Every finding on record at Stratford Villa Post-Acute

Based on observation, interview, and record review, for five of six sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5), the facility failed to protect and promote resident rights to maintain privacy and be treated with dignity and respect when Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5 used wheelchairs (w/c[s]) with openly displayed labels hung underneath the resident seats, posted resident names, and made visible to others. These failures had the potential to affect Residents 1, 2, 3, 4, and 5's sense of self-worth and self-respect due to the public display of personal information as residents of the facility.A review of Resident 1's admission Record, printed on 8/21/26, indicated Resident 1 was admitted to the facility in 2025 with diagnoses that included osteoarthritis (a degenerative joint disease) of knee, right knee effusion (fluid build up), unsteadiness of feet, and limitation of activities due to disability. A review of Resident 2's admission Record, printed on 8/21/26, indicated Resident 2 was admitted to the facility in 2023 with diagnoses that included hypotension (low blood pressure), chronic gout (inflammatory arthritis), unsteadiness of feet, and history of repeated falls. A review of Resident 3's admission Record, printed on 8/25/26, indicated Resident 3 was admitted to the facility in 2026 with diagnoses that included dementia (memory loss; a group of thinking and social symptoms that interferes with daily functioning, fracture of left femur (longest and strongest bone in the body), and history of falls. A review of Resident 4's admission Record, printed on 8/21/26, indicated Resident 4 was admitted to the facility in 2018 with diagnoses that included dementia, generalized muscle weakness, difficulty walking, and history of falling. A review of Resident 5's admission Record, printed on 8/21/26, indicated Resident 5 was admitted to the facility in 2022 with diagnoses that included dementia, low back pain, weakness, and difficulty walking. During an observation on 8/20/26, at 10:07 a.m., in the hallway from across Resident 1's room, Resident 1 was up in a w/c with an openly displayed label of personal information (last name and first name initial) typed on a white, legal-sized paper in see-through protector, placed underneath the resident's seat. The label was visible from behind the resident w/c and can easily be seen by others entering the facility or when residents go out using the resident-designated w/cs. During concurrent observations on 8/20/26, at 10:10 a.m., Resident 2 wheeled himself towards Resident 1. Resident 2's w/c had the same identifiable label displaying Resident 2's name underneath Resident 2's seat. Resident 3, currently situated in the hallway one room up from where Resident 1 and Resident 2 were, was also seated in a w/c with the same identifiable label displaying Resident 3's name underneath Resident 3's seat. During concurrent interviews on 8/20/26, at 1:05 p.m., with Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), ADM stated it was the facility's as well as rehab department's goal to label individually designated resident w/c(s) with signs of resident names posted underneath the seats. ADM stated this practice was to promote easy identification of individual w/cs by residents and/or staff, as well as to maintain infection control prevention so that residents do not share or mistakenly use other resident's w/c. ADM, DON and ADON neither admitted nor denied communication with residents and/or respective family members regarding open public display of resident names in resident designated w/cs. DON stated facility should refrain from public display of resident names on the w/cs. ADON stated facility should come up with a more discreet way of labeling the w/c(s) to protect resident privacy. During an interview on 8/21/26, at 10:50 a.m., with the Director of Staff Development (DSD), DSD stated openly displayed labels on individual resident w/cs have been discontinued and removed by rehab department since yesterday due to resident privacy and dignity concerns. During concurrent observations on 8/21/26, at 11:30 a.m., in the hallway near Resident 1's room, Resident 2 and Resident 4 were seen up in their designated w/cs with identifiable labels displaying their individual names underneath their seats. Past the Nurses Station, next to the back exit door, Resident 5 was with a visitor and seated in a w/c with an identifiable label displaying Resident 5's name underneath Resident 5's seat. During a follow up observation and concurrent interview on 8/21/26, at 11:50 a.m., with the DSD, DSD confirmed labels remained openly displayed and showed individual names underneath Resident 2, Resident 4, and Resident 5's designated w/cs. DSD stated rehab department was responsible for removing the labels in the resident w/cs. During an interview on 8/21/26, at 12:20 p.m., with the Occupational Therapist (OT), OT stated resident labels on resident w/cs were used to track the resident w/cs for which resident the w/cs belong to. OT, however stated openly displayed signs that showed resident names hung underneath the seats of resident individual w/cs created a privacy concern of which should be discontinued. A review of the facility's policy and procedure (P&P) titled, Dignity, revised date October 2025, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Staff promote, maintain, and protect resident privacy.Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on interview and record review, the facility failed to ensure for two out of four residents (Resident 1 and 2), that their rights were protected, when facility did not verify the informed consents were obtained from the responsible party, and informed consent were not in Resident 1 and 2's medical records. These failures resulted in violating the residents' right to be informed with their medical treatment.Cross reference to F 684Findings:A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/08/2025 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05 (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact). During a review of facility's admission Record (AR), it indicated Resident 2 was admitted on [DATE], with diagnoses that included Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Aphasia. Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 02.During an interview on 02/11/2026 at 10:45 a.m., with Administrator (ADM), ADM stated the Brain Mapping/Neurofeedback treatment (a biofeedback, which teaches self-control of brain functions to subjects by measuring brain waves and providing a feedback signal. Neurofeedback usually provides audio and/or video feedback) was performed by a third party provider in the facility. ADM further added the brain mapping/neurofeedback treatment provider obtains the informed consent from Resident 1 and 2' Responsible Party (RP). Furthermore, the facility verifies the informed consent that was obtained by the provider by reviewing a copy of the informed consent and filing this copy in the resident's medical chart.During a concurrent interview and record review on 02/11/2026 at 12: 27 p.m. with ADM, ADM stated the consent for brain mapping/neurofeedback was emailed by the provider when Resident 2's Responsible Party requested informed consent. ADM stated a copy of the informed consent was not among his medical records.During an interview on 02/11/2026 at 01:28 p.m., with ADM, ADM stated she requested Resident 1's informed consent for the brain mapping/neurofeedback from the provider today to email the informed consent. During an interview on 03/04/2026 at 10:18 a.m. with Responsible Party (RP), RP stated she was not aware that Resident 2 was referred for brain mapping/neurofeedback treatment. RP stated she was first made aware of Resident 2's brain mapping/neurofeedback treatment when she requested a physician order summary to review Resident 2's medications. RP stated she did not give a consent to treat Resident 2 with brain mapping/neurofeedback and the treatment was not explained to her.During a review of the facility's policy and procedures titled Informed Consent, it indicated a policy statement The facility shall ensure the resident's rights are maintained and a copy of these rights and pertinent policies are made available to the resident and to any representative of the resident. Among these rights under this section are the right to: a. Receive in advance all information that is material to a decision to accept or refuse treatment, b. Consent to or to refuse treatment or procedure or participation in experimental research, and c. Participate in care planning. 1. Informed Consent: The voluntary agreement of a patient or a representative of an incapacitated patient to accept a treatment or procedure after receiving information. Guidelines 1. The disclosure of material information and obtaining informed consent is the responsibility of the licensed health care practitioner who, in acting within the scope of his/her professional licensure. 2. The facility staff shall verify the resident or his/her surrogate has given informed consent to the propose treatment or procedure.

