Every finding on record at Superior Health & Rehab, LLC

Based on record review, interview, and facility document review, the facility failed to ensure care plan interventions were consistently implemented for one (Resident #109) of four residents reviewed. The findings include: A review of Resident #109’s Nursing Progress Notes on 04/23/2025 at 3:37 PM, read in part, the resident was transferred from their wheelchair to their recliner by Certified Nursing Assistant (CNA) #2. The Nursing Progress Notes also indicated Resident #109’s “legs gave out”, the resident fell backwards onto the floor and hit their head on the wheelchair. Resident #109 sustained a small abrasion to the rear left of their head. The Medical Director was notified via secure conversation on 04/23/2025 at 3:00 PM. The facilities Advance Practice Registered Nurse was in the facility at the time of the incident and assessed the abrasion with no new orders obtained. A review of Resident #109’s admission Record indicated the facility admitted the resident on 12/18/2019, with diagnoses which included acute and chronic respiratory failure, chronic right sided heart failure, muscle wasting and atrophy, type 2 diabetes with diabetic polyneuropathy, and severe obesity. A review of Resident #109’s Minimum Data Set (MDS) with an Assessment Reference Date of 02/05/2025, revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Resident #109’s MDS also revealed the resident required partial to moderate assistance for transfers and used a wheelchair for mobility. A review of Resident #109’s Care Plan Report, with a revision date of 02/21/2025, indicated the resident had a history of falls. Resident #109’s Care Plan Report specified interventions of a two-person assist during transfers, directed staff to encourage resident to let staff assist them to ensure safe transfers, and the resident needed prompt response to all requests for assistance. During an interview on 08/12/2025 at 1:17 PM, Medication Aide-Certified (MA-C) #3, who relayed their observation of the incident that occurred on 04/23/2025, indicated that while passing Resident #109’s room, MA-C #3 observed the resident fall. She then stated that Certified Nursing Assistant (CNA) #2 was there but could not hold the resident. MA-C #3 went to be of assistance after going for a nurse CNA #2 and MA-C #3 did not complete Resident #109’s transfer until the nurse assessed the resident. During an interview on 08/12/2025 at 1:41 PM, CNA #4 reported the closet care plan was where a CNA would look for care instructions on a resident. CNA #4 then stated fall interventions were added to the closet care plan, and the nurses kept the CNAs updated as well. During an interview on 08/12/2025 at 1:50 PM, CNA #5 reported the CNAs have face sheets and pages in the resident’s closet that help CNAs to know what care needs are. CNA #5 then stated the CNAs chart in kiosks and could have also referred to resident care plans there. CNA #5 verified if a resident had a history of falls, the bed would have been put in a low position, and interventions would have been checked to see if in place. During an interview on 08/12/2025 at 1:55 PM, CNA #6 indicated if the resident had not been seen before, if they were a new admit, or it was the staff member’s first time to work that particular hall, reviewing the face sheet or closet care plan would have been first step in providing care. The face sheet and care plan were one and the same and would have been in the resident’s closet. CNA #6 stated review of the closet care plan should be daily, because it could change daily. During an interview on 08/12/2025 at 1:58 PM, CNA #7 reported the caregivers learn about the residents through the closet care plan in the resident’s room. The CNAs would look to find interventions that are in place on the closet care plan if the resident had a history of accidents or falls. During an interview on 08/12/2025 at 2:15 PM, the Assistant Director of Nursing (ADON) indicated when residents were admitted with a history of accidents, the information would have been relayed to the nurses and CNAs during report. The appropriate interventions would be on the closet care plan like low bed position, and whatever else the resident needed. The closet care plan was completed by the admission nurse upon admission. This surveyor placed a call on 08/14/2025 to CNA # 2, there was no answer, and a message was left requesting a call back. During an interview on 08/14/2025 at 10:17 AM, the Director of Nursing (DON) reported that it was expected that all staff review the closet care plans every time they enter a room, and the closet care plan should be updated every three months. DON indicated she agreed with the termination of this staff member for non-compliance with closet care plan. During an interview on 08/14/2025 at 12:53 PM, the Administrator reported the employees must acknowledge and sign the “orientation document” indicating understanding that it was expected the care plan was to be followed, before they started to work at the facility. The Administrator reported that CNA #2 was interviewed after the incident and asked if they knew better than to transfer a resident independently when Resident #109 was a two person assist, and CNA #2 replied she did know better. The Administrator reported asking “then why did you do it?” CNA #2 indicated not knowing why. On 08/13/2025, this surveyor requested a policy regarding utilization of resident closet care plans from the Administrator. On 08/14/2025, the DON reported that no policy existed. A review of an orientation document provided by the Administrator, signed on 06/29/2023 with CNA #2’s name, read in part, that in signing this form the employee acknowledged understanding and acceptance of the disciplinary action when not following the resident’s face sheet or plan of care. A review of the Centers for Medicare and Medicaid Services (CMS) form 7734 for Resident #109 revealed that a closet Care Plan was copied by the facility after the incident on 04/23/2025, and included in the CMS 7734 documentation, under the heading of transfers: assist of two was clearly marked. Further review of CMS form 7734, confirmed through attached signed witness statements, facility documents, signed orientation on boarding document, and Resident #109’s closet care plan, Resident #109 was transferred by CNA #2 independently, which resulted in a fall. On 8/15/2025 at 9:01 AM, CNA #2 returned this surveyor’s call and confirmed that she had known the resident had a care plan for a two person assist. CNA #2 confirmed she had signed the pre-employment agreement to follow care plans and that failure to follow would result in termination. CNA #2 stated she felt pressured by Resident #109 to hurry and did not wait for help to transfer the resident.

