Every finding on record at Suwannee Valley Nursing Center

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 1 of 3 residents, Resident #11, reviewed for Minimum Data Set assessments. Findings include:Review of Resident #11's Minimum Data Set (MDS) titled Significant Change dated 05/20/26 documented under Section N, High-Risk Drug Classes, antipsychotics was coded as yes. Review of Resident #11's Medication Administration Record for May 2026 revealed no antipsychotic medications administered during the look-back period for the MDS dated [DATE]. During an interview on 08/12/26 12:48 PM, the Director of Nursing stated that Resident #11 has not taken an antipsychotic medication during her stay at the facility.During an interview on 08/12/26 at 01:25 PM, the Corporate MDS Coordinator stated that the MDS for Resident #11 had antipsychotic medication clicked yes instead of no for her lamotrigine. She stated that the MDS was incorrect.Review of the facility's policy titled, MDS 3.0 Completion, dated 09/19/22 read, According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State.

Based on record review and interview, the facility failed to ensure residents with newly evident or known diagnosis of serious mental disorders have a coordinated Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents, Resident #31, reviewed for PASRR. Findings include:Review of Resident #31's PASRR dated 07/24/26 revealed no related conditions, including traumatic brain injury, checked off. Review of Resident #31's Minimum Data Set (MDS) titled Admission dated 07/02/26 documented under Section I, Active Diagnoses, personal history of traumatic brain injury. Review of Resident #31's physician progress notes revealed a Nursing Home Progress Note dated 07/14/26 read, [Name and age of Resident #31] with a PMH [personal medical history] of Atrial fibrillation, Vascular dementia, TBI [traumatic brain injury], Anemia, HTN [hypertension], HLD [hyperlipidemia], Pulmonary fibrosis, speech and language deficits, Cerebrovascular disease and Parkinson's.During an interview on 08/12/26 at 12:48 PM, the Director of Nursing confirmed that the resident has a history of traumatic brain injury and that this diagnosis should be reflected on his PASRR. She stated that the PASRR needs to be updated. Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, dated 01/2026 read, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents, Resident #11, reviewed for unnecessary medications. Findings include:Review of Resident #11's psychiatry note dated 04/29/26 read, Diagnoses Rationale and Justifications Bipolar Disorder: The patient's history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient. There is no consistent substance use or organic brain disorder to explain these consistent mood symptoms. As bipolar disorder is a lifelong disorder, mood stabilizer medicine needs to be continued on a long-term basis; Other anxiety disorder: Patient has vague symptoms of anxiety, but they are causing distress. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Review of Resident #11's psychiatry note dated 07/29/26 read, This is a [age of Resident #11] patient with a past psychiatric history of bipolar disorder, depression, anxiety and dementia; Dementia is persisting, but no other behaviors noted. The patient reports benefiting from medication regimen. Trazodone along with Prozac are managing with depression, Donepezil is helping dementia, Lamotrigine is assisting with bipolar disorder and Clonazepam is assisting with anxiety. Review of Resident #11's care plan did not document a focus area for bipolar disorder or anxiety disorder. During an interview on 08/12/26 01:25 PM, the Corporate Minimum Data Set Coordinator-Corporate stated that anxiety disorder and bipolar disorder were not included in Resident #11's care plan and will be added to the care plan.Review of the facility's policy titled, Care Plans, Development Baseline and Comprehensive, dated 01/2026 read, The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review, and interviews, the facility failed to ensure a resident assessed as being at high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. This failure was identified for 1 of 3 residents reviewed for fall prevention (Resident #50).Findings Include : Review of Resident #50's clinical record documented Resident #50 was admitted [DATE] with the diagnosis that included ortho-static hypo-tension ( sudden drop in blood pressure when standing up), lack of coordination, reduced mobility and communication deficit.During an observation on 8/10/2026 at 10:45 AM, Resident #50 was observed up in a wheelchair at the bedside. The resident was dressed in personalized clothing and appeared clean and groomed. The bed was observed locked and in the lowest position. A Certified Nursing Assistant (CNA) was present at the bedside assisting the resident in the wheelchair to activities. No fall mat was observed on the floor on the right side of the bed and was not located in the room.During an observation on 8/11/2026 at 8:18 AM, Resident #50 was observed sitting on the right side of the bed with both feet dangling off the bed. No fall mat was observed on the floor on the right side of the bed.Review of the fall risk assessment dated [DATE] revealed a score of 50, indicating high risk for falling.Review of Resident #50's physician orders dated 6/7/2026 read, mat right side of bed.Review of Resident #50's care plan dated 5/20/2026 documented a focus identifying the resident as being at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. Interventions included assisting with toileting and transfers with a stand aide, completing fall-risk screening as indicated, cueing for safety awareness, encouraging the bed to remain in the lowest position as appropriate, encouraging use of non-skid socks, ensuring the call light was within reach, keeping frequently used items within reach, observing for medication side effects that could contribute to falls, orienting the resident to the environment, and obtaining a therapy screen as needed. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed medications and treatments were documented as administered as ordered; however, the physician order for the fall mat on the right side of the bed was not reflected on the TAR as an implemented intervention.During an observation on 8/11/2026 at 12:46 PM, Resident #50 was observed sitting in a wheelchair at the bedside on the right side of the bed. No fall mat was observed on the floor beside the bed or located in the room.During an interview on 8/11/2026 at 12:46 PM, Resident #50 stated, I use to have a fall mat here but I got a new bed and they took the fall mat away. That was a long time ago.During an interview on 8/11/2026 at 1:18 PM, Staff A, Registered Nurse (RN) stated Resident #50 was a fall risk and became somewhat confused when she woke up. Staff A, RN stated the resident required sit-to-stand assistance. Staff A , RN further stated, I reviewed the orders and there is an order for a fall mat on the right side of the bed we should follow that order or have it cancelled if she no longer needs the fall mat.During an interview on 8/11/2026 at 1:30 PM, the Director of Nursing (DON) stated, I do remember her bed being changed out and the mat would get in the way, we should have got the order for fall mat on the right side of the bed cancelled. Review of the facility policy titled Fall Prevention Program, dated 1/6/2026, revealed, in part, that each resident would be assessed for fall risk and receive care and services in accordance with the resident's individualized level of risk to minimize the likelihood of falls. The policy further identified high-risk protocols requiring patient-centered interventions addressing unique risk factors and additional interventions as directed by the resident's assessment, including ix. Fall mat.

Based on observation, interview, and record review the facility failed to ensure medications were securely stored when unattended for 1 of 5 hallways. Findings include:Review of Resident #41's physicians order dated 07/06/26 read, May self administer medications. Review of Resident #41' Self Administration of Medication Evaluation dated 07/06/26 read, The resident can demonstrate secure storage of medications kept in room. Completely Capable. During an observation on 08/10/26 at 10:19 AM, an inhaler was observed to be unsecured on top of a small dresser under Resident #41's television. Lubricant eye drops were observed to be unsecured on Resident #41's bedside table. During an interview on 08/10/26 at 10:19 AM, Resident #41 stated that her bedroom does not lock. She explained that she would prefer that her room had a lock so other residents could not enter her room. During an observation on 08/11/26 at 02:06 PM, Resident #41 was observed retrieving nasal sprays from an unlocked drawer in her bathroom. Observed an inhaler in a wicker box on a dresser and nebulizer vials on her nightstand. During an interview on 08/11/26 at 02:06 PM, Resident #41 stated that she does not have a lockbox but would like to have one. Resident #41 said, I didn't know we could get a lockbox. I don't have one, can I ask? During an interview on 08/12/26 at 09:55 AM, Staff B, LPN, stated that Resident #41 is able to manage her own medications, but the nursing staff keep her oral medications locked in the medication cart. The resident keeps her breathing treatments in her room. She has no concerns about the resident's ability to manage her medications. She stated that she was unsure if the resident's medications need to be locked up when kept in her room. During an observation on 08/12/26 at 10:08 AM Staff B, Licensed Practical Nurse (LPN), confirmed that medications were unsecured in Resident #41's bedroom. During an interview on 08/12/26 at 10:18 AM, Staff B, LPN stated that she was unsure if Resident #41's medications needed to be locked up, but that makes sense, she probably leaves them out to reminder herself to take them. During an interview on 08/12/26 12:36 PM, the Director of Nursing stated that Resident #41 has been assessed for self-administration of medications and as part of that, has to be able to administer the medications correctly and keep them secure. She stated that the resident keeps her inhalers and artificial tears in her room, but nursing staff keep her oral medications locked in the medication cart. She stated that Resident #41 likes to keep her medications within sight on her table. She stated that Resident #41 has a private room and was not offered a lockbox for her medications. She explained that when Resident #41 leaves her room, she keeps the medications in an unlocked drawer. She stated that Resident #41's bedroom does not lock from the outside. Review of the facility's Resident Self-Administration of Medication policy dated 01/2026 read, when determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: The resident's ability to ensure that medications is stored safely and securely; Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required on if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.