Based on interview and record review, the facility failed to ensure for two out of four residents (Residents 1 and 2), Residents 1 and 2 receive treatments according to their needs. Residents 1 and 2 were treated with brain mapping/neurofeedback treatment (a biofeedback, which teaches self-control of brain functions to subjects by measuring brain waves and providing a feedback signal. Neurofeedback usually provides audio and/or video feedback), without after treatment plan and care provided. These failures had potential to affect Residents 1 and 2's health and safety due to lack of care coordination.Cross reference to F 578Findings:1. During a review of Resident 1's admission Record (AR), indicated Resident 1 was admitted on [DATE], with diagnoses that included Parkinson's Disease without dyskinesia, without mention of fluctuations. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 11/08/2025, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05, (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact). During a review of facility's admission Record (AR), indicated Resident 2 was admitted on [DATE], with diagnoses that included Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Aphasia. Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 02.During an interview on 02/11/2026 at 01: 10 p.m., with Medical Doctor (MD), MD stated that he made the referrals for Brain Mapping/Neurofeedback treatment for Residents 1 and 2. MD stated the referrals was for Parkinson's disease and dementia. MD stated the brain mapping/neurofeedback treatment was not a standard treatment for Parkinson's disease or dementia, but it may be beneficial to Residents 1 and 2. MD stated he discontinued the treatment after three to four weeks because he did not see an improvement.During an interview on 02/11/2026 at 10:45 a.m., with Administrator, (ADM) stated the Brain Mapping/Neurofeedback treatment was performed by third party provider in the facility.During a review of Resident 1's physician order dated 03/17/2023, indicated Brain Mapping/NeuroFeed Back (NFB) due to: Altered Mental Status. QEEG [Quantitative electroencephalography] Brain Mapping now, and after every 5th NFB therapy session. NFB therapy 2 -3 times a week for 20 - 40 sessions, with re-evaluation for continuance thereafter based on therapeutic appropriateness/patient response.During a review of Resident 1's Brain Mapping/Neurofeedback treatment record, indicated treatment started on 03/17/2023 through 10/24/2023.During a review of Resident 2's physician order dated 03/13/2024, indicated Brain Mapping/NeuroFeed Back (NFB) due to: Altered Mental Status. QEEG Brain Mapping now, and after every 5th NFB therapy session. NFB therapy 2 -3 times a week for 20 - 40 sessions, with re-evaluation for continuance thereafter based on therapeutic appropriateness/patient response.During a review of Resident 2's Brain Mapping/Neurofeedback treatment record, indicated treatment started on 03/13/2024 through 05/01/2024.During an interview on 02/11/2026 at 11:20 a.m., with ADM, ADM stated Responsible Party (RP) requested to discontinue the brain mapping/neurofeedback treatment because there were no improvements after months of treatment. ADM further added that Resident 2's RP requested to stop treatment and Resident 2's RP claimed they did not give consent for the brain mapping/neurofeedback treatment. 2. During a concurrent interview and record review on 02/11/2026 at 11:40 a.m., ADM, ADM reviewed Resident 2's nursing care plan, and ADM stated that there was no nursing care plan for Resident 2's Brain Mapping/Neurofeedback treatment.During a concurrent interview and record review on 02/11/2026 at 12:00 p.m., with ADM, ADM reviewed Resident 1's nursing care plan, and ADM stated there was no nursing care plan for Resident 1's Brain Mapping/Neurofeedback treatment.During a concurrent interview and record review on 02/11/2026 at 01:04 p.m., with ADM, ADM stated she contacted the brain mapping/neurofeedback treatment provider to obtain Resident 1's first visit notes.During an interview on 02/11/2026 at 01:33 p.m., with Director of Staff Development/Licensed Vocational Nurse (DSD/LVN), DSD/LVN stated the Brain mapping/neurofeedback provided did not give after treatment care instructions for Resident 1 and 2's brain mapping/neurofeedback treatment. DSD/LVN stated the visit notes were not given immediately after the visit, and he was unaware when the visit notes were provided to the facility.During a review of Resident 1 and 2's Brain Mapping/Neurofeedback Nursing Home Visit notes indicated Plan of care coordinated with primary care team, nursing staff. Counseling provided to staff regarding adequate patient hydration and nutrition in conjunction with Neurofeedback.

Based on observation, interview, and record review, the facility failed to ensure for one out of four residents (Resident 1), that Resident 1 was in a room with Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities), EBP was not followed during nursing care. This failure had the potential to spread infection when prevention was not consistently practiced.Findings:During a review of the facility's admission Record (AR), it indicated that Resident 2 was admitted on [DATE], with multiple diagnoses that included Encounter for attention to gastrostomy(a surgical opening into the stomach for a feeding tube to deliver nutrition, hydration, or medication directly). Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 12/25/2025 indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 02 (BIMS score of 00 - 07: severe impairment; 08 - 12: moderately impaired; and 13 - 15: cognitively intact).A review of Resident 2's Order Summary Report indicated Enteral Feed Order every 3 hours Enteral: Flush with a minimum of 130 ml water via PEG tube, . Enhanced Barrier Precaution during high contact time secondary to: G-tube indwelling device every shift.During a review of Resident 2's Care Plan Report it indicated Enhanced Barrier Precautions Required: [Resident 2] requires enhanced barrier precaution during high contact care activities due to: G-Tube indwelling device.During a concurrent observation and interview on 02/11/2026 at 11:24 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she would flush Resident 2's g-tube with water. LVN 1 entered Resident 2's room and prepared and administered the water flush via g-tube. Resident 2's family was at bedside visiting. LVN 1 and Resident 2's family member repositioned Resident 2 in bed. LVN 1 did not wear a gown before administering Resident 2's g-tube water flush, and to reposition Resident 2 in bed.During a concurrent observation and interview 02/11/26 at 12:54 p.m., with, LVN 1, LVN 1 stated that Resident 2 was on enhanced barrier precautions for the presence of a g-tube. There was a sign posted outside Resident 2's room that read : Enhanced Barrier Precaution. LVN 1 stated she did not put on a gown when she flushed water into Resident 2's g-tube.During a review of facility's policy and procedures titled Enhanced Barrier Precautions it stated Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as infection prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing a high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities required the use of gown and gloves for EBPs include. g. device care or use (central line, urinary catheter, feeding tube.).