Based on observation, interview, and facility record review it was determined that the facility failed to ensure that residents were treated with dignity and respect for two (Resident #93 and Resident #88) of two residents observed for dignity. The findings include: Resident #93 A review of an admission Record indicated Resident #93 was admitted to the facility on [DATE] with diagnoses that included paralysis affecting one side of the body, one-sided muscle weakness, stroke, difficulty swallowing, and altered mental status. A review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/2025, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #93 was severely cognitively impaired. The MDS also indicated Resident #93 was dependent on staff for eating. A review of a Care Plan Report indicated Resident #93 was able to feed themselves after setup, had an actual or the potential for a nutritional problem, and had a stroke that affected the right side of their body initiated 07/07/2025 and limited physical mobility initiated 07/08/2025. Resident #88 A review of an admission Record indicated Resident #88 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, abnormal weight loss, dementia, paralysis affecting one side of the body, one-sided muscle weakness, difficulty swallowing, and stroke. A review of the quarterly MDS with an ARD of 05/22/2025 revealed Resident #88 had a BIMS of 08, which indicated Resident #88 was moderately cognitively impaired. The MDS also indicated Resident #88 was dependent on staff for eating. A review of a Care Plan Report with an initiated date of 09/11/2024, indicated Resident #88 had a self-care deficit, related to one sided muscle weakness, and paralysis affecting the dominant side. The Care Plan Report also indicated Resident #88 was dependent on staff for food intake. A review of Resident #88’s active Physician’s Orders as of 08/14/2025 indicated the resident had a regular-enhanced diet with pureed texture, and honey consistency. Investigation On 08/11/2025 at 12:26 PM, Resident #93 and Resident #88 were observed during the lunch meal. A red napkin was observed under a white napkin on the table next to Resident #93 and Resident #88. CNA #1 indicated the red napkin meant the resident was a “feeder”. CNA #1 clarified a feeder” meant the resident was a feeder pointing to both Resident #93 and a tablemate Resident #88. The tray cards were reviewed while at the resident’s table, both Resident #93 and Resident #88’s meal tray cards indicated feeder in the alerts section. On 08/13/2025 a policy on treating residents with dignity and respect was requested of the Administrator. On 08/13/2025 the Activity Director reported the facility did not have a specific policy on resident dignity and respect, but the facility had the resident’s rights documented in the admission packet and the admission packet was provided to all residents on admission. The Activity Director provided a copy of the dignity in-service training presented in July 2025, that all employees were required to participate in. Certified Nursing Assistant (CNA) #1’s signature was next to her name on the dignity in-service which read in part that dignity was the quality or state of being worthy of respect, esteem, nobility and honor. An “admission Packet” with a review date of “12/21” was reviewed and read in part that the facility would promote and protect the rights of each resident. The residents had the right to be treated without discrimination regardless of their disability. Each resident had the right to be treated with consideration and respect. On 08/13/2025 at 12:53 PM, the Administrator reported all employees go through dignity training during orientation and yearly. On 08/13/2024 at 12:57 PM, the Dietary Manager (DM) while speaking with another surveyor made the statement, “they were through with the dining room service, with only the feeders left.” The DM was asked to clarify what “feeders” meant. The DM indicated feeders were in reference to the residents who had to be fed, not the aides who provided assistance with the meal. The DM indicated not being aware that labeling a resident a “feeder” was a derogatory term. The DM reported never being told not to call a resident a “feeder”. The DM reported the meal cards also labeled the residents as “feeders. The DM stated she would get right on that and get the cards changed. During a phone interview on 08/14/2025 at 9:47 AM, CNA #1 confirmed participating in the dignity training in July 2025, during the facility wide training. CNA #1 reported being a CNA for more than eight years and while working as a CNA had dignity training yearly. CNA #1 explained that when a resident was referred to as a feeder, it meant they had to be fed. CNA #1 stated, “when they are feeders, we have to assist them with feeding.” A review of CNA #1’s employee training regarding resident’s rights and agreement to comply with the Resident’s Rights Policy, revealed CNA #1’s name on the signature line. During an interview on 08/14/2025 at 10:12 AM, the Director of Nursing (DON) reported that when a resident was referred to as a feeder, it signified that the resident required feeding or extensive assistance with feeding. The DON reported labeling a resident, who required extensive assistance, as a feeder was how they had always referred to them. The DON indicated the facility expectation was for all facility staff to follow policies. The DON indicated CNA #1 should not have pointed to the residents and called them “feeders. During an interview on 08/14/2025 at 8:45 AM, the Administrator, who remarked that she understood how it must have sounded, stated she had already instituted a change in the meal tickets. The administrator stated the aide should not have pointed at the residents and referred to them as feeders.

Based on observation and interview, the facility failed to ensure food items were used prior to their use by date, and food items, utensils and dishes and were stored in a manner to limit cross contamination. The findings are: On 04/30/2024 at 9:25 AM, two 5 pound bags of shredded mozzarella were observed on the top shelf of the walk-in refrigerator. One bag had a use by date of 02/14/2024 and one bag had a use by date of 03/19/2024. The second bag had a greenish spot located on the cheese that was approximately 1.5 to 2 inches wide. On 04/30/2024 at 9:27 AM, a 1/2 full, 2 pound package of sliced turkey, was located in a storage bag that was not sealed. Located on the same shelf was a bag containing a ham sandwich with a use by date of 4/29/24. When asked how food should be stored the Dietary Manager verbalized the importance of ensuring food is stored in a sealed container and used before the expiration date. On 04/30/2024 at 9:35 AM, 2 large stainless-steel bowls were observed to be nested on the bottom shelf of a rolling dish rack. A large pot was resting inside the top bowl. All three items were stored right side up. On the second shelf from the bottom there were 4 stacks of small bowls. Each stack was sitting with the top side up, exposing the inside of the bowl to contaminants. On the bottom of a rolling shelving unit, 3 large plastic pitchers were observed to be sitting right side up, along with a small pitcher which was also right side up exposing the inside of the items to contaminants. On 04/30/2024 at 9:30 AM, 3 large square containers of cereal were observed on a top shelf in the dry storage area. Each container had one corner of the lid that was not secured exposing the contents to air and contaminants. Upon observation the Dietary Manager secured the corners of the containers and the corners of the containers. On 04/30/2024 at 9:35 AM, the reach in ice cream freezer was observed to have debris on the bottom. On 05/03/2024 at 9:10 AM, 6 large plastic pitchers were observed in the refrigerator. The lids were turned to open exposing the contents to air and contaminants. The Dietary Manager said 3 of the pitchers contained house shakes and 3 contained tea. The Dietary Manager expressed that the container lids should have been turned to close. On 05/03/2024 at 9:13 AM, the reach in ice cream freezer was observed with a variety of debris (white food particles, paper, and frozen liquid) on the bottom. On 05/03/2024 at 10:01 AM, the Administrator provided a policy titled, Food Storage. The policy stated that food was stored and prepared in a clean safe sanitary manner that complies with state and federal guidelines. The procedure describes food storage as clean, organized, and free of dirt. The containers for bulk items are leak-proof, non-absorbent, sanitary and have tight fitting lids. All food not in original containers will be labeled, dated, and stored in National Sanitation Foundation approved containers.

Based on record review, observations, and interviews, it was determined that the facility failed to initiate on the care plan, goals, and interventions to be in place for a resident with the use of position change alarms for 1 (Resident #54) of 1 resident reviewed for position change alarms on the care plan. Findings include: A review of the Order Summary Report, indicated the facility admitted Resident #54 with diagnoses that included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 revealed Resident #54 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. Under section P, restraints and alarms were coded as not used. A review of Resident #54's Care Plan, initiated, revealed the resident was at risk for falls related to muscle wasting and atrophy, weakness, and gait abnormalities. Interventions did not include pressure change alarms. During an observation on 04/30/2024 at 11:15 AM, pressure change alarms were in place on Resident #54's bed, chair, and under the resident. During an observation on 05/01/2024 at 10:00 AM, pressure change alarms were in place on Resident #54's bed, chair, and under the resident. During an observation on 05/03/2024 at 10:32 AM, pressure change alarms were in place on Resident #54's bed, chair, and under the resident. During an interview on 05/03/2024 at 11:11 AM, the Assistant Director of Nursing (ADON) stated that when a resident is prone to be at risk for falls, they put alarms in place as an intervention. The ADON confirmed that alarms were not addressed on the care plan and confirmed that the care plan and tasks should be updated as soon as alarms are put into place. The ADON also included that it's the unit manager's responsibility to ensure the care plan is updated based on follow-up observations. During an interview on 05/03/2024 at 11:35 AM, Licensed Practical Nurse (LPN) #1 confirmed that alarms are in place at this time and have been for at least a couple months, but they were not addressed on the care plan.