Based on observation, interview, and record review, the facility failed to ensure foods were properly labeled and stored. Findings include: During an observation on 3/24/2025 at 9:20 AM while conducting the initial tour of the kitchen with the Certified Dietary Manager (CDM), there were thirteen bags of frozen variety of meats, without an identifying label, and one bag that was left open exposing chicken with ice particle buildup and the appearance of freezer burn in the reach-in freezer. During an interview on 3/24/2025 at 9:25 AM, the CDM confirmed that there were thirteen bags of a variety of meats without an identifying label and one bag of chicken that was completely open exposing the product to the elements and freezer burn. Review of the facility policy and procedure titled Date Marking for Food Safety dated 11/2020 and revised on 1/2025 showed it read, Policy Explanation and Compliance Guidelines for Staffing . 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and followed infection control standard of practice during medication administration for 1 of 4 residents observed for medication administration, Resident #7, to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 3/26/2025 at approximately 9:10 AM, Staff A, Licensed Practical Nurse (LPN), prepared medications for administration to Resident #7, which included Baby Shampoo on a wet washcloth. Staff A donned a gown and gloves and proceeded to clean Resident #7's eyelids with the washcloth containing Baby Shampoo and placed the soiled washcloth on a piece of aluminum foil. Staff A did not remove her gloves or did not perform hand hygiene and proceeded to administer medications to Resident #7 through her gastrostomy tube (G-tube: a thin, flexible tube inserted through the abdominal wall and into the stomach. It is used to provide nutrition and medication to individuals who cannot eat or drink adequately by mouth.) While holding a medicine cup containing a crushed pill of Amlodipine (a medicine for treating high blood pressure) mixed with a small amount of water, Staff A used her gloved finger to stir the mixture before she administered it through Resident #7's G-tube. Review of Resident #7's physician order dated 3/18/2025 showed it read, Enhanced Barrier for tube feeding. During an interview on 3/26/2025 at approximately 9:30 AM, Staff A, LPN, stated, I should have washed my hands and changed my gloves after I washed her eyes, before I gave her meds. I shouldn't have mixed the medicine with my finger. During an interview on 3/26/2025 at 10:50 AM, the Director of Nursing (DON) stated, For a resident who was on Enhanced Barrier Precautions who had a procedure requiring cleaning on her eyes, the nurse should wash her hands and change her gloves before administering any medications through the gastric tube. The nurse should only use a spoon to mix the crushed medication suspended in water in a medication cup. Review of the facility's policy and procedures titled Medication Administration last reviewed on 1/19/2025 showed it read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the facility's policy and procedures titled Infection Prevention and Control Program last reviewed on 1/19/2025 showed it read, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines . Policy Explanation and Compliance Guidelines . 4. Standard Precautions . b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Review of the facility's policy and procedures titled Hand Hygiene last reviewed on 1/19/2025, showed it read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table - Condition . Before preparing or handling medications . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site.