Based on observation, interview, and record review, the facility failed to ensure state requirements were met for a full-time registered dietitian or the person designated to serve as the director of food and nutrition services was hired on staff on a full-time basis (35+hours/week). This failure had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services for 26 out of 26 residents. Findings: During an interview on 3/19/24 at 8:39 a.m., with the Dietary Supervisor (DS) and Registered Dietician (RD), DS stated he did not work full time in the Kitchen. DS said he also worked next door at the sister facility. DS further stated he provided dietary staff training and checked their competencies. DS stated he did not work full time and works at least 20 hours a week for the facility. DS further stated he also worked at the sister facility next door for 20 hours a week. RD stated she works part time at the facility, between 8-16 hours a week. During an interview on 3/19/24 at 12:30 p.m., with the Administrator (Admin), Admin stated she was aware the facility did not have a full time DS or RD and Admin was working on it.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. Hand washing sink was located right next to coffee machine and beverage dispenser. 2. Multiple food items opened with no use-by dates; bag of permecian gravy opened 3/5/24, bag of chicken gravy mix opened 3/2/24, carton of lactose free milk opened 3/12/24, cartoon of pineapple juice opened 3/10/24. There were five pounds of Monterey jack cheese opened 3/11/24, and a plastic container of apple sauce, dated 3/10/24. 3. Three-compartment sink was not operated according to instructions. 4. Ice machine had brownish whitish hard sticky substance on the right area on the outside difficult to wipe off. 5. Three kitchen air vents and one fly trap by the outside door with excessive blackish dust. 6. Floor drains and air gap by the ice machine and walk-in refrigerator had brownish black discoloration. 7. Dietary staff picked up trash from the kitchen floor and proceeded to distribute water from beverage cart without hand washing. These failures increased the risk for food contamination and food borne illness for 26 residents who received food from the kitchen. Findings: During initial tour of the kitchen on 3/18/24 at 9:00 a.m., with Dietary Services Supervisor (DS), the following were observed: the container of coffee creamer was situated next to the coffee and beverage dispenser that was next to the hand washing sink. DS stated as long as the coffee dispenser is covered, he was not concerned about the water splashes from staff use of hand washing sink. Multiple food items in the refrigerator and walk-in refrigerator had an open date with no use-by date. DS stated the food items had no use-by date. During concurrent observation of the kitchen and interview on 3/18/24 at 9:34 a.m., with DS accompanied Registered Dietician (RD), the dishwashing machine was not operational. RD stated facility had been using the 3 compartment sink for dishwashing. The water in the 3-compartment sink had brownish discoloration. Dietary aide (DA1) stated he uses the 3 -compartment sink to wash pots and dishes, then rinse and immerse in the sanitizer for 5 minutes to sanitize. DA 1 further stated the water temperature was checked in the morning before starting wash and the temperature are recorded. DA 1 stated the water temperature and test strip result where not repeated or recorded every 30 minutes. RD stated the water temperature needs to be repeatedly checked every 30 minutes. Review of the emergency 3-compartment washing log posted on the wall indicated from 3/13/24 to 3/18/24, temperature of the 3 compartment sink and result of the sanitizer test strip were check with initial setup for each meal (breakfast, lunch and dinner), there was no record of the temperature and sanitizer test strip results documented every 30 minutes as instructed. During a follow up tour of the kitchen on 3/19/24 at 9:32 a.m., with Maintenance Supervisor (MS) and Administrator (Admin), the ice machine had a brownish white hard, sticky substance on the right side of the wall which was difficult to wipe off. MS stated the build up on the ice machine could not be removed because the manufacturer did not want any chemical use on the outside of the machine. Three ceiling vents and fly trap above the exit door had excessive black dust. MS stated he missed cleaning the vents located in the kitchen ceiling. During further observation, the airgap/back flow area next to the ice machine and walk-in freezer were with brown-black discoloration. MS stated the air gaps area will be added to their maintenance cleaning schedule. During a concurrent observation and interview on 3/19/24 at 9:38 a.m., with RD and Admin,the coffee and beverage dispenser was next to the handwashing sink. RD stated there was a possible infection control concerns related to the coffee and beverage dispenser next to the sink. RD stated she was hired three months ago and had no documentation the kitchen sanitation checks were done. During tray line observation and concurrent interview on 3/19/24 at 11:56 a.m., DA 1 with gloved hands picked up a piece of trash from the kitchen floor and threw it in the trash can, using the same gloved hand to distribute water from the bevereage cart. DA 1 stated he was supposed to change his gloves before he distribute cup of water from the beverage cart. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2023, the P&P indicated, the food and nutrition services (FNS) director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employee to use appropriate techniques. The Maintenance Department will assist FNS as necessary in maintaining equipment and in doing janitorial duties which the FNS employees cannot do and maintain maintenance records on all equipments.

Based on observation, interview, and record review, the facility failed to dispose of garbage and contain refuse properly when the dumpster was not closed. This failure had the potential of harborage and feeding of pests. Findings: During an observation on 3/19/24 at 8:39 a.m., with Dietary Services Supervisor (DS), one dumpster located by the side of the facility was full of trash bags and not closed or covered. There was no staff presence around the dumpster area. During an interview on 3/19/18 at 8:39 a.m., DS stated the dumpster was supposed to be closed. During an interview on 3/19/24 at 09:01 a.m., with Maintenance Director (MS) and Administrator (Admin), MS stated the dumpster was to be closed when not in-use. During a review of the facility's policy and procedure (P&P), titled, Medical Waste, Handling of, revised September 2010, indicated outside compactor/dumpster must be locked when not in use and at night.

Based on interview and record review, the facility failed to follow a written hospice (end-of-life) agreement that included joint responsibilities to develop and implement plan of care for one sampled resident (Resident 23) was admitted into the hospice program, when Resident 23 and Resident 23's representative (FM 1) were not included or participated in the development and implementation of Resident 23's hospice plan of care (POC). This failure had the potential to result in negative outcomes and lack of communication of a person-centered care needs for residents. Findings: Review of the Significant change in status-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 2/24/24, indicated; Resident 23's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language) and senile degeneration of the brain (Dementia). Resident 23's Basic Interview of Mental status (BIMS) score was 01 poor cognition). Resident 23 had a clear speech, usually understood and understood others. During a telephone interview on 3/18/24 at 11: 20 a.m., with Resident 23's representative (FM 1), FM 1 stated Resident 23 was admitted to hospice for terminal care. FM 1 stated the concern she had was that there was not enough communication with staff regarding Resident 23's care. FM 1 stated the care planning conference she was invited and participated was in June 2023 when Resident 23 was admitted to the facility. FM 1 stated Resident 23 and herself had not participated in Resident 23's hospice plan of care or in any other care planning. Review of Resident 23's hospice plan of care initiated 2/17/24 indicated Resident 23 was admitted to hospice care for senile degeneration of the brain interventions included to encourage participation to the extent the resident wishes to participate. Review of order summary report dated 2/17/24 indicated the physician admitted Resident 23 into hospice for senile degeneration of the brain. During a concurrent interview and review of the IDT (interdisciplinary team is comprised of different staff from different departments of the facility, like nursing, social services etc.) care planning conference records, on 3/20/24 at 9:26 a.m., with Social Services Director (SSD), Director of Nursing (DON) and Registered Nurse (RN 1), SSD stated Resident 23 and FM 1 had not been invited to participate in the development of Resident 23's hospice care plan. SSD stated she had not arranged for a care planning conference with Resident 23, FM 1. and the hospice provider. SSD further stated sometimes a quick care conference was done when FM 1 visited the facility. SSD could not provide documentation that Resident 23 and FM 1 was invited, included or participated in the hospice plan of care. Review of Resident 23's clinical records indicated the plan of care attended by Resident 23 and FM 1 was completed in June 2023 before Resident 23 was admitted into hospice. During an interview on 3/21/34 at 10:29 a.m., with Administrator (Admin) and DON, Admin stated hospice care planning was to be initiated when the resident was admitted into the hospice program. Admin stated the facility's policy was for SSD to coordinate with the facility staff and hospice provider. During a review of the Hospice Services Agreement (Agreement), dated 2/16/24, the Agreement indicated the Joint Responsibilities/Mutual Promises- Development and implementation of plan of care (POC). When a facility resident is authorized by hospice for admission to the Hospice Program, or when the facility admits a hospice patient to the facility, hospice and facility staff shall jointly develop and agree upon the patient's POC. {

