the right to be free from abuse; -Abuse is willful and purposeful. During an interview on 04/14/25 at 01:20 P.M., the Administrator said: -All resident-to-resident altercations are investigated and reported to the DON and the Administrator. -Any threats of violence or intentional actions that result in an injury would be reportable incidents. -The facility reported the incident to the state survey agency. -Abuse is a reportable incident. MO252055

Based on observation, record review and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to label and date food when it was received, opened for use with the year, did not wash hands before serving food, failed to record food cooking temperatures, failed to document food temperatures before meal service, and only had one inch of water in sanitizer container. The facility census was 54. Review of the facility policy, food preparation and service, revised ,d+[DATE], included -The 'danger zone' for food temperatures is 41 degrees -135 degrees Fahrenheit (F). This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. -Thermometers will be placed in hot and cold storage areas and checked for accuracy in accordance with accepted health standards -The temperature of foods held in steam tables will be monitored by food service staff -The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic micro-organisms: a.) Poultry and stuffed foods - 165 degrees F b.) Ground meat, ground fish and eggs held for service - at least 115 degrees F c.) Fish and other meats - 145 degrees F d.) Fresh, frozen or canned fruits/vegetables - 135 degrees F e.) Unpasteurized eggs - until all parts of the egg (yolks and whites are completely firm (160 degrees F) f.) Foods cooked in a microwave - 165 degrees F in all parts of the food. It is critical to measure the food temperature at multiple sites and allow the food to stand covered for two (2) minutes after microwave reheating. -Previously cooked food must be reheated to an internal temperature of 165 degrees F for at least 15 seconds. Reheated foods that are not consumed within 2 hours will be discarded. -Food service staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays. -Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use. -Dietary staff shall keep fingernails trimmed and clean. Jewelry shall be worn minimally, and hand jewelry (i.e. wedding rings) shall be covered with gloves Review of facility policy, sanitization, dated ,d+[DATE], included -Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty Review of facility policy, food receiving and storage, dated ,d+[DATE], included: -All foods stored in the refrigerator of freezer will be covered, labeled, and dated 'use by' date. -Beverages must be dated when opened and discarded after twenty-four (24) hours. Review of facility policy, preventing food borne illness-food handling, dated ,d+[DATE], included: -This facility recognizes that the critical factors implicated in food borne illness are: a. poor personal hygiene of food service employees b. Inadequate cooking and improper holding temperatures; c. Contaminated equipment; and d. Unsafe food sources -Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. -Potentially hazardous foods held in the 'danger zone' (41 degrees F to 135 degrees F) for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) will be discarded. Dry Storage showed: -Undated receipt date of items on top shelf included hash browns, rice pilaf, scalloped potatoes, and mashed potatoes. Freezer storage showed: -Undated and unopened with no receipt date of 3 frozen broccoli bags. -Undated and unopened with no receipt date of 3 frozen imperial vegetables. Walk in cooler showed: - Undated opened 1 gallon of red hot sauce almost gone. - Undated opened 8 lb mild salsa. - 2 packages undated browned red cabbage slices. - Undated and opened 24 oz Hershey chocolate syrup. - Undated and opened 22 oz Strawberry syrup. - Undated leftover cherry cobbler covered in plastic cling wrap. - Tray of leftover desserts in serving bowls on tray dated ,d+[DATE] included banana pudding and five cakes. - Undated and opened gallon of milk. Record review of food temperature logs showed: -[DATE] no evening meal temperatures recorded, only one temperature documented for each item served at breakfast and noon meal. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded, only one temperature documented for each item served at breakfast and noon meal. -[DATE] no evening meal temperatures recorded. -[DATE] no noon and evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded, only one temperature documented for each item served at breakfast and noon meal. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] only one temperature documented for each food item at breakfast, noon, and evening meal. -[DATE] only one temperature documented for each food item at breakfast, noon, and evening meal. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no noon and evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded, only one temperature documented for each item served at breakfast and noon meal. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded. -[DATE] no evening meal temperatures recorded, only one temperature documented for each item served at breakfast and noon meal. During an interview on [DATE] at 10:48 A.M., Dietary Manager said: -He/She expected staff to date food items. -Staff were supposed to date items when they arrive to the facility. During an interview and observation in the kitchen on [DATE] at 4:08 P.M., showed: - Cold food items included lettuce salad and dessert was not temperature checked by the facility staff before the food service. - Food observed on the steam table with no food temperatures recorded on food temperature log. - 4:21 P.M., Dietary Aide A (DA) A exited the kitchen and re-entered the kitchen. DA A did not wash his/her hands placed meal cards on room trays. - 4:29 P.M., DA A entered the kitchen he/she did not wash his/her hands, and did not have on gloves. DA A grabbed a plate of uncovered corn bread and left the kitchen to take the cornbread to the resident care unit. - 4:30 P.M. Cook A did not wash hands before serving food. -4:33 P.M., DA A entered the kitchen and did not wash his/her hands. -4:35 P.M., Cook A left the kitchen to take food cart to hallway he/she re-entered the kitchen. He/She did not wash his/her hands. -4:36 P.M., Dietary Manager entered the kitchen, did not wash his/her hands, grabbed a plate from the stack below the steam table. -4:36 P.M., DA A entered the kitchen did not wash his/her hands, DA B entered kitchen and used hand sanitizer. -4:38 P.M. Cook A used the rag from the sanitizer solution container to wipe down cook prep tables by staff. The sanitizer solution had only 1 inch of water and three rags sitting in container. Cook A put away recipe book, did not wash hands and began meal service by plating meals. Cook A said he/she thought the sanitizer solution needed to be remade as it was almost out of water. The sanitizer solution was not remade. - Cold food items were not temperature checked before food the service. -5:05 P.M., DA A entered the kitchen, he/she did not wash his/her hands. He/she obtained vinegar for residents from the container and took the vinegar to the dining room. DA A returned to the kitchen and used hand sanitizer. -5:15 P.M. DA C entered kitchen he/she did not wash his/her hands. He/She applied gloves and got a sandwich out of the cooler. Spice rack showed: -Expired cumin dated [DATE] on the shelf. -Undated year of paprika dated ,d+[DATE]. -Undated year of celery seed dated ,d+[DATE]. -Undated year of chopped Italian seasoning dated ,d+[DATE]. -Undated year cinnamon dated ,d+[DATE]. -Undated year onion powder dated ,d+[DATE]. -Undated year garlic powder dated ,d+[DATE]. -Undated year dark chili dated ,d+[DATE]. -Undated year old fashioned oats dated ,d+[DATE]. -Undated and opened ground ginger. -Expired sesame seed dated [DATE]. -Undated year celery seed dated ,d+[DATE]. -Expired sage dated [DATE]. -Undated year poultry seasoning dated ,d+[DATE]. -Undated year lemon pepper dated ,d+[DATE]. -Undated year red pepper dated ,d+[DATE]. -Undated year ground ginger dated ,d+[DATE]. -Undated year cayenne pepper dated ,d+[DATE]. -Expired ground cayenne pepper dated [DATE]. During an interview on [DATE] at 10:44 A.M., Cook B said: -Food should be temperature checked whenever it is cooked. -Food should be temperature checked before service and when it is put on steam table. -Food items should be dated for the day it is delivered including the year. -Leftovers should be thrown out within three days. During an interview on [DATE] at 2:44 P.M., the Dietary Manager said: -Food items should be dated when they are put up for storage. -Cans should be dated when they arrive to the facility. -His/Her expectation is for staff to date food items. -Leftovers should be thrown out in four days. -Food should be labeled including the year. -Food temperatures should be taken at beginning of food service and end of food service, both temperatures are recorded on the temperature log. -Food should be temperature checked when it is cooked to ensure proper cooking temperature has been reached, those temperatures are not recorded anywhere. -Hands should be washed as the staff enter the kitchen, after food preparation, after removing gloves, or go to the restroom. -Staff should wash their hands at the beginning of the meal service. -Every time staff go in and out of kitchen they have to use alcohol based hand sanitizer when they are serving plates and when serving snacks. -The sani-bucket should be changed twice a day and should be approximately half-way full of water. During an interview on [DATE] at 3:20 P.M., Administrator said: -Kitchen was supposed to follow the facility policies for hand hygiene which included washing hands at start of meal service and when the staff enter the kitchen. -Food temperatures should be completed according to the policy when starting meal service. -Temperatures should be documented at meal service. -Food should be dated when it is received and put away. -Leftovers should be dated and thrown out after four days. -Foods should be dated when they are opened.