Based on observations, record review, and interview, the facility failed to ensure necessary foot/toenail treatment and care was provided to keep toenails trimmed and dry and to prevent flaky skin to decrease the potential for foot complications for 1 (Resident #367) of 1 sampled resident who was dependent on staff for foot/toenail care. The findings are: Resident #367 had a diagnosis of cellulitis of the left lower limb. The Nursing Admission assessment dated [DATE] documented Resident #367 had a Brief Interview for Mental Status (BIMS) score on 10 (8-10 indicates moderately impaired) and required partial/moderate assistance with shower/bathing and partial/moderate assistance with putting/taking off footwear. a. On 05/01/2024 at 09:05 AM, Resident #367 was lying in bed with both feet uncovered. Dry, scaly, and flaky skin was observed on both feet. The toenails on the right foot (the second, third and fourth toes) and the toenails on the left foot (third and fifth toes), were noted to be 1/4 inch over the tip of the toes. A string from the bedspread was observed to be hung on the resident's right third toenail. b. On 05/02/2024 at 09:47 AM, Resident #367 was sitting up in a chair at the bedside. Resident #367 had on a pair of house shoes with both feet on the floor. Certified Nursing Assistant (CNA) #1 was asked to accompany the surveyor to Resident #367's room. c. On 5/02/2024 at 09:47, CNA #1 said Resident #367 had a shower on Tuesday and that she usually puts lotion on both of Resident #367's feet after a shower and do a stop and watch to notify the nurse of the condition of Resident #367's feet but stated she hasn't done it yet. CNA#1 said she told the treatment nurse on Tuesday. CNA#1 said she could have trimmed Resident #367's toenails because Resident #367 wasn't a diabetic. CNA #1 said Resident #367's toenails needed trimming. d. On 05/02/2024 at 10:28 AM, Treatment Nurse #1 described Resident #367's feet as extremely dry and scaly with concern to the left big toe tip and the right inside of the heel with a blanchable fluid filled blister under a callous. e. On 05/02/2024 at 01:52 PM, the Assistant Director of Nursing (ADON) described Resident #367's feet with a lot of dry skin, mushy heels and not much blood flow. The ADON said Resident #367's toenails on the right foot, the second, third and fourth toes and the toenails on the left foot, third and fifth toes needed to be trimmed. f. On 05/02/2024 at 01:54, the Director of Nursing (DON) said a nursing assessment was done upon admission but should have included the feet. The DON described Resident #367's feet as dry and scaly with poor blood circulation to both feet. g. On 05/02/2024 at 3:30 PM, the Administrator was asked for a policy on ADL (activities of daily living)/nail care, admission assessments, and prevention of skin breakdown on feet. The Administrator said there were no policies.

Based on record review, observations, and interviews, it was determined that the facility failed to accurately assess the resident and code the Minimum Data Set (MDS) to reflect the use of position change alarms for 1 (Resident #54) of 1 resident reviewed for position change alarms on the MDS. Findings include: A review of the Order Summary Report, indicated the facility admitted Resident #54 with diagnoses that included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #54 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. Under section P, restraints and alarms were coded as not used. A review of Resident #54's Care Plan, initiated, revealed the resident was at risk for falls related to muscle wasting and atrophy, weakness, and gait abnormalities. Interventions did not include pressure change alarms. During an observation on 04/30/2024 at 11:15 AM, pressure change alarms were in place on Resident #54's bed, chair, and under the resident. During an observation on 05/01/2024 at 10:00 AM, pressure change alarms were in place on Resident #54's bed, chair, and under the resident. During an observation on 05/03/2024 at 10:32 AM, pressure change alarms were in place on Resident #54's bed, chair, and under the resident. During an interview on 05/03/2024 at 11:11 AM, the Assistant Director of Nursing (ADON) stated that when a resident is prone to be at risk for falls, they put alarms in place as an intervention. The ADON confirmed that alarms were not coded on the MDS, and that the MDS is coded to reflect the resident care. During an interview on 05/03/2024 at 12:11 PM, the MDS Coordinator confirmed that alarms were not coded on the MDS and that it would need to be modified to reflect they are in place.

Based on observation, the facility failed to ensure foods stored in the walk-in freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect all residents who received meals from the kitchen (total census: 104), as documented on a list provided by Dietary Supervisor on 05/09/23 at 10:24 AM. The findings are: 1. On 05/08/23 at 4:26 PM, the following observations were made in the walk-in freezer: a. An opened box of cookies was on a shelf in the walk-in freezer. The box was not covered or sealed. b. An opened box of hamburger patties. The box was not covered or sealed. c. An opened box of dinner rolls. The box was not covered or sealed. d. An opened box of breaded okra was on a shelf in the walk-in freezer. The box was not covered or sealed. e. An opened box of pork fritters was on a shelf in the freezer. The box was not covered or sealed. f. Two opened boxes of corn on the cob were on a shelf in the freezer. The boxes were not covered or sealed. g. One opened box of sausage was on a shelf in the walk-in freezer. The box was not covered or sealed.

Based on observation, and interview, the facility failed to ensure privacy and confidentiality of resident ' s personal and medical records by failure to lock the computer screens when not in use, and not ensuring confidential information on a notepad such as names, diagnoses, and medications were not visible to passersby. The failed practice has the potential to affect all residents who received medications on the G and H halls during the 12:00 PM medication pass. The findings are: 1. On 05/09/23 at 12:23 PM, the Surveyor observed a medication cart left unattended with a laptop resting on top. The laptop screen was unlocked, and resident names and photos were visible. A notepad with resident names, medications, and diagnoses with a line drawn through them was also on top of the cart left unattended and visible. 2. On 05/09/23 at 12:26 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if he left his medication cart unattended on a regular basis. LPN #1 answered, No, I got called to take somebody down in the middle of med [medication] pass. The Surveyor asked if he should lock his laptop computer when he left his medication cart unattended. LPN#1 answered, Yes. The Surveyor asked what could happen if he didn't lock his laptop screen and left it unattended for others to see. LPN #1 answered, Well, I guess it could be a violation of HIPAA [Health Insurance Portability and Accountability Act]. 3. On 05/09/23 at 12:39 PM, the Surveyor asked the Director of Nursing (DON) what should happen if a nurse is passing medications and gets called away by staff to help with another resident. The DON answered, They should complete their medication pass, lock the med cart, and lock their screen before leaving to help. The Surveyor asked what could happen if they didn't do those things. The DON answered, It would be a privacy issue or a safety issue. The Surveyor asked for a copy of the facility's HIPAA policy. The DON referred the Surveyor to the Administrator. 4. A facility HIPAA Policy and Procedure titled, Confidentiality of Resident Information Policy, provided by the Administrator on 05/09/23 at 1:33 PM documented, .All information regarding the Facility's residents shall be kept confidential . In a setting where information can be read or transferred from an unattended computer monitor .