Based on observation, interview and record review, the facility failed to ensure safe medication storage when the following medications were found in medication cart one: 1. Resident 22 did not have an accurate medication card label for Colchicine that matched the order the physician had prescribed. (Colchicine is a medication used to prevent or treat gout attacks. Gout is a disease that causes severe pain, swelling, redness and tenderness in joints). 2. Three and one-half loose pills were not in a labeled container. This failure had the potential for medication error and contamination. Findings: 1. During a review of the admission record, dated 3/19/24, indicated Resident 22 was admitted on [DATE], with the diagnosis of gout. During a medication administration observation on 3/19/24, at 8:21 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 gave Resident 22 one tablet of Colchicine 0.6 milligrams (mg) from Resident 22's medication card with a direction label that indicated to give Colchicine one tablet two times a day. During a concurrent interview and record review on 3/19/24, at 3:00 p.m., with LVN 1, Resident 22's physician's order, dated 3/19/24, was reviewed. The physician's order indicated to give one tablet of Colchicine 0.6 mg. once a day for gout. LVN 1 acknowledged Resident 22's medication card did not match the current physician's order, because the card indicated to give Colchicine one tablet two times a day. LVN 1 further stated having direction labels that did not match the current physician's order was a risk for medication administration error. During an interview on 3/21/24 at 9:05 a.m., with Registered Nurse 1 (RN 1), RN 1 stated the risk of having medication cards with direction labels that did not match Resident 22's current physician's order could be suffering an adverse (undesirable) effect of the medication. During a review of the facility's policy and procedure titled, Medication Labeling and Storage, dated February 2023, indicated .The nursing staff must inform the pharmacy of any changes in physician's orders for a medication . 2. During an observation and concurrent interview with RN 1, on 3/19/24, at 12:50 p.m., upon inspection of the medication cart 1, three and one-half loose tablets were found. RN 1 was unable to identify the loose tablets and stated loose tablets should not be in the medication cart and should have been disposed. During a review of the facility's policy and procedure titled, Medication Labeling and Storage, dated February 2023, indicated . Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents .

Based on observation, interview, and record review, for one of four sampled residents (Resident 1), the facility failed to ensure staff provide immediate life-saving measures (cardiopulmonary resuscitation [CPR] - rescue breathing and or chest compressions when the heart stops) when Resident 1 was found in bed without vital signs (Vs, temperature, pulse, respirations, blood pressure ). Resident 1 was a full code (desired all medical emergency interventions when breathing and or heart stops). Licensed Vocational Nurse (LVN) 2 declared Resident 1 expired (dead) and did not initiate CPR or call emergency personnel ([DATE]). This failure of LVN 2 to provide CPR and call emergency personnel was determined to constitute an Immediate Jeopardy (IJ). IJ represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. The facility ' s Administrator (Adm) and Registered Nurse Consultant (RNC) were verbally notified of the IJ on [DATE], at 4:35 p.m. The facility submitted an acceptable Plan of Action on [DATE], at 2:26 p.m. Through observations and interviews with staff members, and record reviews of the facility ' s training records, the facility initiated a CPR in-service course on how to respond to an emergency situation. The IJ was lifted on [DATE] at 4:25 p.m. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1 ' s Physician Orders for Life Sustaining Treatment form (POLST-directs individual end-of-life preferences during a medical emergency), dated [DATE], was signed by Resident 1 ' s legally recognized decision-maker and his physician. The POLST form included . Cardiopulmonary Resuscitation (CPR) .If patient has no pulse and is not breathing .Attempt Resuscitation/CPR . Review of Resident 1's progress notes dated [DATE] at 7:15 a.m., by LVN 2 indicated, Resident 1 was found unresponsive in bed, with no vital signs at 5:20 a.m. The progress notes did not indicate that LVN 2 attempted CPR on Resident 1. During an interview on [DATE], at 12:03 p.m., with the Director of Nursing (DON), DON stated, LVN 2 should have initiated CPR and called [DATE] (emergency personnel) when Resident 1 was found with no vital signs. DON further stated it should be the doctor, and not LVN 2 to pronounce Resident 1 ' s death. During an interview on [DATE] at 10:29 a.m., with LVN 2, LVN 2 stated, she did not initiate CPR because it was reported to her by the nurse from the previous shift that Resident 1 ' s code status was DNR (Do Not Resuscitate). LVN 2 stated she did not check the POLST form in Resident 1 ' s medical chart. LVN 2 further stated after she found Resident 1 without vital signs, she just informed the DON, the physician, and the resident ' s family that Resident 1 expired. Also, LVN 2 stated she did not know she was supposed to check the POLST for the facility residents ' code status and used the residents ' progress notes for information of their code status. During an interview on [DATE] at 4:00 p.m., with Medical Doctor (MD), MD stated, I am sorry, it was a mistake the facility did not call [DATE]. The resident ' s code status was a full code, and the nurse on duty should have called [DATE]. The [DATE] (emergency personnel) would be the one to pronounce the resident ' s death. During a review of the facility ' s policy and procedure (P&P) titled, Emergency procedure- Cardiopulmonary Resuscitation, dated February 2018, indicated, .if an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual . Emergency Procedure- Cardiopulmonary Resuscitation indicated if an individual is found unresponsive, briefly assess for abnormal breathing .begin CPR, instruct a staff member to activate the emergency response system and call 911 .verify or instruct a staff member to verify the DNR or code status of the individual .