Based on observation, interview, record review, the facility failed to provide reliable pharmaceutical services to establish and maintain a system to ensure medications were available for the licensed and certified nursing staff to provide to the residents and according to the physician orders. This affected four Residents ( #4, #13, #18, #210) out of the 16 sampled residents. This additionally placed other residents at risk of not receiving medications as ordered. The facility census was 62. There was no medication or pharmacy policy provided. 1. Review of Resident #4's quarterly MDS (Minimum Data Set), a federally mandated assessment, completed by facility staff, dated 3/11/23., showed: - BIMS ( Brief Interview of Metal Status) score of 15, cognitively intact; - Diagnoses: Heart failure, insulin dependent diabetic, high blood pressure, irregular heart beat. Review of Resident #4's physician orders for June 1,2023 showed: - Ferrous Sulfate 325 mg, one tablet to be given by mouth with meals 8 A.M., 12 P.M., 6 P.M. for diagnosis of anemia (low iron in the blood). Observation on June 1, 2023 at 9:02 A.M., showed CMT A: - Did not have Ferrous Sulfate 325 mg of the stock supply to give to the resident; - Requested someone help obtain some over the counter medications. A member of the activities staff was sent to local drug store to obtain the Ferrous Sulfate 325 mg over the counter medication. Observation on June 1, 2023 at 10:11 A.M., showed that CMT A: - Obtained the Ferrous Sulfate 325 mg medication from the activities person; - Administered the Ferrous Sulfate 325 mg as ordered to Resident #4 two hours later. 2. Review of Resident #13's quarterly MDS, dated [DATE]., showed: - BIMS score of 7, indicating moderate cognitive impairment. -Diagnoses: Dementia, stroke with impaired ability to swallow, depression. Review of Resident #13's physician orders for June 1, 2023 showed: -Vitamin D 1000 iu, by mouth daily at 8 A.M., for osteoporosis (degenerative bone and joint disease) Observation on June 1, 2023 at 9:32 A.M., showed that CMT A: - Did not have stock supply of the Vitamin D, 1000 international units (IU) available to give the resident or a bubble pack card from the pharmacy. - Did not provide the Vitamin D medication to resident #13 - He/She wrote down the Vitamin D medication that needed to be ordered for replenish of the facility stock if unable to obtain from the resident's pharmacy. 3. Review of Resident #18's quarterly MDS, dated [DATE]., showed: - BIMS score of 15, Cognitively intact; - Diagnoses: Anemia, arthritis, seasonal allergies. Review of Resident #18's physician orders for June 1, 2023 showed: - Ferrous Sulfate 325 mg, one tablet to be given with meals for diagnosis of anemia; 8 A.M., 12 P.M., 6 P.M. - Zaditor eye drops 0.25%, one drop to each eye twice daily (for allergy eyes, redness, and itching) at 8 A.M., and 8 P.M. Observation on June 1, 2023 at 9:42 A.M., showed CMT A: - He/She did not have Ferrous Sulfate 325 mg of the stock supply to provide to the resident; - He/She did not have Zaditor eye drops 0.25% available to provide the resident for allergy eyes. - He/She requested to LPN A for someone help obtain some over the counter medications. A member of the activities staff was sent to the local drug store to obtain the Ferrous Sulfate 325 mg over the counter medication and the Zaditor eye drops. Observation on June 1, 2023 at 10:21 A.M., showed CMT A: - Obtained the Ferrous Sulfate 325 mg medication from the activities person; - Administered the Ferrous Sulfate 325 mg and the Zaditor eye drop as ordered to Resident #18 two hours later. 4. Review of Resident #210's Quarterly Assessment on 4/15/23., showed: - BIMS score of 7, indicating moderately impaired cognition; - Diagnosis: Dementia, diabetes, high blood pressure. - Review of Resident # 210's physician order for June 1, 2023 showed: -Amoxicillin 187/125 mg, 1 tablet by mouth twice a day for 10 days for upper respiratory infection 8 A.M. and 8 P.M. -Amlodipine 10 mg, 1 tablet by mouth daily for high blood pressure at 8 A.M. Observation on June 1, 2023 at 10:28 A.M., showed that CMT A: - Did not have the Amoxicillin antibiotic or the Amlodipine medication available for the resident through the established resident pharmacy. - He/She asked the Assistant Director of Nursing to pull these medications from the emergency supply medication cart in order for the resident to receive the medications. - Medication Technicians had been pulling these two medications from the emergency supply for greater than five days. Observation on June 1, 2023 at 10:31 A.M., showed that CMT A: - Obtained the medications from the Assistant Director of Nursing and given two hours late to the resident. During an interview on June 1, 2023 at 10:35 A.M., CMT A said: - He/She did not always have the medications needed during the scheduled medication pass times. - Often he/she had to ask the licensed staff to pull medications from the emergency medication stock supply. - He/She will indicate the number 9 in the medication administration record when medication is not available to give the residents. - Shortage of medications and the delay in receiving medications from local pharmacies had been an increasing problem over the last several months. -He/She was aware that looking for available medications delay's the delivery of the medication to the resident. - He/She believed there was a plan in place for different pharmacy to take over the medication medication delivery due to delay's from the local pharmacies. 5. During an interview on June 1, 2023 at 11:05 A.M., the Director of Nursing said: - She was aware of the delay in receiving medications from local pharmacies. 6. During an interview on June 1, 2023 at 2:45 P.M., the Administrator said: - She was aware of the new pharmacy services starting soon; - Residents were still able to use the pharmacy of their choice; - She was aware that there had been some delays with receiving medications at times. - It is her expectation that the residents have their medications available and on time.

Based on observation, interview, and record review, the facility failed to ensure they developed a comprehensive person-centered plan of care consistent with measurable objectives and timeframe to meet the residents medical, nursing, mental, and psychosocial needs for four (Resident #12,#23,#27, and #41) of 16 sampled residents. The facility census was 62. Review of the facility's Care Plan Policy, dated September 2022., showed: - 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 time frames to meet a resident's medical, nursing, and mental as well as psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of Resident #23 Prospective Payment Schedule 5 day Minimum Data Set (PPS MDS a federally mandated assessment tool completed by facility staff. ) showed: -Brief Interview of Mental Status (BIMS) of 13 which indicates minimal cognitive loss. -Limited assistance from staff for Activities of Daily Living (ADL's: the tasks of everyday life. Basic ADL's include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet.) -Occasional incontinence of bladder -Frequent incontinence of bowel -Used a walker and wheelchair -History of recent falls. -Diagnoses of need for assistance with personal care, moderate protein calorie malnutrition (the state of inadequate intake of food) , hypertension, atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). , chronic kidney disease and use of anticoagulants (medications used to prevent the clotting of blood). Review of the resident's medical record showed: -Initial admitted [DATE] -Readmission after hospitalization due to confusion on 4/21/23. -Individual care plan dated 4/21/23 showed he/she was at risk for falls. The resident required assistance with ambulation and transfers. -No baseline care plan for assistance with ADL's, use of walker, or use of anticoagulant medication. -No comprehensive care plan. Observation and interview on 5/31/23 at 4:15 P.M. showed the resident had several days growth of beard. The resident said he/she didn't like it , but that was how it was. He/She thought he/she needed help with shaving. He/she wanted something to do, there was nothing to do. Observation and interview on on 6/01/23 at 9:44 A.M. showed the residents eyes were matted, clothes soiled with food debris, and the resident had several days growth of beard on his/her face. During an interview on 6/01/23 at 9:53 A.M. Certified Nurse Aide A said: Care needs should be in the care plan. He/She did not know if resident #23 had a care plan. 46987 2. Review of Resident #12's quarterly MDS, dated [DATE]., showed: - Diagnoses: Non-surgical dislocation of right humerus bone, insulin dependent diabetic, depression, anxiety, high blood pressure. - BIMS of 12 (Brief Interview for Mental Status) indicates cognition is impaired. Review of Resident #12's Care Plan, dated 8/19/22., showed: - There were no care plans to address individualized activities for the resident. - There were no psychosocial care plans to address my goals and strengths, wishes or needs. Review of the medical record on 5/31/23., showed: - No activity assessment. - No updated activity note for the month. - Resident at risk for falls. Observation of Resident #12 on 5/31/23 at 2:10 P.M. showed: - Resident sleeping in his/her wheelchair with head tilted forward, no television of lights on in room. During an interview on 6/1/23 at 10:20 A.M., Resident #12 said: - He/She use to receive an activities calendar monthly, but have not in a long time. - He/She enjoys playing the card game UNO, but has not played in a long time. - He/She has pain in right arm which makes going to activities difficult. - He/She lost son recently and struggles with depression, and feelings of loneliness. 3. Review of Resident #27's most recent comphrensive change in condition MDS, dated on 4/21/23 showed: - Diagnoses: Muscular Dystrophy (degenerative muscle weakness, and loss of muscle mass), Contracture of the right and left hands ( the folding of the fingers and wrist into the palm of the hand). - Resident had urinary catheter marked on MDS for neurogenic bladder (the inability for the brain to let the bladder know if is time to urinate). Review of Resident#27's most current care plan, dated 3/28/23., showed: - He/She used an electric scooter for mobility, - He/She had a Foley catheter to manage neurogenic bladder. Review of Resident #27's most recent physician orders and nursing progress notes for the month of May, 2023., showed: - New physician order to discontinue the urinary catheter on 5/8/23. - New re-occuring urinary tract infection on 5/23/23 indicated and was the reasoning behind the removal of the urinary catheter. - Nursing documentation 5/25/23 supporting that resident had an overall decline in daily activities as a result of re-occuring infections. Decreased energy, fatigue, decline in activity level. Observation of the resident on 5/31/23 at 11:25 A.M., showed: - The resident sitting in a manual wheelchair. - The resident without a urinary catheter or drainage bag. During an interview on 6/1/23 at 1:22 P.M., the resident said: - He/She had not had an electric scooter in a long time. - He/She did not have a urinary catheter any longer because of frequent infections. - He/She used to be more mobile around the facility when he/she had the scooter. 4. Review of Resident #41's most recent re-admission MDS on 4/3/23., showed: - One person stand by assist for grooming, transfers, and hygiene. - Alert and Oriented with mild confusion. - Diagnoses: Heart failure, blood circulation problems to lower legs and feet, seizures, and confusion. - New medication- anticoagulant for heart failure. Review of Resident #41's care plan dated 4/3/23., showed: - No care plan to address new anticoagulant medication needs for the resident. During an interview on 6/1/23 at 10:45 A.M., the resident said: - He/She was not aware he/she was taking a medication called Eliquis for risk of blood clots. 5. During an interview on 6/1/23 at 3:02 P.M., the MDS/Care Plan RN said: - He/She said all care plans were updated as resident's care or needs change. - Care plans were updated with MDS updates. 6. During an interview on 6/1/23 at 3:45 P.M., the Administrator said: - She would expect that all residents care plans should be accurate and thorough, and updated as needed.