Based on observation, interview, and record review, the facility failed to ensure nails were trimmed, smooth and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #351) of 14 (Residents #4, #14, #27, #29, #31, #39, #46, #51, #55, #64, #77, #143, #342 and #351) sampled residents who were dependent for nail care according to a list provided by the Administrator on 05/12/23 at 7:58 AM. The findings are: 1. Resident #351 had a diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Cerebellar Artery. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and was totally dependent on two plus persons physical assistance with bathing. a. The Care Plan with an initiated date of 04/29/23 did not address personal hygiene or nail care. b. On 05/09/23 at 12:33 PM, Resident #351 was sitting up in a wheelchair eating lunch at the bedside table. Her thumbnails and several of her fingernails extended over 1/2 inch past the tips of the fingers. The tips of the nails were jagged with a brown substance underneath the nails on both hands. c. On 05/10/23 at 1:58 PM, Resident #351 was lying in bed awake. Her thumbnails and several of her fingernails remained over 1/2 inch long past the fingertips, and jagged with a brown substance under the nails. The Surveyor asked Resident #351 if she liked her fingernails the way they were. Resident #351 answered, No and began picking the brown substance from under her nails and dropping it onto her bedside table positioned across her lap. Resident #351 looked at her nails and stated, I need to have them trimmed. Resident #351 asked if the Surveyor could move a chair into the corner of her room. The Surveyor encouraged her to push her call light. Resident #351 had difficulty pushing the call light button on her remote due to the length of her thumbnail and fingernails. After her 3rd attempt, she succeeded in pushing her call light. d. On 05/11/23 at 8:32 AM, Resident #351 was lying in bed awake watching TV. Her thumbnails and several fingernails remained over 1/2 inch long past her fingertips, with jagged edges, and a brown substance underneath them. The Surveyor asked Resident #351 if she would like to have her nails trimmed. She replied, Yes, I need to. They are long and crooked. The Surveyor asked if she had requested the staff to trim her nails. She answered, No. e. On 05/11/23 at 1:49 PM, Resident #351 returned from Physical Therapy (PT) sitting up in wheelchair with her right leg elevated. The Surveyor asked Resident #351 if she had her nails trimmed yet. She answered, No. The Surveyor asked if she had asked anyone to trim them for her. She answered, No. The Surveyor asked if she liked her nails that long. She answered, No, not really. f. On 05/11/23 at 1:53 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if Resident #351 had asked for help trimming her nails. CNA#1 answered, No, do they need it? The Surveyor asked CNA #1 to accompany the Surveyor to Resident #351's room where she was asked to describe what she saw while looking at Resident #351's fingernails. CNA #1 replied, Oh, her nails are too long. The Surveyor asked how long she would guess the nail length was. CNA #1 answered, I don't know, a couple of centimeters maybe. g. On 05/11/23 at 1:58 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to describe what he saw while looking at Resident #351's fingernails. He answered, Well they are long. We need to get those trimmed up. The Surveyor asked if Resident #351 had ever refused nailcare. LPN #1 answered, Uh no, not with me, but I'm only here two days a week. The Surveyor asked who was responsible for the residents nailcare. LPN #1 answered, Uh, nursing staff is if she's diabetic, the aides if she's not. h. On 05/11/23 at 2:12 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for the residents nailcare. She answered, The CNAs, Restorative Care, or the Nurses. The Surveyor asked if she could provide a policy for nailcare or Activities of Daily Living (ADLs). She answered, Yes. i. On 05/11/23 at 2:28 PM, the DON informed the survey team that there was no facility policy for ADL's or Nail Care.

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 1 resident who received a pureed diet as documented on the Diet List provided by the Dietary Supervisor on 05/09/23 at 10:24 AM. The findings are: 1. On 05/08/23 at 4:03 PM, the pureed carrots to be served to the resident on a pureed diet were in a divided plate on the food preparation counter. The consistency was not formed, it was runny. There were pieces of carrots visible in the mixture. 2. On 05/08/23 at 4:06 PM, Dietary Employee (DE) #1 placed a serving of macaroni and cheese into a blender, added 2% milk and pureed. At 4:07 PM, she poured the pureed macaroni and cheese onto a divided plate. The consistency of the pureed macaroni and cheese was lumpy and not smooth. 3. On 05/08/23 at 4:18 PM, DE #1 placed one baked pork fritter into a blender, added brown gravy and pureed. At 4:23 PM, she poured the pureed pork fritter into a pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed pork fritter was gritty and thick and was not smooth. 5. On 05/08/23 at 5:28 PM, when DE #1 was about to send out a pureed tray consisting of pureed carrots, pureed pork fritters, pureed bread and pureed macaroni and cheese, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items to be served to the resident who was on a pureed diet. The Dietary Supervisor stated, Pureed carrots was not blended enough. It needed to be blended more. There were small pieces of carrot in it. Pureed pork fritters have crust from the outside of the of the pork fritters in it. It was not blended thoroughly. Pureed macaroni and cheese needed more blending. Pieces of noodles were not pureed enough, and pureed bread has pieces of the bread crust in it. 6. On 05/08/23 at 5:29 PM, the Surveyor asked the Assistant Dietary Supervisor to describe the consistency of the pureed food items to be served to the resident who was on a pureed diet. She stated, Pureed carrots has pieces of carrots in it. It needed to be pureed more. Pureed pork fritters have crust from the breaded meat visible in it. It needed to be pureed some more. Pureed macaroni and cheese was not blended enough. You can see pieces of noodles in it. Pureed bread was runny. Bread crust was visible in it. It needs to be smooth.

Based on observation, record review and interview, the facility failed to ensure dietary staff used gloves to handle Styrofoam container and plastic lids, and used gloves when handling plastic scoop in a container of thickener powder; the inside of the microwave was clean and free from food spills, and dietary staff washed hands and changed gloves between dirty and clean tasks and before handling food items to minimize the potential for foodborne illness in 1 of 1 kitchen. This failed practice had the potential to affect 87 residents (total census: 87) who receive a tray from the kitchen, as documented on a list provided by the Business Office Manager on 3/8/22 at 12:56 PM. The findings are: 1. On 03/07/22 at 12:05 PM, Dietary Employee #1 received a closed Styrofoam container with food in it from another dietary employee. She opened the container, and her ungloved hand touched the inside of the container. She closed the container and sent it down the serving line. Dietary Employee #2 obtained a stack of plastic lids and placed them on bowls of soup, salad and drinks with his bare hand touching the inside of the lids on 6 occasions. Dietary Employee #3 washed her hands in the sink. She opened a container of thickener powder and with her bare hands, removed the measuring scoop from the inside of the container. She added thickener to a Styrofoam cup filled with cola and replaced the scoop in the container and closed the lid. Dietary Employee #4 removed her gloves and placed them on the prep table. She washed her hands in the sink and donned clean gloves. She picked up the used gloves with the clean gloved hands and discarded them in the trash can. Wearing the same contaminated gloves, she took a recipe book and flipped through the pages then stirred some food in a metal container and covered the container with foil. 2. On 03/08/22 at 10:59 AM, the Food Service Supervisor opened the door of the microwave. There were splashes of dried yellow substance on the inside of the microwave door. 3. A Policy titled, Cleaning and Sanitation provided by the Food Service Supervisor on 3/8/22 at 12:32 PM documented, . To ensure the food service department is maintained . and is a clean, sanitary and safe environment at all times . A Policy titled, Safety and Sanitation provided by the Food Service Supervisor on 3/8/22 at 12:32 PM documented, . Equipment must be cleaned and sanitized after each use . A Policy titled, Hand Washing provided by the Food Service Supervisor on 3/8/22 at 12:32 PM documented, . To remove contamination after, entering the kitchen . during food preparation . after engaging in other activities that contaminate the hands . 4. On 03/08/22 at 02:20 PM, Dietary Employee #5 was asked, What could happen if you touch the inside of a Styrofoam container, or the food surface of a plate, or the inside of a lid? He answered, If you've got anything on your hands, it could get on the dishes. He was asked, What could happen of you don't wear gloves while using thickener and you place the scoop back into the thickener after using it? He answered, If you have bacteria on your fingers it could get on the scoop and into the thickeners. He was asked, Should you place dirty gloves on the prep table? He answered, No. Never. He was asked, Should you pick up dirty gloves from the prep table while wearing clean gloves, and then handle a recipe book, and then prepare food, all with the same gloves on? He answered, No. He was asked, Why not? He answered, That is cross contamination. 5. On 03/08/22 at 02:30 PM, the Food Service Supervisor was asked, What could happen if you touch the inside of a Styrofoam container, or the food surface of a plate, or the inside of a lid? She answered, It's cross contaminated. She was asked, What could happen of you don't wear gloves while using thickener and you place the scoop back into the thickener after using it? She answered, It's cross contaminated. She was asked, Should you place dirty gloves on the prep table? She answered, No. Never. She was asked, Should you pick up dirty gloves from the prep table while wearing clean gloves, and then handle a recipe book, and then prepare food, all with the same gloves on? She answered, No. She was asked, Why not? She answered, That is cross contamination.