Based on interviews and record review, the facility failed to perform a proficient neurological assessment (a series of questions and or motor tests in the event of a sudden change in condition to detect neurological changes: level of consciousness, orientation, movement of arms and legs, pupil size and reaction to light) for one (Resident 1). Staff did not maintain monitoring according to professional standards to detect early changes that required emergent medical treatment after Resident 1 sustained an unwitnessed fall. This failure resulted in not identifying a change in Resident 1 ' s neurological status. Resident 1 died in the facility the following day after the unwitnessed fall. Findings: A review of Resident 1 ' s hospital record titled, Physician Hospitalist Discharge and Transfer Instruction (PHDTI) dated [DATE], indicated the diagnosis of a subarachnoid hemorrhage (SAH, bleeding in the space that surrounds the brain) due to a fall at home. The PHDTI indicated, Resident 1 was being discharged to a skilled nursing facility for rehabilitation services and recovery. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's Alert Charting (AC) by Licensed Vocational Nurse (LVN) 1 dated [DATE] at 7:29 a.m., the AC indicated Resident 1 was admitted to the skilled nursing facility on [DATE] and was described by LVN 1 on admission as: alert and oriented x ,d+[DATE] (referring to Resident 1 ' s orientation to 1-person, 2-place, and 3-time. Resident 1 was not fully aware of the time). A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool for sharing information between facility team members) written by LVN 1, dated [DATE] at 2:21 a.m., indicated, Resident 1 had an unwitnessed fall and was found lying on the floor next to his bed on [DATE] at 12:00 a.m. The SBAR indicated, Resident was alert and oriented x ,d+[DATE] with confusion and was not able to explain the reasoning behind his fall. Resident 1 knew who he was but was not fully aware of where he was or knew the time). The SBAR indicated a decline in Resident 1 ' s orientation from LVN 1 ' s AC notes on [DATE]. Resident 1 was aao (awake, alert, and oriented) x ,d+[DATE] on [DATE]. Further record review showed LVN 1 was aware of Resident 1 ' s primary diagnosis of SAH due to mechanical fall resulting in head trauma (head injury). Resident 1 was not transferred to the hospital after the fall on [DATE]. A review of Resident 1's Daily Nurses Notes (DNN), dated [DATE] at 7:15 a.m., (the day after the unwitnessed fall) by LVN 2, the DNN indicated, Resident 1 was found without Vital signs (Vs, includes temperature, pulse, respirations, and blood pressure) at 5:20 a.m. The DNN also indicated LVN 2 had informed the Medical Doctor (MD), Director of Nursing (DON), and the resident ' s family that Resident 1 expired (died ). During a concurrent interview and record review, on [DATE], at 12:03 p.m., with DON, and Resident 1 ' s Nursing Progress Notes (NPP), dated [DATE] and [DATE] were reviewed. The NPP indicated the nurses only monitored Resident 1 ' s Vs but did not perform the complete neurological checks every 4 hours because these were not documented by the licensed nurses. DON stated, the licensed nurses were supposed to monitor Resident 1 ' s pupil size, range of motion, changes in behavior, pain, mentation, and responsiveness to environment, aside from his Vs, to ensure Resident 1 had no head injury after the unwitnessed fall and to determine if the resident needed further medical interventions. DON also stated, LVN 1 should have asked for an order from the MD to transfer Resident 1 to the hospital for further medical evaluation after the unwitnessed fall. During a phone interview with LVN 2 on [DATE] at 10:29 a.m., LVN 2 stated her definition of performing neuro checks was only checking the safety of Resident 1. LVN 2 stated she performed neuro checks by checking the resident ' s vital signs, alertness and stated she could not recall what other neuro assessments she needed to check. During a phone interview with LVN 1, on [DATE] at 9:48 a.m., LVN 1 stated she informed the MD regarding Resident 1 ' s unwitnessed fall by texting MD and MD did not tell LVN 1 to transfer the resident to the hospital. During a phone interview with the Deputy Coroner (DC), on [DATE] at 9:15 a.m., DC stated, with Resident 1 ' s diagnosis of SAH due to a mechanical fall at home, the facility should have done more interventions for Resident 1 by doing the complete neurologic assessments and sending Resident 1 to the hospital for further evaluation to determine if Resident 1 sustained a head trauma after the unwitnessed fall in the facility. During a review of the facility ' s policy and procedure (P&P) titled, Neurological Assessment, dated [DATE] indicated, Neurological Assessments are indicated: upon physician order; following an unwitnessed fall . any change vital signs or /neurological status in a previously stable the resident should be reported to the physician immediately. The P&P also indicated, Steps in the procedure include: .Perform neurological checks with the frequency as ordered; Determine resident ' s orientation to time, place and person; Observe resident ' s speech and speech clarity; Check pupil reaction; Determine motor ability; Determine sensation in extremities; Check eye opening, verbal, and motor responses . Also, The following information should be recorded in the resident ' s medical record: the date and time the procedure was performed, the name and title of the individual(s) who performed the procedure, all assessment data obtained during the procedure, how the resident tolerated the procedure .

Based on interview and record review, the facility failed to ensure Resident 1 ' s admission record showed all diagnoses from the hospital were included in Resident 1's admission record to the facility. This deficient practice resulted in the incomplete and inaccurate history of medical diagnoses that prevented Resident 1 from receiving comprehensive and anticipatory care. On [DATE], Resident 1 suffered an unwitnessed fall in the facility and expired (died ) in the facility on [DATE]. Findings: A review of Resident 1 ' s hospital records titled, Physician Hospitalist Discharge and Transfer Instruction (PHDTI), dated [DATE], indicated Resident 1 was admitted to the hospital due to a fall at home. The PHDTI indicated, Resident 1 was diagnosed with subarachnoid hemorrhage (SAH, bleeding in the space that surrounds the brain), traumatic brain injury (a form of acquired brain injury which occurs when a sudden trauma causes damage to the brain), and cerebral contusion (scattered areas of bleeding on the outside part of the brain). A review of Resident 1's Admission Record (AR) dated [DATE], the AR indicated, Resident 1 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus (blood sugar disorder). The AR did not include Resident 1 ' s past medical history from the hospital that included the diagnoses of SAH due to a fall, traumatic brain injury and cerebral contusion for anticipating and planning care. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used to share information between facility health team members), dated [DATE] at 2:21 a.m., the SBAR indicated, Resident 1 had an unwitnessed fall and was found lying on the floor next to his bed on [DATE] at 12:00 a.m. The SBAR also indicated Resident 1 was not transferred to the hospital after the fall on [DATE]. Review of Resident 1's nurses notes dated [DATE] at 7:15 a.m., by Licensed Vocational Nurse 2 (LVN 2) indicated, Resident 1 was found unresponsive in bed, with no vital signs (temperature, pulse, respirations, blood pressure) at 5:20 a.m. During an interview on [DATE], at 4:48 p.m., with the Director of Nursing (DON), DON stated she was responsible for updating Resident 1 ' s current diagnoses in the admission record. DON further stated the purpose of an updated diagnoses in the admission record was to make sure Resident 1 ' s current specific needs would be identified and addressed. DON further stated Resident 1 ' s risk of confusion, needing assistance in activities of daily living (activities related to personal care), and gait and balance problem while walking, due to a SAH were not addressed before Resident 1 expired because the facility's admission records diagnoses were not accurate. During a review of the facility ' s policy and procedure (P&P) titled, Admission Notes, dated 2012, the P&P indicated, When the resident is admitted to the nursing unit, the Director of Nurses/Designee and/or Admitting Nurse must document the following information . in the nurses ' notes, admission form, or other appropriate place, as designated by facility protocol: the date and time of residents admission; . from where the resident was admitted ; . reason for admission; the admitting diagnosis . Should the resident be discharged from and readmitted to the facility, new admission data must be recorded.