Based on observation, interviews and record review, the facility failed to ensure base line care plans were completed within 48 hours of admission for two residents (Resident #23 and Resident #41) out of sixteen sampled residents. The facility census was 62. There was no facility policy provided for base line care plans. Review of Resident #23 Prospective Payment Schedule 5 day Minimum Data Set (PPS MDS a federally mandated assessment tool completed by facility staff. ) showed: -Brief Interview of Mental Status (BIMS) of 13 which indicated minimal cognitive loss. -Limited assistance from staff for Activities of Daily Living (ADL's: the tasks of everyday life. Basic ADL's include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet.) -Occasional incontinence of bladder -Frequent incontinence of bowel -Used a walker and wheelchair -History of recent falls. -Diagnoses of need for assistance with personal care, moderate protein calorie malnutrition (the state of inadequate intake of food) , hypertension, atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart)., chronic kidney disease and use of anticoagulants (medications used to prevent the clotting of blood). Review of the resident's medical record showed: -Initial admitted [DATE] -Readmission after hospitalization due to confusion on 4/21/23. -Individual care plan dated 4/21/23 showed he/she was at risk for falls. Assist the resident with ambulation and transfers, notify the provider of any falls, and evaluate fall risk on admission and as needed -No baseline care plan for assistance with ADL's, use of walker, diagnosis or use of anticoagulant medication. - There was no baseline care plan completed within 48 hours of the resident's admission to the facility. Observation and interview on 5/31/23 at 4:15 P.M. showed the resident had several days growth of beard. The resident said he/she didn't like it , but that was how it was. He/She thought he/she needed help with shaving. Observation and interview on on 6/01/23 at 9:44 A.M. showed the residents eyes were matted, clothes soiled with food debris, and the resident had several days growth of beard on his/her face. The resident said he/she did not have a good night and was up to the toilet several times. During an interview on 6/01/23 at 9:53 A.M. Certified Nurse Aide A said: Care needs should be in the care plan. He/She did not know if Resident #23 had a care plan. 46987 Review of Resident #41's most recent re-admission MDS on 4/3/23 showed: - One person stand by assist for grooming, transfers, and hygiene is now total assist. - Alert and Oriented with mild confusion. - Diagnoses: Heart failure, blood circulation problems to lower legs and feet, seizures, and confusion. - He/She has urinary catheter, wounds to feet with skin infection and upper respiratory infection. Observation and record review on 5/30/23 at 8:05 A.M., showed: - There was no new base line care plan done with in 48 hours after re-admission from the hospital to address the new care needs of the resident. - The older care plans had not been revised to address the new changes with the residents condition. - He/she started antibiotics on 5/24/23 for both an upper respiratory infection and wound infection on left foot. - This was not indicated in the care plan. - Observed the resident in the dining room trying to use a fork to cut up his/her meat and was not able to, was unable to reach the juice on the breakfast tray and had a tremor in his hand. Current care plan states the resident is independent. During an interview on 5/31/23 at 8:45 A.M., resident #41 said: - He/She needed more help with feeding him/her self. - He/She felt much weaker and loss of strength. - He/She did not feel well over the last few days. - He/She was not aware that he was on antibiotics, only that his/her feet hurt, and he/she had a cold. During an interview on 6/1/23 at 3:02 P.M., the MDS/Care Plan RN said: - Base line care plans are done by the admissions liaison. - Updates to care plans are done as needed for changes in the residents conditions. During an interview on 6/1/23 at 3:45 P.M., the Administrator said: - She would expect that all residents care plans should be accurate and thorough, and updated as needed.

Based on observation, interview and record review, the facility failed to ensure a Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) was completed and submitted when one resident (Resident #41) had a significant change in two or more care areas out of 16 sampled residents. The facility census was 62. There was no MDS policy provided by the facility. Review of Change in a Resident's Condition Policy, Revised May 2017, showed: - If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the residents condition will be conducted as required by current regulation as outlined in the MDS, RAI instruction manual. 1. Review of Resident #41's quarterly MDS dated [DATE] showed: - Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. - Diagnoses included: Heart failure, blood circulation problems to lower legs and feet, seizures, and confusion. - He/She required the assistance of two staff members to transfer, groom, and hygiene care. - He/She had a urinary catheter (a tube inserted into the bladder from outside of the body to drain urine), wounds to his/her feet with a skin infection and upper respiratory infection. Review of his/her admission MDS dated [DATE] showed: - He/She required the assistance of one staff member to groom, transfer, and get dressed. - He/She had a BIMS score of 15, indicating no cognitive deficit. - Diagnoses included: Heart failure, blood circulation problems to lower legs and feet, seizures, and confusion. Observation and record review on 5/30/23 at 8:05 A.M., showed: - The resident had declines in activities of daily living, transfers, mobility, infections, meals, and now required assistance of two staff for positioning and mobility; - One staff physical assist for grooming and meal tray set up, and assistance with meals and drinking at the table, since the last comprehensive assessment. - He/She started antibiotics on 5/24/23 for both an upper respiratory infection and wound infection on left foot. - Observed the resident in the dining room trying to use a fork to cut up his/her meat and was not able to, was unable to reach the juice on the breakfast tray and had a tremor in his hand. During an interview on 5/31/23 at 8:45 A.M., the resident said: - He/She needed more help with feeding him/her self. - He/She was not aware that he/she was on antibiotics, only that his/her feet hurt, and he/she had a cold. During an interview on 6/1/23 at 3:02 P.M., the MDS/Care Plan RN said: - A significant change MDS is completed on residents who have had a significant change in their activities of daily living. - He/She did not work full time in the facility, but was in the building once weekly. - He/She was informed about changes in residents conditions by staff emailing him/her. - He/She was dependent upon CNA documentation in the electronic medical record the week before the MDS is due to be completed. During an interview on 6/1/23 at 3:45 P.M., the Administrator said: - She would expect that all residents MDS assessments should be accurate and thorough, and updated as needed.

Based on observation, interviews and record review, the facility staff failed to maintain resident dignity when the staff did not empty Resident #1's bedside commode after he/she had a bowel movement (BM) and urinated in it causing the resident to feel embarrassed. This affected one of three sampled resident's. The facility census was 55. Review of the dignity policy dated 8/2009 showed: - Residents shall be treated with dignity and respect at all times. - Treated with dignity means the resident will be assisted in maintaining and enhancing his/her self-esteem and self-worth. - Practices and standards of care that compromise the resident's dignity are prohibited. Review of the resident rights policy dated 10/2019 showed: - The resident has the right to be treated with dignity and respect. Review of the toileting policy dated 2022 showed: - Help the resident to the bedside commode. - When using a bedside commode, remove the container from the commode and empty its contents into the resident's toilet. - Use the water sprayer attached to the toilet to clean the commode if available. - Dry the clean container and replace it in the commode. Review of Resident #1's Admission Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 6/27/22 showed: - He/she was admitted to the facility on [DATE]. - Diagnoses included: End-stage kidney disease, diabetes mellitus type two, (a disorder in which the body does not process blood sugar correctly), and respiratory failure. - He/she required the assistance of two staff members to transfer, reposition while in bed, get dressed, and use the toilet. - He/she was continent of bowel and occasionally incontinent of urine. Review of the undated Activities of Daily Living (ADL's) care plan showed: - He/she required two staff members to assist him/her on to the bedside commode. - He/she required two staff to provide perineal care. During an interview and observation on 7/26/22 at 8:55 A.M. showed: - His/her bedside commode sitting in front of the bathroom door. - Brown BM, urine and white toilet tissue are in the bedside commode, filling the bucket halfway. - He/she said that he/she was assisted to the bedside commode before breakfast and was assisted off by two staff members and the staff members did not clean his/her bedside commode. - He/she expected the staff to clean his/her bedside commode after each use. - He/she said that it embarrasses him/her when the staff do not clean his/her bedside commode especially when he/she has visitors. - The BM odor bother's him/her making him/her feel embarrassed. - He/she keeps room deodorant spray next to his/her recliner to minimize the BM odor. - He/she sprayed the room deodorizer this A.M. During an interview on 7/26/22 at 11:31 A.M. nurse's aide (NA) A said: - He/she is supposed to clean resident's bedside commodes after each use. - He/she did not know that Resident #1 bedside commode needed to be cleaned until he/she was alerted to clean it by the resident. During an interview on 7/26/22 at 11:31 A.M. NA B said: - He/she placed Resident #1 on and off the bedside commode this morning. - He/she was aware that he/she was supposed to clean the bedside commode after the resident used it, but he/she did not clean the commode. - He/she does not know why he/she did not clean the bedside commode. During an interview on 7/26/22 at 11:55 A.M. the Director of Nurses (DON) said: - He/she expected the nursing staff to clean the bedside commode immediately after each use. Observations on 7/26/22 showed: - 12:08 P.M. and 12:50 P.M. Resident #1's bedside commode still half full of brown BM, urine, and white toilet tissue. MO203501