Based on observation, interview, and record review, the facility failed to ensure resident assessments accurately reflect the resident's status for 2 (Resident #1 and #5) of 3 residents reviewed for respiratory care. Findings include: 1.) Review of the admission record documented Resident #1 was admitted to the facility on [DATE] with diagnoses that include COPD (Chronic Obstructive Pulmonary Disease and OSA (Obstructive Sleep Apnea). During an interview on 5/21/24 at 9:59 AM, Resident #1 confirmed it was her CPAP (Continuous Positive Airway Pressure) machine sitting on the nightstand. She stated that she is still using the machine; she just cannot clean it with her SoClean(R) [CPAP cleaner and sanitizer machine]. Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented Resident #1 is not using a CPAP machine. 2.) Review of the admission record documented Resident #5 was readmitted to the facility on [DATE] with diagnoses including CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and Pulmonary Edema. During an observation on 5/21/24 at 11:40 AM, Resident #5 was observed in his bedroom with a CPAP machine on the nightstand next to the bed. During an interview on 5/21/24 at 11:41 AM, Resident #5 stated, That is my CPAP machine on the table there, indicating the device on the nightstand next to the bed. Review of the care plan dated 7/25/22 for Resident #5's care plan dated 7/25/22 documented at risk for respiratory complications related to dx (diagnosis) of: CHF, COPD, Pulmonary Edema, with interventions that include Monitor use of Bi-Pap (Bilevel Positive Airway Pressure) machine use as ordered. Review of the MDS Quarterly assessment dated [DATE] documented Resident #5 as not using a CPAP machine. During an interview on 5/21/24 at 1:30 PM, the Minimum Data Set Coordinator confirmed Resident #1 and Resident #5's MDS assessments documented that they were not using CPAP machines.

Based on observation, interview, and record review, the facility failed to ensure an attending practitioner's orders and indication of use for CPAP (Continuous Positive Airway Pressure) or BIPAP (Bi-level Positive Airway Pressure) devices for 1 (Resident #5) of 3 residents reviewed for respiratory care services. Findings include: Review of the admission record documented Resident #5 was readmitted to the facility on [DATE] with diagnoses including CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and Pulmonary Edema. Review of the physician's orders for Resident #5 as of 5/21/24 documented no orders for the use or care of a CPAP or BIPAP machine. During an observation on 5/21/24 at 11:40 AM, Resident #5 was observed in his bedroom with a CPAP machine on the nightstand next to the bed. During an interview on 5/21/24 at 11:41 AM, Resident #5 stated, That is my CPAP machine on the table there, indicating the device on the nightstand next to the bed. Review of the care plan dated 7/25/22 for Resident #5 documented at risk for respiratory complications related to dx (diagnosis) of: CHF, COPD, Pulmonary Edema, with interventions that include Monitor use of Bi-Pap machine use as ordered. During an interview on 5/21/24 at 1:45 PM, the Director of Nursing confirmed the facility did not have any current orders for Resident #5's use of a CPAP or BIPAP machine. A policy on physician's orders was not provided during the survey.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 1 of 4 residents reviewed for mood and behavior, Resident #33. Findings include: Review of Resident #33's admission record showed the resident was admitted on [DATE] and diagnosed with major depressive disorder on 12/5/2020. Review of Resident #33's Quarterly MDS dated [DATE] showed no diagnosis of depression under Section I. Active Diagnosis. During an interview on 12/12/2023 at 12:17 PM, the MDS Coordinator stated, The system pulls it through and it missed that. I normally will review and when I find this, I modify and correct it. Review of the facility's policy and procedures titled MDS 3.0 Completion with the last review date of 1/4/2023 reads, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.

Based on record review and interview, the facility failed to ensure residents received medications in accordance with standard of practice for 1 of 7 residents reviewed, Resident #4. Findings include: Review of Resident #4's Medication Administration Record revealed Amlodipine Besylate was administered on 12/5/2023 with a pulse of 53 and on 12/6/2023 with a pulse of 55. Review of Resident #4's physician order dated 11/14/2023 reads, Amlodipine Besylate oral tablet 10 mg (Amlodipine Besylate) Give 1 tablet by mouth in the morning for hypertension related to essential (primary) hypertension (110) Administer 1 tablet by mouth in the morning. If pulse is below 60 hold and recheck BP [Blood Pressure] and pulse in two hours. Administer if within parameters. During an interview on 12/12/2023 at 1:27 PM, the Medical Director stated, The staff should let me know if parameters are not being met. The order should be followed. During an interview on 12/13/2023 at 7:27AM, Staff A, Licensed Practical Nurse (LPN), stated, It depends on the resident if it is close to the parameter, I will ask the resident. I prefer not to give it since I have worked in a hospital setting and here you do not have all the things you do in a hospital. During an interview on 12/13/2023 at 10:58 AM, the Director