Based on interview and record, the facility's Quality Assessment Performance Improvement (QAPI) committee failed to identify an adverse event (untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses) and the root cause resulting in the death of one (Resident 1) of three sampled residents. Resident 1 was a full code (all emergency interventions in the event breathing and or heart stops). Staff failed to provide emergency medical treatment when Resident 1 was found unresponsive because nursing staff mistakenly thought Resident 1 had a Do Not Resuscitate (DNR) order. This failure resulted in the QAPI committee not taking steps to review the circumstances of Resident 1's death and monitor their system for code status verification to correct the issue. Findings: A review of resident 1 ' s Physician Orders for Life Sustaining Treatment form (POLST-directs individual end-of-life preferences during a medical emergency), dated [DATE], was signed by Resident 1 ' s legally recognized decision-maker and his physician. The POLST form included . Cardiopulmonary Resuscitation (CPR, chest compressions and rescue breathing) .If patient has no pulse and is not breathing .Attempt Resuscitation/CPR . Review of Resident 1's nurse's progress notes, dated [DATE] at 7:15 a.m., by Licensed Vocational Nurse 2 (LVN 2), indicated Resident 1 was found unresponsive in bed, with no vital signs (Vs, temperature, pulse, respirations, blood pressure) at 5:20 a.m. The progress notes had no documentation that LVN 2 provided CPR on Resident 1 and no [DATE] emergency personnel were summoned for emergency care. During an interview on [DATE] at 3:50 p.m., with the Administrator (ADM), who also serves as the facility's head of QAPI, ADM stated the committee meets quarterly and during daily stand-up meetings to determine if there are concerns from family or others that could be (an activity) for the QAPI committee. ADM further stated for every death, we (QAPI committee) ask if there was a cause of death, and review when the Director of Nurses (DON) was notified and whether it was a DNR or full code. ADM further stated the facility's goals and benchmarks for concerns has a tracker and conducts monthly or quarterly audits from the start date. The QAPI committee evaluates and revaluates their performance and decides when it may be discontinued. Record review of the QAPI Committee Meeting Records with ADM, dated [DATE] through [DATE], reflected there were no identified concerns about CPR, POLST forms or adverse events concerning resident deaths. ADM acknowledged there were no other documents that Resident 1's death was identified as a concern for the QAA committee to address. The facility's policy and procedure (revised February 2020) titled, QAPI Program indicated the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance. b. establishing goals and thresholds for performance measurement. c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. The facility's policy and procedure (revised [DATE]) titled, QAPI Program Analysis and Action indicated the methodology for analysis and action is guided by a written QAPI plan that includes: a. definition of the problem, based on information obtained through data, self-assessment and feedback systems. b. an analysis of the root cause of the problem from a systems perspective. c. establishing measurable goals or benchmarks for improvement. d. specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. e. methods and frequency of monitoring performance improvement objectives.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. The walk-in refrigerator had four trays of previously frozen raw meat in the refrigerator for more than three days; the raw meat was not labeled with a use by date. 2. The reach-in refrigerator had undated and unlabeled individually packaged liquids and a bowl of cooked oatmeal. 3. Two dietary personnel did not perform hand hygiene and or glove changes during food handling. 4. The ice machine interior had a pink substance on the ice chute surface, and the exterior surface of the ice bin had a white residue along the bin seams. These failures had the potential to result in food contamination and foodborne illnesses. Findings: 1. During a concurrent kitchen observation and interview with Cook 1, on 3/21/22, at 9:43 a.m., the walk-in refrigerator's temperature was 38 degrees Fahrenheit (F). The bottom shelf of the refrigerator had four separate trays of raw meat labeled and dated as follows: pork 3/18/22; beef 3/18/22; chicken 3/19/22; beef 3/19/22. Cook 1 stated the label on the trays indicated the type of meat and the date when the package of raw meat was removed from the freezer and put into the refrigerator for defrosting. During a concurrent observation and interview, with Dietary Supervisor (DS), on 3/22/22, at 10:31 a.m., in the kitchen, the walk-in refrigerator's bottom shelf had the same four trays of raw meat: pork 3/18/22; beef 3/18/22; chicken 3/19/22; beef 3/19/22. DS stated each tray of raw meat weighed five pounds and had been pulled out from the freezer and placed in the refrigerator to defrost at the same time, for convenience. DS stated the pork and beef dated 3/18/22 was stew meat, chicken thighs were dated 3/19/22, and the beef dated 3/19/22 was ground beef. During a telephone interview on 3/23/22, at 9:50 a.m., with the Registered Dietitian (RD), RD explained the process of safely thawing raw meat. RD stated raw meat is labeled with a pull-out date when taken out of the freezer and thawed for three days in the bottom shelf of the refrigerator. Defrosted meat should be cooked on the third day. Raw meat if not used on the third day should be cooked and kept in the freezer until ready to serve within 48 hours. Unused thawed raw meat past three days should be discarded. During a review of the facility's P&P titled, Food Preparation, dated 2018, the P&P indicated, .Thawing meat properly can be done in these four ways: 1. In a refrigerator at 41 degrees F or colder. Allow two to three days to defrost, depending on quantity and total weight of meat. Label defrosting meat with pull and use by date . 2. During a concurrent kitchen observation and interview with Cook 1, on 3/21/22, at 9:43 a.m., inside the reach-in refrigerator were six glasses with liquids of assorted colors and a cup of cooked oatmeal undated and unlabeled. Cook 1 stated he poured the drinks into glasses and prepared the oatmeal when he arrived on the morning of 3/21/22. Cook 1 stated food items should be labeled to ensure residents received fresh food and drinks and did not get ill from food. During an interview on 03/22/22, at 10:31 a.m., with the DS, DS stated poured drinks should either be individually labeled with the date or placed in a dated tray inside the refrigerator. 3. During an observation on 3/22/22, at 11:30 a.m., in the kitchen, kitchen staff plated food for the residents' lunch service. Cook 3 wore gloves and put plated food onto the serving cart. While wearing the same gloves, Cook 3 used his hands to place a dinner roll on a plate. Cook 3 removed his soiled gloves, and donned new gloves without intervening hand hygiene, and used his hands to place a parsley garnish on a plate. During an observation on 3/22/22, at 11:35 a.m., in the kitchen, during lunch preparation service, DS doffed soiled gloves and without performing hand hygiene, DS donned new gloves and used a scoop to place dried herbs on top of food on a plate. During a review of the facility's P&P titled, Glove Use Policy, dated 2018, the P&P indicated, The appropriate use of gloves is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded after each use, especially before handling clean food items .Wash hands when changing to a fresh pair. Gloves must never be used in place of handwashing .When Gloves Need to be Changed .before beginning a different task .before handling all food as described in food handling procedures . 4. During a concurrent kitchen observation and interview with Cook 1, on 3/21/22, at 9:53 a.m., the ice machine interior had a pink substance on the ice chute surface, and the exterior surface of the ice bin had a white residue along the bin seams. Cook 1 stated the Maintenance Director (MD) was responsible for cleaning and maintenance of the ice machine. During a concurrent observation and interview on 3/22/22, at 10:40 a.m., with MD, in the kitchen, MD stated the interior of the ice machine had a pink substance on the catch rail of the ice machine chute. MD also stated the white residue on the exterior seams of the ice machine bin was calcium build-up. MD stated the ice machine was supposed to be cleaned every month. During a concurrent record review of the facility, Ice Machine Cleaning Log, MD stated the Log indicated the ice machine was last cleaned on 1/5/22. A review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated 2020, indicated, The ice machine needs to be cleaned and sanitized monthly or per manufacturer recommendation and the date recorded when cleaned .Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions . A review of the ice machine's manufacturer's manual titled, Maintenance, indicated, Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation. A review of the 2017 Federal Food Code, section 4-601.11 titled, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils, indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on record review and interview, the facility failed to monitor and document the fluid intake of one (Resident 19) of one resident that required [CONDITION(S)] (a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to monitor Resident 19's fluid intake for 29 of 90 shifts had the potential to result in Resident 19 consuming more fluids than ordered by the physician causing fluid overload with resultant problems of swollen extremities and difficulty breathing. Findings: A review of the document titled, Admission Record, dated 3/24/22, indicated Resident 19 was admitted to the facility in February 2022, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) A review of Resident 19's Minimum Data Set (MDS, an assessment tool used to guide resident care) dated 3/1/22, indicated Resident 19 was on [CONDITION(S)]. A review of Resident 21's, Order Summary Report, dated 3/24/22, indicated a physician order dated 2/24/22, for Resident 19's fluid intake to be limited to 1200 milliliters (mLs, 1200 mLs equals 1.2 quarts) per 24 hours. the order further indicated each shift (AM, day shift; PM, evening shift; NOC, night shift) was to record intake and endorse. During a concurrent record review and interview on 3/24/22 at 11:30 a.m., with Director of Nursing (DON), Resident 19's, Oral Fluid Intake from 2/23/22- 3/24/22, was reviewed. The DON stated it was important to monitor and document Resident 19's fluid intake because of Resident 19's need for [CONDITION(S)]. The DON stated Resident 19's Oral Fluid Intake record had no entries for the following dates/shifts: 2/24/22 AM; 2/26/22 AM and NOC; 2/27/22 NOC; 2/28/22 AM; 3/3/22 NOC; 3/5/22 NOC; 3/6/22 PM; 3/7/22 NOC; 3/8/22 NOC; 3/9/22 NOC; 3/10/22 NOC; 3/11/22 NOC; 3/14/22 AM and NOC; 3/16/22 PM and NOC; 3/17/22 AM and NOC; 3/18/22 AM and PM; 3/20/22 AM and PM; 3/21/22 AM; 3/22/22 AM and NOC; 3/23/22 AM; 3/24/22 AM and PM. A review of the facility policy titled, [CONDITION(S)] Resident, Care of, undated, indicated, Diet/Fluid Restrictions 1. [CONDITION(S)] diets/fluid restrictions will be provided as prescribed by a physician order.