Based on observation, interview, and record review, the facility failed to maintain an infection control program during a Coronavirus disease 2019 (COVID-19, a new infectious disease caused by severe acute respiratory syndrome Coronavirus 2, or [DIAGNOSES REDACTED]-CoV-2. Common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell and taste) pandemic, to provide a safe and sanitary environment for all residents. The facility failed to ensure staff performed hand hygiene after resident contact while serving meal-trays to the residents and failed to wash their hands and put on clean gloves when staff assisted residents to cut their food. The facility census was 57. Review of the facility's 2016 Procedure Manual Resource: Staff Fundamentals for Serving Food, showed: - Dirty hands or gloves spread germs/bacteria. - Gloves are used only one time and are changed anytime they become soiled and between tasks. - Gloves are used anytime ready to eat foods must be touched by a hand and are changed if they come in contact with an unclean surface, door, or piece of equipment. - Hands are washed before new gloves are put on. 1. Observation of the noon meal on 12/30/20 at 12:20 P.M., showed Dietary Aide (DA) A passed drinks and meals to the residents in their rooms. DA A did the following: - Carried a drink into the resident in room [ROOM NUMBER], re-entered the hallway and handled the door of the hot cart, removed a tray from the cart and placed it on the top of the hot cart, moved a basket-like container that held plastic silverware, changed his/her gloves without washing his/her hands. DA A carried the Styrofoam container and basket-like container back into a resident in room [ROOM NUMBER], laid the containers on the over-the-bed table and held on to the over-the-bed table to move it closer to the resident. - DA A returned to the hallway, placed the basket-like container on the cart, changed his/her gloves without washing his/her hands. He/She opened the hot cart, pulled out a Styrofoam container, picked up the basket-like container and delivered the meal to the resident in room [ROOM NUMBER]. DA A touched the resident's arm, the handle of the resident's wheelchair and the over-the-bed table when he/she set up the resident's tray. - DA A returned to the hallway, removed and replaced gloves without washing his/her hands. - DA A delivered a drink and silverware into the resident in room [ROOM NUMBER]B, then returned to the hallway, opened the hot cart door, retrieved a Styrofoam container and carried it to the resident. - Without changing gloves or washing his/her hands, DA A delivered cranberry juice and a Styrofoam container to the resident in room [ROOM NUMBER]A. - Without changing gloves or washing his/her hands, DA A pushed the hot cart back into the kitchen. Observation and interview on 12/30/20 at 12:30 P.M., showed DA B with gloves on, pushed the hot cart onto the hallway. DA B delivered meals to the residents in the following way: - DA B handed a glass to DA C, then DA B opened the hot cart, retrieved a tray and delivered it to a resident in room [ROOM NUMBER]. - Changed his/her gloves, but did not wash his/her hands. - Carried two drinks, a bag with bread and silverware into room [ROOM NUMBER]. DA B placed the items on the over-the-bed table and then held the resident's over-the-bed table and positioned it in front of him/her. - DA B returned to the hot cart, did not change his/her gloves or wash his/her hands and opened the hot cart door and pulled out two trays that he/she carried back in to room [ROOM NUMBER]. DA B said: - He/She wore a mask, gloves, and a hairnet when he/she delivered food to the residents; - They just recently started serving one side of the hall and then the other, he/she used to serve back and forth as he/she went down the hall; - Since he/she did not really touch anything and just dropped off the resident's food, he/she tried to change his/her gloves after every two rooms. -He/She thought his/her hands were clean because he/she washed his/her hands before they put the first pair of gloves on and did not touch anything with their bare hands. 2. Observation and interview on 12/30/20 at 12:40 P.M., showed DA A delivered trays to the residents in room [ROOM NUMBER]. Certified Medication Technician (CMT) A followed DA A into the room. CMT A did not wear gloves and carried a brown paper towel in his/her bare hand. When CMT A entered the room, he/she asked if the residents wanted help to cut their pork chops up. CMT A, without performing hand hygiene or applying gloves, pulled a butter knife from the brown paper towel and cut up both the residents' pork chops. CMT A then rinsed the butter knife off in the resident's sink and placed it back in a brown paper towel. - CMT A said he/she helped the staff and cut up the pork chops for the residents. - He/She said he/she should probably wear gloves and wash his/her hands between residents. During an interview on 12/30/20 at 12:50 P.M., DA A said: - He/She used a mask and gloves while he/she delivered meal trays. - He/She probably should wash his/her hands before he/she entered a new room. - He/She did change gloves and thought his/her hands were still clean because he/she did not touch anything without the gloves on. During an interview on 12/30/20 at 1:06 P.M., the Director of Nursing said: - Staff should wash their hands and change gloves after serving each resident. - Staff should wear gloves when assisting residents to cut food. During an interview on 12/30/20, at 1:15 P.M., the Dietary Manager (DM) said: - He/She had staff wash their hands before they started serving the meal and after they finished serving the meal. - Dietary aides should change their gloves between every room. - He/She said he/she needed to get clarification from the director of nursing (DON) as to when the dietary staff should change their gloves and wash/sanitize their hands.

Based on record review and interviews, the facility failed to provide a quarterly statement that included all transactions to the resident, resident representative, and/or conservator on a quarterly basis for three sampled residents (Residents #6, #34, and #108). The facility had seven interest bearing accounts and 18 petty cash accounts. The facility census was 54. Review of an undated facility policy titled Resident Trust Fund Account Policy and Procedure showed the following: - It is the policy of the facility to manage personal funds of the residents, upon request and written authorization of the resident or legal representative. Funds will be managed in accordance with Federal and State Regulations; - The facility will provide individual financial records in the form of quarterly statements. Copies of the quarterly statements will be maintained in the management office in the Resident Trust Fund notebook with two copies sent to the resident's legal representative. - The quarterly statements will reflect each deposit, withdrawal and interest allocation and the beginning and ending balance for the quarter. 1. Review of Resident #6's quarterly statement for the resident interest bearing account, dated 7/1/20, showed the following: - Quarter statement date- 4/1/20; Quarter End date 6/30/20; - The beginning balance- $0.00; - Total deposits this quarter- $3326.00; - Interest earned- $0.02; - Total withdrawals this quarter- $3226.00; - Ending balance- $100.02; - The quarterly statement did not show each transaction during the quarter. 2. Review of Resident #34's quarterly statement for the resident interest bearing account dated 7/1/20, showed the following: - Quarter statement date- 4/1/20; Quarter End date 6/30/20; - The beginning balance- $599.87; - Total deposits this quarter- $54.06; - Interest earned- $0.18; - Total withdrawals this quarter- $36.54; - Ending balance- $617.57; - The quarterly statement did not show each transaction during the quarter. 3. Review of Resident #108's quarterly statement for the resident interest bearing account dated 7/1/20, showed the following: - Quarter statement date- 4/1/20; Quarter End ate 6/30/20; - The beginning balance- $616.51; - Total deposits this quarter- $150.00; - Interest earned- $0.18; - Total withdrawals this quarter- $64.62; - Ending balance- $702.07; - The quarterly statement did not show each transaction during the quarter. 4. During an interview on 9/17/20, at 2:45 P.M., the Business Office Manager said the quarterly statements only showed the total amount of the transactions for the quarter. She had completed the quarterly statements this way for the last [AGE] years.

Based on observations, interviews, and record reviews the facility failed to assure staff used proper infection control methods when performing wound care dressing changes. This affected two residents (Residents #1 and #2). The facility census was [AGE]. 1. Review of the facility policy dated October 2010, on wound care showed: - Staff should remove the resident's soiled dressing and wash hands and change gloves. - Staff should wipe reusable items with alcohol and return to the dressing cart. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/2019, showed: - Cognitively impaired; - Required supervision for cares; - [DIAGNOSES REDACTED]. - Two Stage III pressure ulcers (PU, full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed, may include undermining or tunneling). Observation on [DATE] at 9:30 A.M. of Licensed Practical Nurse (LPN) A providing wound care for the resident showed:- LPN A removed scissors from the treatment cart. He/she did not clean the scissors. - He/she washed his/her hands and applied gloves. - He/she removed the dressing on the resident's back. - Without washing hands or using hand sanitizer, he/she removed his/her gloves and applied a fresh pair of gloves. - He/she used the scissors to cut a piece of collagen (wound dressing) to fit the wound. - He/she cleaned the wound with saline. - Without washing his/her hands or using hand sanitizer, he/she removed his/her gloves and applied a fresh pair of gloves. - Using the scissors, he/she cut a foam dressing and applied the dressing to the wound on the resident's back. - He/she washed his/her hands and changed gloves. - He/she removed the dressing from the left hip. - He/she removed the dressing, washed his/her hands and applied fresh gloves. - He/she rinsed the wound with saline. - Without washing his/her hands and changing gloves, he/she cut a collagen dressing to fit the wound. - He/she applied the dressing to the left hip. 3. Resident #2's significant change in condition MDS, dated [DATE], showed: - Mild cognitive impairment; - Required assistance for transfers, toileting, and hygiene. - [DIAGNOSES REDACTED]. - Had a venous ulcer (wounds caused by abnormal vein function). Observation on [DATE] at 10:05 A.M. of LPN A changing the resident's foot dressing showed: - Wiped the scissors with an alcohol wipe; - He/she removed the resident's dressing; - He/she washed his/her hands and changed gloves; - He/she cleaned the wound with saline; - He/she put skin protector around the wound edges; - He/she sprinkled wound healing powder in the wound; - Without washing his/her hands, he/she changed gloves; - He/she squirted wound healing ointment from a tube into the wound; - He/she applied a fresh dressing. - He/she tore tape from a roll and used it to keep the dressing in place. - He/she washed his/her hands. - He/she put the tape and wound ointment back on the cart. 4. During an interview on [DATE] at 10:15 A.M. LPN A said: - He/she should have cleaned the scissors before and after use; - He/she should have washed his/her hands before changing gloves; - He/she should have torn the tape before going into the room; - He/she should have put the wound ointment in a cup to take in the room During an interview on [DATE] at 12:45 P.M. the Director of Nursing said: - Staff should clean scissors before and after use; - Staff must wash their hands after removing gloves; - Staff should not take rolls of tape into a resident's room; - Staff should put wound healing ointment in a cup before going in a room. MO 9