of Nursing stated, It all depends on the resident. If the staff wants to give medication out of parameters, they should contact the doctor and get clarification. I spoke to the doctor, and he said that the parameters should have been 50. Medication should never be given out of parameters. Review of the facility policy and procedures titled Medication Administration with the last review date of 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 8. Obtain and record vital signs, when applicable or per physician orders. when applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 3 residents reviewed for nutrition, Resident #4, and for 1 of 2 residents reviewed for insulin administration, Resident #57. Findings include: 1. During an observation on 12/11/2023 at 8:10 AM, Resident #4 was eating independently in his room. The meal tray contained eggs, grits, ground sausage, orange juice, and coffee. Review of Resident #4's physician order dated 11/14/2023 reads, Regular diet regular texture. Review of Resident #4's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 11/13/2023 reads, Q. Nutrition/Hydration: Regular soft/thin liquids. Review of Resident #4's Dietary Profile dated 11/14/2023 reads, A. Diet. 1. Current diet order: Regular Mech [Mechanical] Soft Diet. During an interview on 12/12/2023 at 11:08 AM, the Registered Dietician (RD) stated, Usually the registered nurse from the facility or the director of nursing will put in the diet orders. Usually, first orders are what the hospital sends and the facility match the orders. His orders were regular soft/thin liquids that would be equivalent to mechanical soft. We follow the 3008 form. During an interview on 12/12/2023 at 11:22 AM, the Director of Nursing (DON) stated, We were following his home diet. It was a preference. The resident did not need that kind of meal. I do not know. Maybe the CDM [Certified Dietary Manager] made a documentation error. During an interview on 12/13/2023 at 9:12 PM, the CDM stated, [Resident #4's name] has no teeth and wanted his food really soft because he could not chew. After I do the dietary preference, the DON or the RD put the diet orders in place. Mechanical Soft diet is ground meats. Review of the facility policy and procedures titled Documentation in Medical Record with the last review date of 1/4/2023 reads, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Policy Explanation and Compliance Guidelines . 3. Principles of Documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. 49012 2. Review of Resident #57's Progress Notes dated 12/1/2023 at 9:10 PM reads, Insulin Glargine-yfgn 100 Unit/ML [milliliter] Solution pen-injector, Inject 50 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications (E11.9), Resident refused 50 units per order, she stated, I only want 25 units. Review of Resident #57's Medication Administration Record (MAR) showed staff initials indicating administration of 50 units of Insulin Glargine-yfgn on 12/1/2023. Review of Resident #57's Progress Notes dated 11/27/2023 at 9:29 PM reads, Insulin Glargine-yfgn 100 Unit/ML Solution pen-injector, Inject 50 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications (E11.9), Resident refused to be administered the 50 units, she only wanted 25 units at this time. Review of Resident #57's MAR showed staff initials indicating administration of 50 units of Insulin Glargine-yfgn on 11/27/2023. Review of Resident #57's Progress Notes dated for 11/26/2023 at 8:52 PM reads, Glargine-yfgn 100 Unit/ML Solution pen-injector, Inject 50 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications (E11.9), Resident stated she feels 50 units at night is too much for her because she stated she is dropping at night, resident agreed to 25 units tonight and would like the dosage revaluated. Review of Resident #57's MAR showed staff initials indicating administration of 50 units of Insulin Glargine-yfgn on 11/26/2023. During an interview on 12/10/2023 at 2:30 PM, the DON stated, When staff is not giving the prescribed dosage, they are supposed to document in a progress note and refer to it on the MAR with the number 9. I see that they didn't do that. We will have to re-educate them.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards of practice while administering medications. Findings include: During an observation on 12/12/2023 at 8:59 AM, Staff B, Licensed Practical Nurse (LPN), removed 4 tablets for Resident #41 from the pill blister pack and medication bottle by grabbing the medication with her hands without wearing gloves. Staff B placed the medications in the medication cup, which contained other medications. Staff B entered Resident #41's room and administered medications. Staff B exited the room and used hand sanitizer stored in the medication cart to sanitize her hands. During an interview on 12/12/2023 at 9:10 AM, Staff B, LPN, stated, I did not realize I was touching the medication with my hands. Normally, I pop them straight into the medication cup. During an interview on 12/12/2023 at 9:40 AM, the Director of Nursing stated, Staff should not be touching medication with their hands while preparing medication. Review of the facility policy and procedures titled Medication Administration with the last review date of 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 13. Remove medication from source, taking care not to touch medication with bare hand.