Based on observation, record review, and interview, the facility failed to ensure the mask and tubing for a [CONDITION(S)] (Continuous Positive Airway Pressure) were stored in a bag or other closed container when not in use to prevent potential contamination for 2 (Residents #44 and #45) of 3 (Residents #44, #45 and #64) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident [R] #44 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Physicians Orders dated 1/7/22 documented, .Nurse to apply [CONDITION(S)] at HS [hour of sleep] at bedtime .Nurse to remove [CONDITION(S)] every morning . b. On 03/07/22 at 12:24 PM, the resident's [CONDITION(S)] mask and tubing were lying uncovered on the resident's dresser next to her bed. c. On 03/08/22 at 09:06 AM, the [CONDITION(S)] mask and tubing was lying uncovered on the dresser. d. On 3/08/22 at 2:39 PM, Licensed Practical Nurse (LPN) #1 was in the resident's room, assessing the resident. The nurse then picked up the [CONDITION(S)]/[CONDITION(S)] mask and tubing that was hanging over the dresser and placed them on top of the dresser without placing them in a storage container or bag. e. On 3/8/22 at 2:43 PM, when the LPN exited the resident's room she was asked, Where is [R #44's] [CONDITION(S)] mask and tubing? She stated, It's laying on top of her nightstand with the mask dropped on top of it. The LPN was asked, How should the [CONDITION(S)] mask and tubing be stored? She stated, The mask is supposed to be in a bag. She was asked, What is a potential complication of the resident's [CONDITION(S)] mask and tubing not being stored properly? The LPN stated, It could get dirty and cause a respiratory infection. The LPN was asked, Whose responsibility is it to ensure the [CONDITION(S)] mask and tubing are stored correctly? The LPN stated, The nurse. 2. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 03/07/22 at 01:00 PM the resident's [CONDITION(S)] machine with tubing attached and nasal pillow prongs was lying on the bedside table, uncovered. c. On 03/08/22 at 08:30 AM the resident was in the bed with oxygen on at 4 liters per minute via nasal cannula. The resident stated, I have not been able to wear my [CONDITION(S)] in days due to the oxygen tubing connector not right. It helps my Restless Leg Syndrome and everything else. The [CONDITION(S)] nasal pillow prong and tubing were lying on the bedside table uncovered. d. On 03/09/22 at 02:00 PM LPN #2, was asked Has Resident #45 been wearing her [CONDITION(S)] at night? The LPN stated, No she has been refusing to wear it because she thinks it is not connected right, we have all the documentation in her chart where she has refused for the last 6 days. She was asked, Who is responsible for putting the nasal pillow prong mask away when she is not wearing it? She stated, The nurses are, if she refuses, I guess it should be in a bag, and if she is not wearing it, I guess it should be in a bag. 3. On 3/8/22 at 2:57 PM, the DON was asked, How should a resident's [CONDITION(S)] mask and tubing be stored? She stated, Nurses put it in the bag. The DON was asked, What is a potential complication of a resident's [CONDITION(S)] tubing and mask being out in the open on top of a dresser? The DON stated, .I don't know. They could get sick.

Based on record review and interview, the facility failed to ensure residents and their representatives were notified by 5:00 p.m. the next calendar day of a single positive COVID-19 test result to prevent the further transmission of COVID-19 in 1 of 1 facility. This failed practice had the potential to affect all 87 residents as documented on the Resident Census and Conditions of Residents form dated 3/7/22. The findings are: 1. A Document titled Employee Form and dated 2/12/22, documented a positive COVID test result for Certified Nursing Assistant (CNA) #1. 2. A Document titled Resident Contacts dated February 15, 2022, documented, BN BM LB [Facility Employees] Called families - 0 residents, 2 staff . 3. On 03/08/22 at 12:54 PM, the Progress Notes for 5 (Residents #58, 29, 64, 75, and 72) residents were reviewed from 2/12/22 to 2/16/22. The Progress Notes for the 5 random residents had no documentation of representative telephone notifications for the last positive COVID test. 4. A document titled, COVID-19 Recommendations provided by the Administrator on 3/8/22 at 1:55 PM documented, . page 12 . If the facility has a confirmed case of Covid-19 . the facility will notify resident and resident responsible party by 5pm the next day . 5. The Centers for Medicaid and Medicare memorandum, QSO 20 29 NH dated May 6, 2020, documented, . COVID-19 Reporting - The facility must . inform residents, their representatives and families of those residing in facilities by 5 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other . 6. On 03/08/22 at 09:08 AM, the Administrator was asked, When was the last positive test result? She answered, February 12, 2022. 7. On 03/08/22 at 01:19 PM, the Administrator was asked, How does the facility notify the resident representatives of changes with COVID 19? She provided a binder that contained printed lists of resident representatives. She stated, We recently started the Cliniconex. Before that, they divided the lists into three parts, and they all called people. As you can see, they always called the families within 48 hours of each positive like clockwork. She reviewed the Resident Contact list dated 2/15/22 and stated, We usually called within 48 hours. The 12th was on a Saturday. I'm not sure why we didn't call until Tuesday on this one, but you can check the binder. We always made it a point to call within 48 hours of the positive test result. She was asked to provide the guidance that states to contact representatives within 48 hours of the positive result. 8. On 03/08/22 at 01:55 PM, the Administrator stated, The 48-hour notification was for the Health Department. There's nothing I can say. I did that wrong.