Based on record review and interview, the facility failed to ensure one (Resident 22) of one resident receiving anticoagulation medication (medication to prevent blood clot formation, commonly known as blood thinner) was free from unnecessary medication when staff did not monitor the side effects of Resident 22's use of [MEDICATION(S)] (medication used to thin blood). This failure had the potential to result in Resident 22 developing adverse side effects such as bleeding. Findings: A review of Resident 22's Admission Record indicated Resident 22 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 22's, Order Summary Report, Active Orders as of 3/24/22, indicated a physician order, start date 2/28/22, for Resident 22 to receive one [MEDICATION(S)] tablet two times a day for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent record review and interview, on 3/24/22 at 11:03 a.m., with the Director of Nursing (DON), Resident 22's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated there should be documentation from staff about monitoring for the side effects of anticoagulation therapy because there could be serious side effects which would require physician notification. A review of the facility's policy titled, Anticoagulation, revised November 2018, indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems . If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment for two of five sampled residents (Resident 14, Resident 16) when staff failed to: 1. perform hand hygiene between glove changes when administering medication to Resident 14, and 2. clean the oxygen mask and tubing for Resident 16. This failure had the potential for infection of Resident 14 and Resident 16. Findings: 1. During a concurrent observation and interview on 3/23/22 at 09:03 a.m., in Resident 14's room, Licensed Vocational Nurse 2 (LVN 2), LVN 2 prepared Resident 14's medication by opening multiple medication bottles and medication packs with gloved hands and placing the medication into separate medicine cups. With the same gloved hands, LVN 2 went to Resident 14's bedside and touched Resident 14's remote control to adjust Resident 14's bed, adjusted Resident 14's blankets, and handed the medicine cups to Resident 14 without changing gloves or performing hand hygiene. A review of the facility's policy titled, Hand Washing/Hand Hygiene, revised August 2019, indicated, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before and after direct contact with residents; before preparing or handling medications .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. 2. A review of Resident 16's Admission Record, dated 3/23/22, indicated Resident 16 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 16's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 3/21/22, at 10:20 a.m., inside Resident 16's room, a nebulizer (a device used to change liquid medicine into a very fine mist that a person can inhale through a face mask or mouthpiece) was on the top of Resident 16's bedside table. On top of the nebulizer was Resident 16's oxygen mask with tubing connected to the mask. The mask had scattered dry white matter adhered to the interior of the mask. The tubing was connected to the mask at one end, and open to air at the end which was used to connect to the nebulizer. During an interview on 3/21/22 at 10:25 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 16's oxygen mask did not look clean. LVN 1 stated the mask and tubing should be kept in a bag when not in use to prevent bacterial growth and contamination. During an interview on 3/23/22, at 10:51 a.m., with the Director of Nursing (DON), the DON stated oxygen tubing, and oxygen masks should be dated when changed and stored in a Ziploc bag when not in use, for infection control purposes. Review of the facility's undated policy and procedure, titled Use of Oxygen, indicated, To promote patient safety in administering oxygen .The following guidelines will be observed in oxygen administration A. The oxygen cannula or mask does not require scheduled changing when used on one patient. It should be changed when soiled or dirty . Further review of the facility's undated policy and procedure, titled Oxygen Equipment, indicated, .D. Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be regularly monitored to prevent the build-up of respiratory secretions/mucous. E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms .

Based on observation, interview and record review, the facility failed to provide a safe environment for one (Residents 1) resident when staff did not follow the facility's policy to report the incident of suspected abuse/neglect immediately. This failure had the potential to result in Resident 1 not protected and neglected that could cause avoidable physical and psychological harm. Findings: Review of the Face Sheet indicated that Resident 1 was admitted on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/25/20 at 11:00 a.m. Resident 1 came from the bathroom sitting in her wheelchair. A staff was pushing Resident 1 back to her bed. In an interview on 8/25/20 at 11:15 a.m., Resident 1 stated she had to go to the bathroom and was tired and wanted to go to bed. In an interview with the Licensed Vocational Nurse (LVN1 on 8/25/20 at 11:30 a.m., LVN1 stated, on 8/19/20, Resident 1 was sitting in her wheel chair after lunch crying. Resident 1 told him CNA1 refused to take her to the bathroom and always gave her a hard time whenever she asked her to take her to the bathroom. Resident 1 added that CNA1 always makes her wait and reaches the point where she wets herself. Review of the plan of care, dated, 3/9/19 indicated, TOILET USE: The resident requires (extensive assistance) by 1 staff for toileting. In a telephone interview with LVN1 on 8/25/20 at 12:00 a.m., LVN1 stated he reported this incident to the Administrator around 3:00 p.m. LVN1 added, CNA1 continued her assignment on Resident 1 until she ended her shift at 3:25 p.m. LVN1 added, it was his first experience with an abuse/neglect case and he did not know if he needed to report the incident immediately. LVN1 stated he wasn't sure if the accused staff needed to be relieved of her assignment immediately. In an interview with the Administrator on 8/31/20 at 11:55 a.m., ADM confirmed CNA1 completed her shift and left at 3:25 p.m. CNA1 was informed by phone that she was suspended after she got home. Review of the facility's policy titled, Abuse Investigation and Reporting, dated, July 2017 indicated, All reports of resident abuse, neglect, exploitation, . shall be promptly reported to local, state, and federal agencies . The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.

Based on observation, interview and facility document review, the facility failed to label and store food under sanitary conditions when: 1. Five containers of strawberries had white fur on them. Three bananas had black and yellow skin. 2. One loaf of open large wheat bread was without a date. 3. Five small white bowls, two medium bowls two scoops with green handles were stacked and placed in the cabinet with water sitting in them. 4. Registered Dietician (RD) came into the kitchen and did not immediately wash her hands and completely cover her hair. These failures had the potential to cause food contamination and food borne illness in residents. Findings: 1. During an observation on and concurrent interview 8/21/19 at 8:05 a.m., in the walk in freezer, in a box there were five containers of strawberries with white fur on them dated 8/16/19. In the dry storage area, there were three bananas with black and yellow skin . The Dietary Manger (DM) stated fruit is kept three to five days. A review of the policy and procedure titled Storing Produce , dated (YEAR), indicated to check boxes of fruit and vegetables for rotten or spoiled items. Throw away all spoiled items. A review of the Produce Storage Guidelines dated (YEAR)' indicated strawberries should be stored in the refrigerator two to three days A review of the policy titled Corrective Action When Food in the Store Room Reaches Above 85F undated, indicated bananas will ripen faster in higher heat and should be checked that they have not become soft, moldy or bruised. Discard spoiled bananas. 2. During an observation and concurrent interview on 8/21/19 at 8:05 a.m., one loaf of large wheat bread in the standup freezer was open without a date. The Dietary Cook (DC) stated when the bread was opened, it should have been dated. A review of the policy and procedure titled , General Receiving of Delivery of Food and Supplies, dated (YEAR), indicated label all items with the delivery date or a use-by date. A review of of the Dry Goods Storage Guidelines, dated (YEAR), indicated open bread on the shelf should be stored five to seven days. 3. During an observation and concurrent interview on 8/21/19 at 8:24 a.m., two medium size white bowls, five small white, and two scoops with green handles had been stacked and placed in a cabinet with water sitting inside of them. The DM stated the bowls and scoops should have been air dried. The DM stated contamination could occur if they are not dried properly. During an interview on 8/21/19 with the (RD) at 9:50 a.m., the RD stated the importance of having dishes air dry is to prevent bacteria from growing on the them. A review of the policy and procedure titled , Dish Washing', dated (YEAR), indicated dishes are to be aired dried before stacking and storing. 4. During an observation and concurrent interview on 8/20/19 at 8:05 a.m., the RD entered the kitchen from a back door into the kitchen and did not wash her hands immediately upon entering the kitchen . The RD's bangs were not covered by her hair net. The RD, she stated anyone who comes in the kitchen should wash their hands and have their hair completely covered. During an interview with the RD on 8/21/19 at 9:50 a.m., the RD stated hand hygiene is done to prevent food born illness. You should wash your hands when you enter the kitchen. A review of the policy and procedure titles , Hand Washing Procedure, dated (YEAR), indicated hands need to be washed before starting work in the kitchen. A review of the policy and procedure titled, Dress Code, dated ' indicated hair net or hat which completely covers the hair.

Based on interview and record review, the facility failed to implement their Performance Evaluations policy and procedure when the Director of Staff Development (DSD): a. did not conduct a 90-day post probationary period performance evaluations for two of two Licensed Vocational Nurses (LVN) 3 and 4, and; b. did not conduct annual performance evaluations for three of three LVNs (LVN 2, 3, and 4) or for Registered Nurse (RN) 1. This failure had the potential to result in physical or psychosocial harm to residents. Findings: Review of the employee files on 9/25/18 indicated: 1. RN 1 was hired on 5/16/16. Further review of the employee file indicated no annual performance evaluations conducted for RN 1. 2. LVN 2 was hired on 6/27/16. Further review of the employee file indicated no annual performance evaluations conducted for LVN 2. 3. LVN 3 was hired on 8/15/17. Further review of the employee file indicated there was no 90-day post probationary period performance evaluation or annual performance evaluation conducted for LVN 3. 4. LVN 4 was hired on 8/21/17. Further review of the employee file indicated there was no 90-day post probationary period performance evaluation or annual performance evaluation conducted for LVN 4. During an interview and concurrent record review on 9/25/18, at 4:01 p.m., the DSD stated there were no Quarterly Skills Check (90-day post probationary period performance evaluations) conducted and no Annual Competency Skills Check (annual performance evaluations) in the employee files for RN 1, or for LVNs 2, 3, and 4. The DSD further stated Staff Competency Skills Checks were done during orientation only. Review of the Policy and Procedure titled, Performance Evaluations, revised on (MONTH) 2010, indicated .A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter The performance evaluation meeting will occur at the same time as the employee's compensation review A performance evaluation will be conducted 90 days after an employee's promotion or transfer to a new position A special performance may be conducted when there has been an unusual change or decline in an employee's work performance