Based on observation, interview, and record review, the facility failed to post the nurse staffing information on a daily basis. Findings include: During an observation on 12/10/2023 at 9:15 AM, the facility's staffing information posted on the bulletin board adjacent to the A Hall Nursing Station was dated 9/7/2023. During an interview on 12/10/2023 at 9:40 AM, the Director of Nursing (DON) confirmed that the staffing information was dated 9/7/2023 and stated it was supposed to be updated daily and the facility did not have the records from 9/8/2023 until current. Review of the facility policy and procedures titled Nurse Staffing Posting Information with the last review date of 1/4/2023 reads, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing sheet will be posted on a daily basis and will contain the following information: a. Facility name, b. The current date, c. Facility's current resident census, d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses, ii. Licensed Practical Nurses/ Licensed Vocational Nurses, iii. Certified Nurse Aides. 2. The facility will post the Nurse Staffing sheet at the beginning of each shift.

Based on observation, interview, and record review, the facility failed to prevent possible complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, and vomiting for 1 of 3 residents, Resident #34. Findings include: During an observation on 6/14/22 at 7:58 AM, Resident #34 was observed to have tube feeding being administered. The head of the resident's bed was flat. During an interview on 6/14/22 at 8:00 AM, Staff A, Registered Nurse (RN), confirmed the head of the bed was not elevated and stated it should be elevated to at least 30 degrees. During an interview on 6/14/22 at 8:05 AM, Staff D, Certified Nursing Assistant (CNA), stated that the head of the bed should be elevated. During an interview on 6/14/22 at 8:10 AM, the Director of Nursing (DON) stated her expectations were for the staff to make sure to elevate the bed 30-45 degrees while tube feeding was running and for any staff rendering care to ensure they raised the bed back after finishing the task. Review of Resident #34's care plan reads, Problem/Need - Requires G-tube [gastrostomy tube] feedings for adequate nutritional intake due to resident's inability to swallow nutrients without chocking aspiration ([CONDITION(S)] with dysphagia). Goal: Will remain adequately nourished & hydrated and without s/s [signs/symptoms] of aspiration/infection. Gtube will remain viable daily. Approaches: HOB [head of bed] elevated 30 degress [sic] @ [at] all times when in bed. Monitor for s/s aspiration, infection, dehydration. Review of the policy and procedure titled, Enteral Feedings--Safety Precautions reads, Preventing Aspiration: 3. Elevate the head of the bed (HOB) at least 30 degrees during tube feeding and at least 1 hour after feeding.

Based on observation and interview, the facility failed to ensure residents receiving respiratory care were provided such care consistent with professional standards of practice for 1 of 3 residents, Resident #48. Findings include: During an observation of Resident #48's room on 6/13/22 at 11:36 AM, his oxygen and nebulizer tubing were uncovered and laying on the floor. His nebulizer mask was uncovered and sitting on a chair in the room, and the nebulizer machine was sitting on the floor. The oxygen and nebulizer tubing did not have a date to show when the oxygen and nebulizer tubing were changed. During an observation of Resident #48's room on 6/13/22 at 2:26 PM, the oxygen and nebulizer tubing were on the floor, undated and uncovered. His nebulizer mask was uncovered and sitting on a chair in the room, and the nebulizer machine was on the floor. During an interview on 6/14/22 at 3:55 PM, the Director of Nursing (DON) stated, The day nurse or unit managers are supposed to change and date the tubing changes weekly.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and failed to separate expired medications from active use medications in 2 of 2 medication storage rooms and 1 of 2 medication carts. Findings include: During an observation of the drug/medication storage room on Unit A on 6/13/22 at 10:03 AM, there were four (4) 12.5 mg (milligram) [MEDICATION(S)] suppositories stored in the medication refrigerator with active use medications that showed an expiration date of 5/2022. During an interview on 6/13/22 at 10:05 AM, the Director of Nursing (DON) confirmed the [MEDICATION(S)] was expired. The DON stated, The medication nurse is supposed to check the drug room refrigerator every night. During an observation of the B-Hall medication storage room on 6/13/22 at 10:18 AM, there was one (1) sterile culture swab II diagnostic tube that showed an