Based on observation, record review and interview the facility failed to ensure care plans were reviewed and revised to identify correct diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These failed practices had the potential to affect 19 residents who had alarms in use and 4 residents with hospice services according to lists provided by the Director of Nursing (DON) on 03/09/22 at 1:11 p.m. The findings are: 1. Resident # 8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/2022 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status. a. A progress note dated 06/23/21 documented, .Incident Description: Alerted by CNA [Certified Nursing Assistant] that resident was in the floor, upon entering her room resident noted sitting in floor on fall mat leaning against her bed. Alarms in place and working properly. Fall mat in place . b. A progress note dated 12/28/2021 documented, Incident Description: Alerted by CNA that resident was sitting on the floor. Upon entering room, resident noted sitting on her bottom on fall mat next to bed. Chair alarm noted in recliner in room . c. On 03/07/22 at 12:06 p.m., the resident was not in the room. A fall mat was noted beside the bed. At12:23 p.m. Resident #8 was in the dining room in a wheelchair with a pressure alarm in use. d. On 03/08/22 at 09:07 a.m., Resident #8 was in her room, with a pressure alarm in place on the back of the wheelchair and a fall mat beside the bed. e. As of 03/08/22 at 1:40 p.m., there was no documentation on the care plan for a pressure alarm or fall mat. f. On 03/09/22 at 2:40 p.m., the DON was asked if the pressure alarm and fall mat should be on the care plan. The DON stated the care plan items are pulled from tasks on the MDS and needed to look at the care plan. The DON returned at 3:15 p.m. and stated, It's not on there. 2. Resident # 64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan revised 12/4/21 documented, The resident has an internal pacemaker r/t [CONDITION(S)] . [CONDITION(S)] and Hx [History] of Pulmonary Embolism . Monitor Vital Signs weekly and prn [as needed] . There was no documentation of Hospice services. c. On 03/08/22 at 9:35 a.m., the resident stated he received Hospice services. d. On 03/09/22 at 3:00 p.m., the DON was asked if the hospice services should be documented on the care plan? The DON stated, Yes.

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessment accurately reflected the resident's status for Hospice and alarms used for 2 (Residents #64 and #40) sampled resident whose MDS were reviewed. This failed practice had the potential to effect 4 residents who received hospice services and 19 residents with bed and chair alarms according to lists provided by the Director of Nursing (DON) on 03/09/22. The findings are: 1. Resident # 64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/2022 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and did not receive Hospice services. a. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 03/08/22 at 9:35 a.m., the resident stated he received Hospice services. c. On 03/09/22 at 2:40 p.m., Registered Nurse (RN) #1 was asked if the hospice services should be documented on the Quarterly MDS with ARD of 02/15/22? RN 1 stated, Yes, I have been off and am working on them. d. On 03/09/22 at 3:00 p.m., the DON was asked if the hospice services should be documented on the Quarterly MDS and care plan? The DON stated, Yes. 2. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS with an ARD of 01/12/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and documented not used for bed alarms. a. The Care Plan dated 3/18/21 documented, . Resident educated to use call light for assistance and educated to not turn off her bed alarm . b. On 03/07/22 at 11:56 a.m., Resident #40 was lying in bed with a pressure alarm on the bed. c. On 03/08/22 at 8:50 a.m., Resident #40 was lying in bed with a pressure alarm in use on the bed. d. On 03/09/22 at 2:40 p.m., RN #1 was asked if the alarm should be documented on the Quarterly MDS with ARD of 01/12/22. RN 1 stated, Yes, we took it off for a while and had to put it back on. e. On 03/09/22 at 3:00 p.m., the DON was asked if the alarm should be documented on the Quarterly MDS. The DON stated, Yes. 3. On 03/09/22 at 8:23 a.m., the Administrator was asked for a policy and procedure on MDS assessments and care planning. The Administrator stated the facility goes by the MDS Resident Assessment Instrument (RAI) manual. The manual documented, .identify all alarms that were used at any time (day or night) during the 7-day look-back period . 4. The CMS's (Centers for Medicare and Medicaid) RAI Version 3.0 Manual CH 3: MDS Items .Special Treatments, Procedures, and Programs .Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions .

Based on observation and interview, the facility failed to ensure foods stored in the freezer and refrigerator were covered, sealed, labeled, and dated, to maintain freshness and prevent potential cross contamination; failed to ensure expired cream was promptly removed / discarded on or before the expiration or use by date; failed to ensure Dietary Staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 69 residents who received meals from the kitchen (total census: 70), as documented on the list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 10:35 a.m., the following observations were made in the refrigerator and the walk- in freezer: a. On [DATE] at 10:36 a.m., one open box of biscuits was stored on a shelf in the refrigerator. The box of biscuits was not covered or sealed. b. On [DATE] at 10:37 a.m., one open box of steak fingers was stored on a shelf in the freezer. The box of steak fingers was not covered or sealed. c. On [DATE] at 10:38 a.m., one open box of sausage was stored on a shelf in the freezer. The box of sausage was not covered or sealed. d. On [DATE] at 10:50 a.m., a five-pound container of sour cream was stored on a shelf in the refrigerator. The container of sour cream had an expiration date of [DATE]. e. On [DATE] at 11:04 a.m., Dietary Employee #1 pushed a utility cart that contained soft drinks and individual bottles of milk towards the cold area of the steam table. She removed all the drinks from the cart and placed them on ice. She pushed the utility cart towards the clean area of the dishwashing machine. She reached out to pick up a pitcher from the shelf and the pitcher and the lid fell on the floor. She picked them up and placed them on a cart. She picked up glasses by their rims and placed them on the cart. She pushed the cart towards the food preparation area by the ice cream freezer. She turned on the faucet and filled the pitcher with water and covered it with the same lid that had been on the floor to be served to the residents with their lunch meal. Dietary Employee #1 did not wash the pitcher or the lid before she used the pitcher to obtain water to be served to the residents with their meal and / or before using the lid to cover the pitcher. f. On [DATE] at 11:08 a.m., Dietary Employee #1 removed a pitcher of orange juice from the refrigerator and placed it on the counter. Without washing her hands, she picked up glasses by their rims and poured orange juice and cranberry juice in them to be served to the residents for the lunch meal. At 12:55 p.m., Dietary Employee #1 was asked, What should you have done after touching dirty objects or before handling clean equipment? She stated, Wash my hands. g. On [DATE] at 11:45 a.m., Dietary Employee #3 lifted a step-on trash can lid and threw away tissue paper. She picked up cups and placed them on the counter with her fingers inside the cups, contaminating the cups. She picked up a spoon from the metal bar above the food preparation counter from the tip that goes in the food and spooned mixed fruits into the contaminated cups to be served to the residents for the lunch meal. At 12:21 p.m., Dietary Employee #3 was asked, What should you have done after touching dirty objects or before handling clean equipment? She stated, Wash my hands. h. On [DATE] at 11:47 a.m., Dietary Employee #4 turned on the sink faucet and rinsed tomatoes. She turned off the faucet and placed the tomatoes in a colander. Without washing her hands, she placed gloves on her hands contaminated the gloves. She picked up lettuce leaves and placed them on the cutting board and chopped them up. She placed the chopped lettuce leaves on an individual plate. She diced tomatoes and placed them on top of the chopped lettuce to be served to the residents who requested salad with their lunch meal. At 12:11 p.m., Dietary Employee #4 was asked, What should you have done after touching dirty objects or before handling clean equipment? She stated, I should have washed my hands. i. On [DATE] at 10:43 a.m., Dietary Employee #2 placed a pan of ground chicken in the oven. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food for residents who received pureed diets. When she was ready to put grilled chicken into a blender, the Surveyor immediately asked Dietary Employee #2, What should you do after touching dirty objects and before handling clean equipment that will be used in processing food items to be served to the residents? She stated, Wash my hands.