Based on observation, interview and record review, the facility failed to ensure staff followed protocols to prevent the spread of infection when staff did not perform appropriate hand hygiene while checking blood sugars and medication administration, which affected two out of 15 sampled residents (Residents #25 and #56). The facility census was 59. Review of the facility's policy related to hand hygiene, dated (MONTH) (YEAR), showed; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. -Use an alcohol-based hand rub containing at least 62% alcohol, or soap and water before and after direct contact with a resident, before preparing or handling medications, before and after handling an invasive device, after contact with blood, and after removing gloves. -The use of gloves does not replace handwashing/hand hygiene. 1. Review of Resident #56's current electronic physician order [REDACTED]. -Check blood sugar before meals and at bedtime; -Administer [MEDICATION NAME] (a fast-acting insulin used to lower blood sugar) insulin, 2 units (u.), per a [MEDICATION NAME] before meals for diabetes. Observation on 2/21/19 at 11:24 A.M., showed Certified Medication Technician (CMT) A checked the resident's blood sugar and administered insulin in the following manner: -Performed hand hygiene and put on gloves -Placed supplies on a clean field in a private room; -Pricked the resident's finger with a lancet and touched a drop of blood to a strip in the glucometer (machine used to check blood sugar levels); -Primed (ejected fluid to ensure the needle was filled with insulin) the [MEDICATION NAME], then dialed the pen to 2 u. and administered the insulin in the resident's right upper arm; -Sanitized the insulin pen and glucometer; -With the same soiled gloves on, CMT A opened the medication cart and placed a bag of blood sugar supplies and the insulin pen in the cart, then took his/her gloves off, but did not perform hand hygiene; -CMT A pushed the resident into the dining room, picked up an ink pen, entered information into the computer, placed the sanitized glucometer inside the medication cart, obtained another bag of blood sugar supplies from the medication cart and put them on a clean field in a private room, then performed hand hygiene and put on gloves. 2. Review of Resident #25's e-POS, dated 2/22/19, showed: -Check blood sugar before meals and at bedtime for diabetes; -[MEDICATION NAME]14 u. before each meal; -[MEDICATION NAME]per sliding scale (specific amount of insulin given according to ranges as directed by the physician). Observation on 2/21/10 at 11:40 A.M., showed CMT A checked the resident's blood sugar and administered his/her insulin in the following manner: -Performed hand hygiene and put gloves on; -Placed the blood sugar and insulin supplies on a clean field in a private room; -Checked the resident's blood sugar, as he/she did with the previous resident, and administered his/her insulin; -Sanitized the glucometer, removed his/her gloves, but did not perform hand hygiene; -Touched the computer mouse and keyboard, opened the medication cart and removed several medication cards, then popped pills from the cards into a medication cup to administer them to Resident #25. During an interview on 2/21/19 at 11:46 A.M., CMT A said: -Staff should perform hand hygiene between each resident between blood sugar checks and medication administrations. -Staff should remove their gloves and perform hand hygiene before they touch other items or surfaces. During an interview on 2/22/19 at 2:55 P.M., the director of nurses said staff should perform hand hygiene before and after blood sugar checks and before and after medication administration.

Based on observation, interview and record review, the facility failed to assure staff maintained a medication error rate of less than 5% when staff made three errors out of 30 opportunities for error resulting in a 10% medication error rate which affected one of 15 sampled residents (Resident #46). The facility census was 54. Review of facility's Administering Medications through the Enteral Tube (a tube inserted into the stomach surgically to administer medications and nourishment), dated March, (YEAR), showed: - Purpose: To provide guidelines for the safe administration of medications through an Enteral tube. - Preparation: Verify that there is a physician's medication order for the procedure; assemble equipment and supplies needed. - General guidelines: Do not mix medications together prior to administering through the Enteral tube. - Administer each medication separately. - Dilute medications and flush tube with room temperature or warm sterile water. - Confirm placement of the Enteral tube. - Check for gastric residual volume (amount of stomach contents that can be aspirated from the stomach via a syringe) to assess for tolerance of feeding or medications administered. - Flush tubing with 15 to 30 milliliters (ml) of warm sterile water or prescribed amount. - Dilute the crushed medications with 15 to 30 ml of sterile or purified water or the prescribed amount. - Attach large 60 ml syringe to the tube and pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. - Allow medication to flow into tube slowly and begin the flush of the tube before the medication drains completely. - If administering more than one medication, flush the tube with 15 ml of warm sterile or purified water. - When the last of the medication begins to drain from the tubing, flush tubing with 15 ml of warm sterile or purified water or prescribed amount. Review of the MIC-KEY G Feeding Tub Guide to Proper Care (type feeding tube inserted into the resident's stomach) showed: - Proper Placement: Turn the extension tubing to the open position, draw 10 ml of water into the 60 ml syringe, connect the 60 ml syringe to the Enteral tube, pull back the plunger of the syringe and look for stomach contents in the extension tubing. - When stomach contents are noted, flush the tubing with the water in the syringe. - If resistance is felt as water is injected, pull back stomach contents again and try to re-inject the water. - Another method: Draw 10 ml of air into the 60 ml syringe; place stethoscope on the left side of the abdomen just above the waist; inject air into the tube and listen for the stomach to growl; try again if the growl is not heard; if the growl is still not heard, do not proceed to administer meds and contact the physician (auscultation). - Keep the extension port and valve of the Enteral tube clean; dried formula may lodge inside the port. - Wash the extension set after every feeding with warm soapy water and rinse thoroughly. Prompt flushing and rinsing prevents formula from drying and building up in the tubing. Review of Resident #46's physician's orders [REDACTED]. - Flush Enteral tube with 10 ml of water between each medication given four times per day (QID); - (MONTH) crush medications unless contraindicated; - Place medications in 15 ml of water before administering two times per day (BID); - [MEDICATION NAME] (Tylenol, used for pain or fever) 325 milligrams (mg) tablets, give two tablets via the Enteral tube BID for pain; - [MEDICATION NAME] HCL (used to prevent gastric reflux, stomach contents from backing into the throat) 10 mg, give one tablet via the Enteral tube QID; - [MEDICATION NAME] (used to treat high blood pressure) 25 mg, give one tablet via the Enteral tube BID; - [MEDICATION NAME] sulfate (used for [MEDICAL CONDITION]) liquid, 220 mg/5 ml, give 5 ml via the Enteral tube one time per day; - [MEDICATION NAME] (used to treat gastric reflux) packet (powder), 40 mg, give one packet via the Enteral tube one time per day. Observation and interview on 4/19/18, at 10:00 A.M., RN B did and said: - Crushed the two [MEDICATION NAME] tablets and placed in a medication cup; - Crushed one [MEDICATION NAME] HCL tablet and placed in a medication cup; - Crushed one [MEDICATION NAME] tab and placed in a medication cup; - Poured one packet of [MEDICATION NAME] powder into medication cup; - Poured 7.5 ml of [MEDICATION NAME] sulfate into a medication cup and said the order and Medication Administration Record [REDACTED] - Collected the five cups of medication and five empty medication cups, gloves, and a 60 cubic centimeters (cc) syringe and entered the resident's room; - Placed all cups and syringe on paper towels; - Washed his/her hands and put on gloves; - Added 15 ml of tap water to each of the [MEDICATION NAME] HCL, [MEDICATION NAME], and [MEDICATION NAME] powder; - He/she did not stir the medications to mix with the water. - He/she poured 10 ml of tap water in the five empty cups and sat the cups of water next to each cup of medication. - Disconnected the extension tubing from the Enteral tube and attempted to wash the tube by pushing water through the tube with the 60 cc syringe; - Several large chunks of solidified tube feeding came out of the tube and he/she did not remove all chunks of tube feeding from the tube. - Said that was the best he/she could do to get the tube clean; he/she always cleaned the tube before he/she administered medications; - He/she did not know if other staff washed the extension tubing or not. - He/she did not know if there was a new/clean extension tube to change the chunk filled tube. - He/she connected the chunk filled extension tube to the Enteral tube. - He/she did not check the tube for residual gastric contents or auscultate to listen for proper placement of the tube in the stomach. - Washed his/her hands, put on gloves, opened the extension tube, inserted the 60 cc syringe into the tube, did not flush the tube with 15 to 30 ml of water prior to administration of medications; - Poured one crushed medication into the syringe, did not stir the medication, a small amount of medication was left in the cup and he/she added another small amount of water from a med cup with 10 ml of water to complete the medication and then poured the remaining water from the water medication cup into the syringe to flush the tube; - Poured the second cup of crushed medication which he/she did not stir, into the syringe; a small amount to the medication remained in the cup; poured a small amount of water from the second cup of 10 ml of water to rinse the medication and poured the medication into the syringe, then poured the remaining water from the water medication cup into the syringe to flush the tubing; - Added 10 ml of water to the [MEDICATION NAME] powder, picked up the cup and swirled the water in the cup, the medication did not mix with the water, poured the water into the syringe connected to the tubing, said the [MEDICATION NAME] had congealed and needed more water, poured water from a larger cup that held water into the [MEDICATION NAME], swished the cup, then stirred the [MEDICATION NAME] with his/her gloved finger and poured the water into the syringe and tube; - The medication remain in the bottom of the cup and was congealed. - Said the medication was not completely administered because it congealed and would not come out of the medication cup; - Used a medication cup of water and flushed the tube; - Added 15 ml of water to the [MEDICATION NAME] sulfate and poured the [MEDICATION NAME] sulfate into the syringe and did not flush the tube with 10 ml of water; - Added 15 ml of water to the last crushed tablet, swished the medication, poured the medication into the syringe, and flushed the tube with 10 cc of water; - Left the room and discarded the [MEDICATION NAME] medication cup in the sharps (container to discard needles and syringes) container; - Said he/she did flush between all medications because he/she used all the cups of water; - Said if he/she did not flush after each medication he/she should have done so; - Said he/she did not flush the tube prior to administration of the medications; - Said he/she should have administered all of the [MEDICATION NAME] but did not; - Said he/she stirred the [MEDICATION NAME] with a clean, gloved finger and thought that was okay to do and asked what he/she should have used to stir the medications; - Showed the surveyor the April, (YEAR) POS and the April, (YEAR) MAR indicated [REDACTED] -Showed the surveyor a faxed order, dated 1/9/18, that said facility had an order for [REDACTED]. - Said the Director of Nursing (DON) was responsible for reconciling the faxed orders and POS at the end of each month. During an interview on 4/19/18, at 2:45 P.M., the Assistant Director of Nursing (ADON) said: - She expected staff to auscultate and check for stomach residual contents prior to administration of Enteral tube medications or feedings. - She expected staff to flush the Enteral tube with 15 to 30 ml of water before administration of medications. - She expected staff to stir medications mixed with water with a spoon, but she did not see anything wrong with using a gloved finger to stir medications. - She expected all medications to be given and physician's orders [REDACTED]. - The type of Enteral tube the resident had was new to the facility, but staff should follow directions for care of the tube.