expiration date of 4/20/2022. During an interview on 6/13/22 at 10:20 AM, the DON confirmed the sterile culture swab diagnostic tube was expired. During an observation of the medication cart with Staff A, Registered Nurse (RN), on 6/13/22 at 10:27 AM, there were one (1) opened bottle of [MEDICATION(S)] 20 ml (milliliters) with an expiration date of 3/2022 and no label showing resident name or an open date; two (2) bottles of [MEDICATION(S)] insulin injection with no label showing open date and a label from the pharmacy that reads, Medication expires 42 days after open. During an interview on 6/13/22 at 12:13 PM, Staff A, RN, stated, The [MEDICATION(S)] is used to mix [MEDICATION(S)] with [MEDICATION(S)] for intramuscular injections for Resident #8. Staff B, licensed Practical Nurse (LPN), stated, Every nurse is responsible for checking each medication cart. Review of the policy and procedure titled, Labeling of Medication Containers with a revision date of December 2021 reads, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Policy Interpretation and Implementation: 1. Medication labels must be legible at all times. 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 3. Labels for individual drug containers shall include all necessary information, such as: a) The residents' name. b) The prescribing physicians name. d) The name, strength, and quantity of the drug. f) The date that the medication was dispensed and i) Direction for use. Review of the document titled Expiration Dates For The Following Medications After Opening provided by the facility reads, [MEDICATION(S)] Insulin vial expires in 42 days. All other multi-dose vials 28 days unless manufacturer states a shorter or longer date.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and maintain kitchen equipment in a clean and sanitary condition, potentially affecting the entire 53 resident population. (Photographic evidence). Findings include: 1. A tour of the main kitchen was conducted as part of the initial tour on Monday, 1/4/21 beginning at 9:33 AM. Areas of concern were identified during the tour and observed by the facility Certified Dietary Manager. The areas included: a. The standup freezer contained an unlabeled zip lock bag of a meat product dated 12/18/20, an unlabeled zip lock bag of a food product dated 12/30/20, an unlabeled container of bologna that had 57 had written on the plastic covering; there was no label or date on the covering, and a plastic bag that was tied closed at the top of unlabeled/undated bread. b. The ice machine located outside the main kitchen door had a black substance on the plastic bar across the back of the ice machine. Ice is observed to be resting on the plastic bar coming in contact with the black substance. An observation in the kitchen was conducted on 1/4/21 at 2:40 PM and showed a dietary aide was observed wiping the black substance off the plastic bar at the back of the ice machine with a cleaning cloth. The cloth was dragging across the ice in the ice machine. The CDM was present during the observation. An interview was conducted with the CDM on 1/4/20 at 2:43 PM. When asked if the dietary aid was cleaning the ice machine, the CDM stated, Yes, but we should empty it shouldn't we? Review of the policy and procedure titled, Food Storage dated 12/20/07, annually reviewed on 1/9/20 reads Food storage areas shall be maintained in a clean, safe, and sanitary manner. 5. Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid. A review of the policy titled, Ice Machines and Ice Storage Chests dated March 2004, annually reviewed on 1/9/20 reads: Policy statement. Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation. 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. The food services manager or designee maintains a copy of these procedures. 2. An observation of the nourishment refrigerator across the hall from the nursing station revealed unlabeled/undated food. There were five containers of Bryers Ice Cream. None of the ice cream containers were labelled with a resident's name or dated. An interview was conducted with the CDM on 1/5/20 at 9:37 AM. The CDM confirmed there was no resident's name on the ice cream containers. When asked how staff would know whose ice cream belongs to whom, she stated the residents would know what ice cream theirs was. She confirmed the resident's food should be labeled with their name and dated. A review of the policy titled Foods Brought by Family/Visitors, annually reviewed on 1/9/20 reads Policy Interpretation and Implementation. 6. Perishable foods must be discarded after an appropriate time (specific to food and temperature). Food kept in the refrigerator for a resident must be labeled with the resident's name and the date.