Based on observation, record review, and interview, the facility to ensure food was prepared by methods that maintained the flavor and appearance to prevent potential loss of nutrients present in the food and encourage good nutritional intake for the residents who received Regular Diets, Mechanical Soft Diets, and Pureed Diets for 1 of 1 meal observed. This failed practice had the potential to affect 56 residents who received Regular Diets, 10 residents who received Mechanical Soft Diets, and 3 residents who received Pureed Diets, according to a list provided by the Dietary Supervisor on 12/8/2020. The findings are: 1. Resident #52 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and was independent with set up help only for eating. a. A physician's orders [REDACTED].Regular Diet . Regular texture consistency . b. On 12/7/2020 at 11:20 a.m., the resident was asked, How is the food? Is it hot when you get it? She stated, The broccoli is mush. They cook it too long. Every time we have broccoli it is over cooked. Everything they serve is over cooked. 2. Resident #37 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/26/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and was independent with set up help only for eating. a. A physician's orders [REDACTED].Regular Diet . Regular texture consistency . b. On 12/7/2020 at 11:30 a.m., the resident was asked, How is the food? Is it hot when you get it? He stated, The food is bad. They cook everything too long. I can't eat a lot of it because it's so bad. It happens a lot more often. 3. On 12/7/2020 at 11:31 a.m., Dietary Employee #2 removed a pan of an unidentified food item from the oven and placed it on the counter. Dietary Employee #2 was asked, What is in the pan? Dietary Employee #2 stated, It is leftover mashed potatoes from 12/5/2020. She added 5 slices of cheese to the leftover mashed potatoes and mixed it up before she placed it on the steam table to be served to the residents who received Pureed Diets and the residents who received Fortified Foods. The mixture was thick and dry. At 11:56 a.m., the pan of mashed potatoes with cheese was on the steam table. The mashed potatoes were thick and dry. 4. On 12/7/2020 at 11:56 p.m., the following observations were made on the steam table: a. On 12/7/2020 at 11:57 a.m., a pan of bacon wrapped steak was on the steam table. The bacon wrapped steaks were burned and the bacon was not identifiable. b. On 12/7/2020 at 11:58 a.m., a pan of cut green beans was on the steam table. The cut green beans were discolored and dry. On 12/7/2020 at 12:08 p.m., the Dietary Supervisor and Assistant Dietary Supervisor were asked to describe the appearance of the food items prepared to be served to the residents who received meals from the kitchen. They both stated, They were burnt. 5. On 12/7/2020 at 3:53 p.m., the Dietary Supervisor was asked to describe the appearance of the food items served to the residents for lunch. She stated, The Fortified Potatoes and Cut Green Beans were a little overcooked.

Based on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was disinfected before and after use to prevent the potential spread of infection for 2 (Residents #22 and #35) of 2 sampled residents who had physician's orders [REDACTED]. This failed practice had the potential to affect 6 residents who resided on the A and the B Hall and had physician's orders [REDACTED]. 1. Resident #22 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/15/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required limited assistance with bed mobility, transfers, dressing, toilet use, and bathing; and received insulin 7 days out of the last 7 days. a. A physician's orders [REDACTED].[MEDICATION NAME] Solution 100 Unit/ml (units per milliliter) (Insulin [MEDICATION NAME]) inject as per sliding scale . 0-60 Notify MD (Medical Doctor) . 61-150-0 Units; 151-199-3 Units; 200-249-6 Units; 250-299-9 Units; 300-349-12 Units; 350-400-15 Units; 401 (and above) Notify MD . subcutaneously three times a day related to Type II Diabetes Mellitus . b. On 12/9/2020 at 7:05 a.m., Licensed Practical Nurse (LPN) #2 removed the glucometer from the top drawer of the Medication Cart and inserted a testing strip. LPN #2 picked up the glucometer and entered Resident #22's room. LPN #2 placed the glucometer on the resident's bed. LPN #2 cleaned the 4th finger on the residents left hand and pricked it with a lancet and obtained the sample for the capillary blood glucose. c. On 12/9/2020 at 7:23 a.m., LPN #2 gathered her supplies and left the room. LPN #2 returned the glucometer to the top right drawer of the Medication Cart without cleaning the device after use. d. On 12/9/2020 at 7:26 a.m., LPN #2 was asked if she had any more fasting blood sugars. LPN #2 stated, Yes, on the other hall. e. On 12/9/2020 at 7:41 a.m., LPN #2 removed the glucometer from the top right drawer of the Medication Cart. LPN #2 inserted the testing strip and gathered supplies for the next resident. 2. Resident #35 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance with bed mobility, transfers, dressing, toilet use, and bathing; and received insulin 0 days out of the last 7 days. a. On 12/9/2020 at 7:41 a.m., LPN #2 removed the glucometer from the Medication Cart, inserted a testing strip, and gathered supplies. b. On 12/9/2020 at 7:43 a.m., LPN #2 entered Resident #35's room and placed the glucometer and supplies on the resident's bed. LPN #2 cleaned the resident's finger, obtained the resident's fasting blood sugar, and placed the glucometer on the resident's over-the-bed table. c. On 12/9/2020 at 7:50 a.m., LPN #2 picked up the glucometer and left the resident's room. d. On 12/9/2020 at 7:51 a.m., LPN #2 placed the glucometer on top of the Medication Cart, removed an alcohol pad from the Medication Cart, and wiped the glucometer with the alcohol pad. LPN #2 placed the glucometer over to the side on top of the Medication Cart to dry. e. On 12/9/2020 at 7:52 a.m., LPN #2 was asked if she could identify anything she should have done differently. LPN #2 stated, Yes. I did not wipe down the glucometer. I think it was my nerves because I always wipe it down. LPN #2 was asked, When should a glucometer be cleaned? LPN #2 stated, Before and after it is used on any resident. f. On 12/9/2020 at 8:19 a.m., LPN #2 was asked, What do you normally clean the glucometer with? LPN #2 stated, I clean it with alcohol if I have no wipes. LPN #2 was asked if she knew what kind of wipes that were normally used. LPN #2 stated, I do not know what they are called. I can recognize the package. I just didn't want to take the time to stop and go get some. I was already behind. g. On 12/10/2020 at 8:31 a.m., LPN #5 was asked, How do you disinfect the glucometer? LPN #5 stated, I clean it in between each resident. Typically, I clean it with alcohol pads. We have wipes that we can also use. h. On 12/10/2020 at 8:40 a.m., LPN #4 was asked, How do you disinfect the glucometer? LPN #4 stated, We have santi-wipes with bleach that I use to disinfect the glucometer. i. On 12/10/2020 at 9:00 a.m., the Director of Nursing (DON) was asked, What is the proper way to disinfect the glucometer? The DON stated, It's supposed to be based on the manufacturer guidelines to clean with a bleach wipe and let it sit between each resident. j. A facility policy titled Glucometers provided by the Administrator on 12/9/2020 documented, .1. Glucometer should be cleaned after each usage using an approved cleaning product . 2. After cleaning, glucometer should be allowed to dry accordingly . 3. After cleaning, glucometer should be stored on Medication Cart . k. The manufacturer's instructions for the glucometer provided by LPN #2 on 12/9/2020 documented, .The meter should be disinfected after use on each patient . The blood glucose monitoring system may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedure are followed . We recommend for your meter cleaning and disinfection you should use the disinfecting wipes / towelettes from below . The following product has been shown safe for use with the (Glucometer) (Disinfecting Product) .