Based on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they did not change gloves and wash their hands between dirty and clean tasks which affected two of 15 sampled residents (Resident #14 and #46) and failed to feed residents under sanitary conditions when staff touched the residents' food with bare hands affecting three additionally sampled residents (Residents #3, #16 and #22). The facility census was 54. 1. Review of the facility's Handwashing/Hand Hygiene policy, dated August, (YEAR), showed: - Hand hygiene was considered the primary means to prevent the spread of infections. - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. - Wash hands with soap and water when hands are visibly soiled. - Use an alcohol based hand rub containing at least 62% alcohol or alternatively soap and water before and after direct contact with residents; before performing non-surgical invasive procedures; before preparing or handling medications; before and after handling invasive devices such as urinary catheters, IV access sites, feeding tubes; before handling clean or soiled dressing materials; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's skin, blood, or bodily fluids; after handling used dressings or contaminated equipment; and after removing gloves. - The use of gloves does not replace hand washing/hand hygiene. Review of the facility's Personal Protective Equipment- Using Gloves policy, dated September, 2010, showed: - Gloves are used to prevent the spread of infection, to protect wounds from infection, to protect hands from infectious materials, and to prevent exposure [MEDICAL CONDITION] from blood or body fluids. - Use gloves when touching excretions, secretions, blood, body fluids, mucous membranes or not intact skin and when cleaning potentially contaminated items. 2. Review of Resident #46's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/18, showed: - A Brief Interview for Mental Status (BIMS) score of 14 which indicated he/she made his/her own decisions; - Feeding tube (a tube surgically placed through the abdominal wall into the stomach to provide nourishment, liquids, and medications); - [DIAGNOSES REDACTED]. Review of the resident's care plan last, updated on 12/6/17, showed: - Problem: Feeding tube due to inability to swallow without aspirating, caused by [MEDICAL CONDITION]; - Dependent upon nurses for feedings; - Continuous feedings with feedings turned off for showers, activities, and physician's appointments; - Dressing around the Enteral tube insertion site; - Did not address care of the MIC-KEY Feeding Tube as instructed in the Guide to Proper Care from the manufacturer. Review of the April, (YEAR) physician's orders [REDACTED]. Observation and interview on 4/17/18, at 10:45 A.M., Licensed Practical Nurse (LPN) A did and said: - Prepared medications to be administered and formula to be administered to the resident; - Washed his/her hands and applied gloves; - Set medications in cups with medication cups of water on the over bed table and did not use a clean field; - Removed an old dressing from around the feeding tube site; - Sprayed a 4x4 gauze sponge with wound cleanser and wiped around the feeding tube insertion site; - LPN A said there was a small amount of drainage noted to the old dressing. - Did not change his/her gloves or wash his/her hands and administered five medications to the resident; - Used the same soiled glove, hung a new bag of formula and a new bag of water to run through the pump to provide nourishment and fluids; - Placed feeding pump tubing in the pump, primed the tubing with water from the bag of water and started the tube feeding drip; - Covered the resident and left the resident's room; - LPN A said he/she should change gloves and wash his/her hands after performing soiled tasks and before performing clean tasks. - He/she should have changed gloves and washed his/her hands after removing old dressing from the feeding tube site and before administering medications and hanging the feeding formula and water to infuse, but he/she did not. Observation and interview on 4/19/18, at 10:00 A.M., Registered Nurse (RN) B did and said: - Poured one packet of [MEDICATION NAME] powder into medication cup; - Washed his/her hands and put on gloves; - Added 15 milliliters (ml) of tap water to the [MEDICATION NAME] powder; - He/she did not stir the medication to mix with the water; - Washed his/her hands, put on gloves, opened the extension tube, inserted the 60 cubic centimeters (cc) syringe into the tube, did not flush the tube with 15 to 30 ml of water prior to administration of medications. - Added 10 ml of water to the [MEDICATION NAME] powder, picked up the cup and swirled the water in the cup, the medication did not mix with the water, poured the water into the syringe connected to the tubing, said the [MEDICATION NAME] had congealed and needed more water, poured water from a larger cup that held water into the [MEDICATION NAME], swished the cup, then stirred the [MEDICATION NAME] with his/her gloved finger and poured the water into the syringe and tube. - Said he/she stirred the [MEDICATION NAME] with a clean gloved finger and thought that was okay to do and asked what he/she should have used to stir the medications. During an interview on 4/19/18, at 2:45 P.M., the Assistant Director of Nursing (ADON) said: - She expected staff to stir medications mixed with water with a spoon but she did not see anything wrong with using a gloved finger to stir medications. - Staff should use a clean field when administering medications or changing a dressing. - Staff should wash their hands and change gloves after removing a soiled dressing and before administering medications and tube feeding. 3. Review of Resident #14's quarterly MDS, dated [DATE], showed: - Cognitively intact; - [DIAGNOSES REDACTED]. - Two venous and arterial ulcers (wound on the leg or ankle caused by abnormal or damaged veins) present. Review of the care plan, updated 3/30/18, showed: - Focus: Open areas to the right and left lower legs; - Goals: Measures put in place to help reduce my risk for skin break down; - Interventions/Tasks: Wound clinic; education on the importance of elevating my legs to help them heal and chose to be noncompliant; notify nurse immediately of any new areas of skin break down; let charge nurse know if dressing to lower legs are soiled or have a foul odor. Observation and interview on 4/17/18, at 11:51 A.M., RN A did and said: - Washed his/her hands and applied gloves; - Set wound supplies and container on the resident's wheelchair without a barrier; - He/she removed the resident's wet socks, pulled up resident's pant legs, and cleaned the left lower leg with weeping [MEDICAL CONDITION]. - With the same soiled gloves, cleaned the right lower leg with weeping [MEDICAL CONDITION]; - With the same soiled gloves, he/she put the tape and scissors on the bedside table without a barrier. - Applied wound dressing to both lower legs and touched the wound supplies, container, wheelchair, and trash can with the same soiled gloves; - Took the wound container from the wheelchair, moved it to the electric wheelchair, then the resident's counter without a barrier; - Removed his/her gloves and washed his/her hands; - Took the wound container back to the medication cart and sat on top of the cart without cleaning or a barrier; - RN A said he/she should have removed his/her gloves and washed his/her hands after cleaning each leg and anytime his/her gloves were soiled or going from a dirty to clean task. -- RN A said a barrier should be used with the wound supplies and container in the residents room. During an interview on 4/19/18, the ADON said: - Staff should use a clean field and barrier when performing a wound dressing change. - Staff should remove their gloves and wash their hands between dirty and clean tasks. - Staff should perform a wound dressing change one leg at a time and use proper hand hygiene per facility policy. 4. Review of the facility's Preventing Foodborne Illness-Food Handling policy, revised (MONTH) 2014, showed all employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illnesses. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Observation on 4/15/18, at 5:40 P.M., showed Certified Nurse Aide (CNA) C picked up Resident #16's egg salad sandwich from the resident's plate with his/her bare hand and placed the sandwich to the resident's mouth. The resident took a bite of the sandwich and the CNA returned the sandwich back onto the resident's plate. The CNA pulled Resident #3's wheelchair closer to the table by grabbing and pull the wheelchair by the wheel toward the table then picked up Resident #16's egg salad sandwich with his/her bare hands (located at the CNA's left) and gave the resident another bite of sandwich. The CNA placed Resident #16's sandwich back on his/her plate and directly picked up Resident #3's (located to the CNA's right) sandwich and gave him/her a bite of the sandwich. The CNA wiped food from Resident #16's mouth with a napkin; picked up the sandwich and gave the resident another bite then laid the sandwich back onto the resident's plate. He/she then picked up Resident #3's sandwich and gave him/her another bite. The CNA went back and forth feeding the resident to the right and then the resident to his/her left; cleaned off their mouths or spills on their clothing and continued to hold the sandwiches with his/her bare hands. The CNA did not wash his/her hands during the meal service. Observation on 4/17/18, at 5:35 P.M., showed CNA D held pieces of no bake cookies to Resident #16's mouth for him/her to eat. The CNA held the cookie with his/her bare hands. Observation on 4/17/18, at 5:43 P.M., showed CNA F repositioned Resident#22 then picked up the top portion of the resident's bun off the resident's sandwich with his/her bare hands and added sour cream and salsa to the taco burger. He/she replaced the top of bun onto the sandwich with his/her bare hands then used a knife and fork to cut up the resident's sandwich into bite size pieces. During an interview on 4/19/18, at 3:10 P.M., CNA C said staff are not supposed to use bare hands to pick up food when feeding residents. Staff are supposed to use utensils. During an interview on 4/19/18, at 3:28 P.M., the ADON said staff are not to touch food they are feeding to residents with their bare hands. Staff are to use utensils. Nursing staff are taught not to touch food with their bare hands.