Based on observation of the 7:00 a.m. and 9:00 a.m. medication passes on 12/9/2020, record review, and interview, the facility failed to ensure physician's orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 2 (Residents #22 and #38) of 3 residents observed during the medication passes resulting in medication errors. Medication errors were made by 2 Licensed Practical Nurses (LPNs) (LPN #2 and #3) of 2 nurses observed. This failed practice had the potential to affect 42 residents who received medications administered from these nurses (total census: 70), according to a list provided by the Director of Nursing on 12/10/2020 at 10:37 a.m. The medication error rate was 13.79%, based on observation of 29 medications administered, and a total of 4 medication errors detected. The findings are: 1. Resident #22 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/15/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required limited assistance with bed mobility, transfers, dressing, toilet use, and bathing. a. A Physician's Order dated 2/17/2020 documented, .Lactobacillus Capsule . Give 2 capsules by mouth three times a day . On 12/9/2020 at 7:04 a.m., LPN #2 administered one tablet to the resident. b. A Physician's Order dated 3/7/2020 documented, .[MEDICATION NAME] Propionate Suspension 50 MCG/ACT (micrograms per actuation) (Give) 2 sprays in each nostril one time a day . On 12/9/2020 at 7:04 a.m., LPN #2 did not administer [MEDICATION NAME] Propionate Suspension to the resident. c. On 12/9/2020 at 7:04 a.m., Licensed Practical Nurse (LPN) #2 prepared and administered the following medications to Resident #22: 1.) Iron 325 mg 1 tablet 2.) Lactobacillus Acidophilus 1 tablet 3.) Geri-Mucil 1 teaspoon mixed in 4 oz of water 4.) Allergy relief [MEDICATION NAME] 10 mg 1 tablet 5.) Vitamin C 500 mg 1 tablet 6.) [MEDICATION NAME] 50 mg 1 tablet 7. [MEDICATION NAME] 5 mg 1 tablet 8.) [MEDICATION NAME] HCL XL 300 mg 1 tablet 9.) [MEDICATION NAME] ER 30 MG 1 tablet 10.) [MEDICATION NAME] 24 units verified d. On 12/9/2020 at 7:18 a.m., LPN #2 entered the resident's room with the resident's oral medications, glucometer, a cup with geri-mucil, an insulin syringe, and [MEDICATION NAME] Propionate nasal spray. LPN #2 handed the resident his cup of pills and his cup of geri-mucil. LPN #2 placed the nasal spray on the resident's bedside table. The oral medications were administered, the resident's blood sugar was obtained, and the insulin was administered. LPN #2 gathered her supplies and exited the resident's room. LPN #2 returned the nasal spray to the Medication Cart and locked it. LPN #2 proceeded to the next resident's room to obtain a fasting blood sugar. LPN #2 administered Lactobacillus Acidophilus one tablet; the Physician's Order documented the resident was to receive two tablets. The [MEDICATION NAME] Propionate nasal spray was not administered. LPN #2 administered Vitamin C 500 milligram 1 tablet to the resident. There was no Physician's Order documented in the clinical record for Vitamin C. e. On 12/9/2020 at 7:52 a.m., LPN #2 was asked, Can you identify anything you might have failed to do while you were in (Resident #22's) room? LPN #2 verbally retraced her steps and could not identify anything she failed to do. LPN #2 was asked, What about the [MEDICATION NAME] nasal spray? LPN #2 stated, Oh man. I didn't give it to him. I guess it was because of my nerves that I forgot. f. On 12/10/2020 at 10:28 a.m., the Director of Nursing (DON) was asked, Does (Resident #22) have a Physician's Order for Vitamin C? The DON stated, I have looked, and I was unable to find an order for [REDACTED].>2. Resident #38 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/2/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required extensive assistance with bed mobility, transfers, dressing, toilet use, and bathing. a. A Physician's Order dated 3/6/2020 documented, .Folic Acid Tablet 400 MCG . Give 3 tablets by mouth one time a day related to Folate Deficiency [MEDICAL CONDITION] .** Give 3 Tabs (tablets) To (equal) 1.2MG** . On 12/9/2020 at 9:28 a.m., LPN #3 administered one tablet of Folic Acid. b. On 12/9/2020 at 9:28 a.m., LPN #3 administered the following medications to Resident #38: 1.) [MEDICATION NAME] 30 milligrams (mg) 1 tablet; 2.) Eliquis 2.5 mg 1 tablet; 3.) Pantoprozole Sodium DR (Delayed Release) 20 mg 1 tablet; 4.) Potassium Chloride 10 milliequivalents (meq) 1 tablet; 5.) Lorsartan 50 mg 1 tablet; 6.) [MEDICATION NAME] 80 mg 1 tablet; 7.) Donepezil 10 mg 1 tablet; 8.) Iron 325 mg 1 tablet; 9.) Folic Acid 400 micrograms (mcg) 1 tablet; 10.) B-12 1000 mcg 1 tablet; 11.) Vitamin C 500 mg 1 tablet; 12.) Aspirin Low Dose Chewable 81mg 1 tablet; 13.) Stool Softener 100 mg 1 tablet; 14.) Breo Ellipta Inhaler 100mcg/25mcg (100 micrograms per 25 micrograms) 1 inhalation. The resident was asked to rinse his mouth out. c. On 12/10/2020 at 9:29 a.m., LPN #3 administered one tablet of Folic Acid 400 micrograms (mcg) to the resident. The Physician's Order documented the resident was to receive 3 tablets.

Based on observation, record review, and interview, the facility failed to ensure fingernails were clean and trimmed and facial hair was removed regularly to maintain good personal hygiene and grooming for 1 (Resident #21) of 7 (Residents #8, #21, #39, #42, #45, #52, and #59) sampled residents who were dependent for nail care and for 1 (Resident #21) of 1 sampled resident who was dependent on staff for facial hair removal. These failed practices had the potential to affect 19 residents who required assistance with nail care, and 4 residents who required assistance for removal of facial hair, according to the list provided by the Director of Nursing on 12/10/2020. The findings are: 1. Resident #21 had a [DIAGNOSES REDACTED]. a. The Care Plan with a revised date of 7/31/2020 documented, .Bathing / Showering . Staff assist (assistance) (times) 2 three times per week and prn (as needed) . Personal Hygiene . Staff assist (times) 1 BID (two times per day) and prn (as needed) . b. On 12/7/2020 at 12:00 p.m., the resident was lying in bed. Her fingernails had a brown substance beneath them, and she had a few inch-long facial hairs on both sides of her chin. c. On 12/9/2020 at 1:39 p.m., the resident was sitting up in her chair in her room with a glass of tea in front of her. The resident's fingernails had a brown substance beneath them, and facial hair on both sides of her chin. d. On 12/10/2020 at 8:38 a.m., Certified Nursing Assistant (CNA) #1 was asked, When do you check fingernails for cleanliness? She stated, During showers. She was asked, Why is it important to keep their fingernails clean? She stated, To keep the spread of infections down. She was asked, When do you check for facial hair on the ladies? She stated, Well, I check (them) when they are in the shower. She was asked, Why would it be important to keep whiskers trimmed for the ladies? She stated, It's more of a confidence thing. She was asked, Are there any residents who refuse care? She stated, No. e. On 12/10/2020 at 9:46 a.m., the Director of Nursing was asked, Who and how often fingernails should be checked for cleanliness? She stated, The CNAs should check (them) on their shower days. She was asked about the resident's facial hair. She stated, Also on shower days. She was asked, Why would this be important for the residents? She stated, They just need to be clean, and for their dignity.