Based on observation, interview and record review, the facility failed to ensure staff followed professional standards of care for residents when staff were not instructed in how to care for an Enteral feeding tube (a tube surgically inserted into the stomach to provide medications and nourishment) which affected one of 15 sampled residents (Resident #46). The facility census was 54. 1. Review of the manufacturer's MIC-KEY G Feeding Tube Guide to Proper Care recommendations showed: - The feeding tube kit contains a Continuous Feed Extension Set for use to provide formula feeding with a pump. - It is important to keep the Extension Set port and the anti-reflux valve (located inside and toward the top of the Extension Set port and helps to prevent stomach contents from leaking out of the tube. The use of the Extension Set will open or unlock the valve) clean. Dried formula may lodge inside the recess and hold the valve open. The best preventative measure is to flush thoroughly with enough water to clear all formula. Clean the anti-reflux valve with a cotton- tipped applicator or a soft cloth to remove oil or food. - Wash the Extension Set after every feeding with warm soapy water and rinse it thoroughly. Prompt flushing and rinsing prevents formula from drying and building up. - Extension sets are disposable and should be replaced every few weeks. Review of facility's Administering Medications through the Enteral Tube dated March, (YEAR) showed: - Purpose: To provide guidelines for the safe administration of medications through an Enteral tube. - Preparation: Verify that there is a physician's medication order for the procedure; assemble equipment and supplies needed. - General guidelines: Do not mix medications together prior to administering through the Enteral tube. - Administer each medication separately. - Dilute medications and flush tube with room temperature or warm sterile water. - Confirm placement of the Enteral tube. - Check for gastric residual volume (amount of stomach contents that can be aspirated from the stomach via a syringe) to assess for tolerance of feeding or medications administered. - Flush tubing with 15 to 30 milliliters (ml) of warm sterile water or prescribed amount. - Dilute the crushed medications with 15 to 30 ml of sterile or purified water or the prescribed amount. - Attach large 60 ml syringe to the tube and pour diluted medication in to the barrel of the syringe while holding the tubing slightly above the level of insertion. - Allow medication to flow into tube slowly and begin flush of the tube before the medication drains completely. - If administering more than one medication, flush the tube with 15 ml of warm sterile or purified water. - When the last of the medication begins to drain from the tubing, flush tubing with 15 ml of warm sterile or purified water or prescribed amount. Review of Resident #46's care plan last, updated on 12/6/17, showed: - Feeding tube due to inability to swallow without aspirating caused by [MEDICAL CONDITION]; - Dependent upon nurses for feedings; - Continuous feedings with feedings turned off for showers, activities, and physician's appointments; - Dressing around the Enteral tube insertion site; - Did not address care of the MIC-KEY Feeding Tube as instructed in the Guide to Proper Care from the manufacturer. Review of the April, (YEAR) physician's orders [REDACTED]. Observation and interview on 4/17/18, at 10:45 A.M., Licensed Practical Nurse (LPN) A did and said: - Prepared medications to be administered and formula to be administered to the resident; - Washed his/her hands and applied gloves; - Did not remove the Extension Set tube from the feeding tube port; - Placed a 60 milliliter (ml) syringe with 10 cubic centimeters (cc) of air in the Extension Set and pushed air in to the stomach to ensure proper placement; - Drew back the plunger of the syringe and there was minimal stomach residual in the syringe, then pushed the residual contents back through the feeding tube into the stomach; - Removed the syringe, removed the plunger, did not flush the Extension Set tubing with 15 to 30 ml of water prior to medication administration, inserted the syringe into the Extension Set tube port again and poured the [MEDICATION NAME] sulfate liquid (an iron supplement) into the syringe for gravity administration; - The Extension Set tube was filled with large chunks of formula and the [MEDICATION NAME] sulfate liquid did not flow through the tube. - LPN A milked the tube with his/her fingers for approximately two to three minutes to try to get the medication to flow through the tube into the resident's stomach. - Said he/she did not know why the medication would not flow through the tube; - Lowered the head of the resident's bed slightly to make sure the feeding tube did not lie against the wall of the stomach to see if the medication would flow through the tubing; - After failed attempts to get the medication to flow through the tubing by gravity, LPN A placed the syringe plunger into the syringe and pushed the medication through the Extension Set tube. - Said he/she did not like to push the medications through the tube but the medication would not flow freely; - He/she should flush the tubing before administering medications. - He/she heard the air 'swoosh' through the tube when he/she injected air to check for placement; he/she thought the tube was open and the medications would flow. - Completed the medication pass and did not flush the Extension Set tube with 15 ml of water and proceeded to hang the feeding tube formula and water to run through the pump; - LPN A did not remove the Extension Set tube from the feeding tube to wash or rinse the tubing. During an interview on 4/19/18, at 11:35 A.M., LPN A said: - The feeding tube was new to him/her; he/she never worked with that type tube prior to the resident having this type tube placed. - He/she was not aware that the Extension Set tube needed to be removed and washed after each feeding or as needed. - He/she was not aware that the Extension Set tube should be discarded and a clean tube placed every few weeks or as needed because the formula would clog the tube. - He/she was not aware of the facility providing in-service training on this type of feeding tube to staff. During an interview on 4/19/18, at 2:45 P.M., the Assistant Director of Nursing (ADON) said: - She expected staff to follow the manufacturer's guidelines for care of the MIC-KEY feeding tube and a book of instructions was in the resident's room. - Staff should be in-serviced on the care of the feeding tube.

Based on observation, interview and record review, the facility failed to ensure staff transferred a resident in a safe manner to prevent accidents or potential for accidents when staff did not lock the wheelchair during a gait belt transfer and failed to use proper transfer technique when resident did not bear weight or pivot during a gait belt transfer which affected one of 15 sample residents (Resident #34). The facility census was 54. Review of the facility's undated Gait Belt Use Protocol policy showed: - Gait belts are required for all residents when performing transfers, ambulation, or repositioning in a chair. - Check the care plan for contraindications that may cause injury to the resident. - Never transfer a resident by lifting him/her under the arms. - Never attempt to move or transfer a resident who cannot bear weight by his or herself. - If it takes more than two to perform the task, use the mechanical lift. - Make sure beds and wheelchairs have working locks. - Lock wheels prior to performing the procedure. - Always follow facility's policy and resident care plans when performing procedures. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/14/18, showed: - Cognitively intact; - Extensive two staff assist with bed mobility, toilet use, and transfers; - No functional limitation in range of motion; - Mobility devices include walker and wheelchair; - [DIAGNOSES REDACTED]. Review of the care plan, updated 3/19/18, showed: - Focus: I require staff assistance with my activities of daily living (ADLs) due to pain in my right hip and my right knee from arthritis, recent fall, and [MEDICAL CONDITION]. I also have dementia and at risk for falls. - Goal: To assist as long as I am able; measures put in place to help reduce my risk for falls and minimize injury. - Intervention/Tasks: I am slow with my ADLs due to pain in my right hip, be patient with me, I like to do as much as possible; I self-propel in the wheelchair to and from meals; I require one to two staff to walk with me with my walker to the bathroom, I am able to pull my pants up and down; I can stand on my own with holding on and elevating my recliner to standing position; Encourage me to participate to the fullest extent possible with each interaction; Monitor/document/report to nurse any changes in ADL activity. Review of the physical therapy discharge summary, dated 3/28/18, showed: - Resident discharged at this time; he/she has reached maximum potential with skilled services due to decreased active participation in treatment and increase frequency of refusals. - Discharge recommendations: assistive device for safe functional mobility and restorative nursing program; - Functional outcomes: maximum transfers; - Prognosis: good with strong family support and with consistent staff follow - through for current level of function (CLOF). Observation on 4/18/18, at 9:43 A.M., Certified Nurse Aide (CNA) A and CNA B did and said: - CNA A and CNA B entered the resident's room to transfer the resident from the recliner to the wheelchair for the resident to use the toilet. - CNA A applied the gait belt around the resident's waist. - CNA A and CNA B did not lock the wheelchair, stood the resident with the gait belt, and transferred the resident to the wheelchair without him/her bearing weight or pivoting. - CNA A and CNA B wheeled the resident to the toilet, did not lock the wheelchair and moved backwards when they stood him/her up, and transferred the resident to the toilet without him/her bearing weight or pivoting with the resident's feet dragging. - CNA A and CNA B lifted the resident from the toilet with the gait belt to perform pericare, the resident's knees buckled and staff were holding the resident by the gait belt that had slipped up under the resident's arms. - Staff transferred the resident to a unlocked wheelchair without bearing weight or pivoting. - CNA B said the wheelchair brakes should be locked when transferring a resident and the gait belt should be snug around the resident's waist and not ride up under the arms. - CNA A and CNA B said the resident had not been bearing weight or pivoting during transfers since his/her fall in (MONTH) (YEAR). - Both CNAs said they have informed the charge nurse of the resident not bearing weight or pivoting during transfers. During an interview on 4/19/18, at 10:52 A.M., CNA E said: - The resident is a one staff assist for gait belt transfers and sometimes a two staff assist. - The resident can bear weight and pivot if he/she wants to but will refuse to pivot and bear weight occasionally. During an interview on 4/19/18, at 10:55 A.M., Registered Nurse (RN) B said: - The resident no longer ambulates in his/her room since he/she fell in (MONTH) (YEAR). - The resident will bear weight and pivot during transfers when he/she assists with the resident. - The resident refused to go to an orthopedic physician for knee pain. - He/she was discharged from therapy and was noncompliant with therapy. - The resident has become less compliant over the last 6 months with ADLs. During an interview on 4/19/18, at 2:45 P.M., the Assistant Director of Nursing (ADON) said: - Staff should apply gait belts to the waist over clothes and should use the gait belt at all times, never lifting under the arms. - Staff should notify the charge nurse if a resident is not pivoting or bearing weight prior to the transfer. - Staff should lock the wheelchair brakes. - Staff provide ADL care and transfers based on the resident's care plan.

Based on observation, record review and interviews, the facility failed to prepare smooth pureed foods for one Resident (Resident #48), who the facility identified as having a physician ordered puree diet. The facility census was 54. Review of the facility's Pureed Food Preparation policy, dated 12/21/12, showed pureed foods will be the consistency of applesauce or smooth mashed potatoes. Staff with be in-serviced on proper preparation of pureed foods. 1. Review of the facility's pureed Cream Of Broccoli soup recipe showed to place prepared soup in a clean and sanitized food processor and blend until smooth. The recipe did not call for crackers or any other thickener. Observation and interview on 4/15/18, at 5:30 P.M., showed staff delivered a pureed meal tray to Resident #48. The pureed soup looked very thick and lumpy and held the shape of the serving scoop. Small pieces of broccoli and crackers were visible in the soup. The pureed egg salad sandwich contained small pieces of boiled eggs and held the shape of the scoop. Dietary Staff (DS) A said he/she used crackers to thicken the cream of broccoli soup. Observation on 4/15/18, at 5:40 P.M., during a taste test of the pureed soup showed hard pieces of broccoli stems and small pieces of crackers were left in the mouth when the mixture was ran between one's mouth and tongue. 2. Review of the pureed oven-fired chicken showed to dissolve 1 and 3/4 teaspoons of chicken base in 1 and 3/4 cups of water to make chicken broth. Place 5 servings of prepared boneless chicken in a washed and sanitized food processor. Gradually add broth as need and blend until smooth. If the product needs thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. Top pureed foods with sauce or gravy. Observation on 4/16/18, at 1:04 P.M., showed the pureed chicken contained pieces of the chicken and was the texture of uncooked instant oatmeal. Gravy was not served over the pureed chicken. Observation on 4/16/18, at 1:08 P.M., showed the sample taste of the pureed chicken contained pieces of chicken that had to be chewed; the chicken tasted dry and contained no sauce or gravy. 3. Review of the pureed taco burger on bun showed for 5 servings to dissolve 1 and 1/4 teaspoons of beef base into 1 and 1/4 cups of water. Place 5 prepared sandwiches and prepared broth in a washed and sanitized food processor and blend until smooth. Reheat to 135 degree Fahrenheit (F). Observation on 4/18/18, at 4:04 P.M., showed DS A prepared beef broth from bouillon and water. He/she added hot beef broth and 5, 1/2 cup servings of taco seasoned ground meat in the food Processor. DS A added 5 hamburger buns plus one more cup of broth into the food processor and ran the food processor a couple of minutes. Small pieces of the ground beef were visible in the thick and lumpy puree. DS A added the puree into a steam pan and placed the puree into the oven to re-heat. Observation and interview on 4/18/18, at 4:23 P.M., showed DS A added 5, 1/2 cup servings of previously cooked mixed vegetables and margarine into the food processor. DS A added no other liquid or thickener to the food processor and ran the food processor for about one minute. The pureed vegetables looked lumpy when he/she added the pureed food into a small steam table pan The Dietary Manager said they used the cooked vegetables left from a prior meal to make the vegetable purees. Observation on 4/18/18, at 5:52 P.M., showed staff fed the resident pureed taco burger. The puree had pieces of ground meat in the puree. The resident worked his/her mouth like he/she was trying to chew the pureed taco burger. Observation on 4/17/18, at 6:21 P.M., of a test tray containing puree taco burger and pureed mixed vegetables showed the pureed mixed vegetables contained pieces of a green vegetables and the pureed taco burger contained pieces of the ground beef. Neither pureed food was smooth and both held the shape of the serving scoop. The pureed foods when tasted were not smooth and contained pieces of the pureed foods that needed to be chewed. During an interview on 4/17/18, at 6:40 P.M., the Dietary Manager said purees should be the consistency of canned pudding but she thought they could have pieces of the food in the puree. She had not checked the pureed foods after DS A ran them in the food processor. DS A was still in training, having only cooked at the facility for about a month.

Based on observation, interview and record review, the facility failed to ensure dietary staff served residents their hot foods hot and cold foods cold. This affected all residents. The facility census was 53. Review of the facility's food safety policy showed hot food should be served at 120°F or above. All high risk foods must be served to the resident at a temperature of 41°F. 1. Review of the facility's recipes showed the Tiramisu dessert contained whipped topping and milk. The tossed salad contained parmesan cheese. Observation on 1/10/17, at 10:00 A.M., showed Cook A tossed the salad in a pan. He/she covered the pan with aluminum foil and left the pan on the counter. Dietary Aide A brought trays of Tiramisu dessert out of the walk in refrigerator at 10:35 A.M. and set them on the counter with no ice. Observation on 1/10/17, at 12:05 P.M., showed the main dining room test tray temperatures were, tossed salad at 71.4 degrees (°) Fahrenheit (F), Tiramisu dessert at 56°F, and milk at 48°F. Observation on 1/11/17, at 7:56 A.M., showed the village dining room test tray temperatures were, sausage patty at 106°F and glass of juice at 53°F. The drinks sat on a tray on the counter with no ice. 2. During an interview on 1/11/17, at 1:30 P.M., the Dietary Manager said hot food should be served at 140°F and cold food should be served at 41°F. During an interview on 1/12/17 at 9:00 A.M., Dietary Aide B said he/she did not know what temperature hot food should be served at. He/she said cold food should be served at 45°F

Based on observation, interview and record review, the facility failed to follow their policy to thoroughly assess two of 12 sampled residents (Resident #3 and #6) to assure the safe and appropriate use of side rails. This had the potential to affect any residents who used side rails. The facility census was 54. Review of the facility's Bed Safety policy, dated 2007, showed: - Provide a safe sleeping environment for the resident; - If bed rails were used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative. -After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security. 1. Review of the facility's Side Rail Assessment for Resident #3, dated 12/15/16, showed under Side Rail Considerations, staff marked the resident did not use side rails. The remainder of the form was blank. Review of Resident #3's Minimum Data Set (MDS), a federally required assessment instrument completed by staff, dated 12/18/17, showed: - Cognitively intact: - Extensive assistance for bed mobility; - Did not use a side rail. Review of the current care plan showed no information regarding the use of a side rail. Observation from 1/9/17 through 1/11/17, showed a quarter side rail attached to one side of the bed in the raised position. The other side of the bed was positioned against the wall. During an interview on 1/10/17, at 1:30 P.M., the resident said he/she used the side rail to assist him/her with getting out of bed. During an interview on 1/11/17, at 3:43 P.M., the MDS coordinator said the assessment tool should have been marked that the resident had a side rail, and further down in the assessment, additional information could have been added to show the rail was an assistive device. The tool was used to determine if the use of side rails was appropriate for the resident. The assessment tool could be used at anytime if the resident did not have a rail, then later started using one. She did not consider the the side rail as a safety concern for Resident # 3. During an interview on 1/12/17, at 2:00 P.M., Certified Nurse Aide (CNA) B said the resident used his/her side rail and staff made sure it was in the up position. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed the resident was severely cognitively impaired. The resident needed extensive assistance for bed mobility. Review of the resident's Side Rail Assessment completed by the MDS coordinator, dated 12/14/16, showed staff did not complete the entire form. The assessment did not show who requested the side rails. Staff did not indicate a reason for the side rail consideration or how the side rail would assist the resident. The assessment showed the facility did not conduct a care conference with the resident or their family about precautions or alternatives to the use of side rails. Review of the resident's care plan, dated 12/27/16, showed alarms or sensors were used on the resident while he/she was in bed. The resident needed one to two staff to reposition in bed, as well as with getting in and out of bed. Staff did not address the use of side rails in the care plan. Review of the resident's physicians' order sheet, dated January 2017, showed a [DIAGNOSES REDACTED]. Observation throughout the survey, showed a quarter side rail on the resident's bed. During an interview on 1/12/17 at 10:00 A.M., CNA A said they did not use the side rail to help the resident in or out of bed. He/she did not know if the resident used the side rail during the night in bed. During an interview on 1/12/17 at 1:00 P.M., the Director of Nursing said the resident's side rail assessment completed by the did not say why he/she needed it. During an interview on 1/12/17 at 1:15 P.M., the MDS coordinator said the resident needed the side rail when staff provided care for him/her.

Based on interview and record review, the facility failed to ensure that staff delivered the residents mail within 24 hours of mail delivery. This had the potential to affect all residents. The facility census was 60. 1. During a group meeting on 3/15/16 at 10:00 A.M. residents who get mail said that mail was not delivered inside the facility to individual residents on Saturdays. During an interview on 3/16/16 at 3:40 P.M., Resident #13 said the activity director delivered the mail. She was not there on the weekends and the Saturday mail was delivered on Mondays. The mail was delivered to the facility to a mailbox outside. During an interview on 3/16/16 at 3:45 P.M., the activity director said she was not here on the weekends. Sometimes a weekend staff member checked the mailbox outside and would place the mail in her mailbox in the copy room. She delivered it on Mondays when she comes back to work. During an interview on 3/17/16 at 9:00 A.M., Resident #11 said he/she did not get his/her mail on Saturdays and would like to. Review of the admission packet showed the only mention of resident mail was a form where residents authorized facility staff to open and read mail to the resident.