Based on interview and record review the facility failed to ensure the resident or resident's representative was provided written notice of the resident's/beneficiary's potential liability for payment for the non-covered services by failing to issue the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident/beneficiary for 2 of 3 residents reviewed, Residents #1 and #354. Findings include: Review of the facility medical record for Resident #1 revealed the resident continues to reside in the facility. The resident's last covered day for skilled services was 12/18/2020. There was no documentation in the record of the resident or the resident's representative having been provided the Skilled Nursing Facility Advance Beneficiary Notice prior to providing care that Medicare usually covers but may not pay. Review of the facility medical record for Resident #354 revealed the resident continues to reside in the facility. The resident's last covered day for skilled services was 12/24/2020. There was no documentation in the record of the resident or the resident's representative having been provided the Skilled Nursing Facility Advance Beneficiary Notice prior to providing care that Medicare usually covers but may not pay. An interview was conducted with the Social Services Director (SSD) on 1/6/21 at 1:10 PM. A request was made for the SNFABN notices for Residents #1 and #354. The SSD stated a SNFABN was not issued to Residents #1 and #354. She stated she was not aware this notice was required for those residents who remained in the facility. She confirmed when Residents #1 and #354 were changed to long term care they had not exhausted their Medicare Part A benefits.

Based on observation, record review and interview the facility failed to maintain large equipment in a clean manner. (Photographic Evidence) Findings: Observation of the Kitchen, on 6/4/19 with the Kitchen Manager and the Registered Dietician, the vents over the stove were observed to be greasy with debris and lint covering the entirety of the vents, the sides of the vent hood and the outside of the vent hood. There were 2 large containers of 5 pound blocks of butter melting in water, a large pot of simmering meat in water and eggs boiling in water. There were no covers on any of the pots to protect the food from falling debris from the dirty vents above the stove. The steam table and food preparation area is pushed against the stove, underneath the hood. During an interview with the Kitchen Manager and the Registered Dietician on 6/4/19 they confirmed the vents over the stove had layers of grease with visible debris clinging to the hood and vents. Further, they confirmed there were numerous large, uncovered pots of food cooking on the stove, underneath the dirty vents and hood. They immediately covered the food cooking on the stove top. They did not provide any information regarding any monitoring of the cleanliness of the vents and hood between the inspections completed with an outside company. Review of the facility documentation revealed no specific policy for large equipment in the kitchen. The facility provided copies of the Work Order forms from the company with which they have a contract for cleaning the vents and hood. The most recent inspection was dated 2/17/19 with a final sign off of 4/14/19. There was no documentation of any monitoring for the cleanliness of the vents and hood provided by the Kitchen Manager. During an interview with the Administrator on 6/4/19 at approximately 4:00 PM, he confirmed the vents and hood were not clean. He stated the Owner of the company providing the services for the kitchen equipment stated he had a sudden loss of staff and had not been able to service his clients. He confirmed there was no additional monitoring information for the time periods between the contracted inspections.

Based on interview and record review, the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents received adequate supervision and assistance to prevent falls. Findings: Record review of Resident #1's clinical record revealed a Face Sheet that documented Resident #1 had [DIAGNOSES REDACTED]. Record review of Resident #1's clinical record revealed a Minimum Data Set (Dated: 10/18/2018) that documented Resident #1 required full staff performance to complete bed mobility. Record review of Resident #1's Care Plan (Dated: 08/05/2017) that documented Resident #1 was at risk for falls related to balance problems and impaired mobility due to a [MEDICAL CONDITION]. Resident #1's Care Plan documented fall prevention interventions that included transfer assistance in and out of bed. Record review of Resident #1's clinical record revealed nurses' progress notes (Dated: 01/11/2019) that documented the following: On 01/11/2019 at 0850, Employee C (Certified Nursing Assistant) came to the nurses station and stated that Resident #1 had fallen out of her bed. Resident #1 was found by Employee A (Registered Nurse) lying supine on the floor between her bed and the other bed in the room. Resident #1 was not clothed as Employee C had been providing activities of daily living care (bed bath) at the time of the fall. Employee A assessed Resident #1 for injuries. Resident #1 was awake and alert but not communicating verbally, which was normal for her. Employee A stabilized Resident #1's head and neck and sent Employee C to get a second nurse to assist to assess Resident #1 for injuries. The facility Director of Nursing came to Resident #1's room to assist. Employee A felt a hematoma to the outer right side of Resident #1's heard and noted a small abraded area to that site. No bleeding was noted. A light blue bruise was noted to Resident #1's right outer foot. After assessing Resident #1, Resident #1 was transferred back into her bed via mechanical lift. At 0915, the facility notified Resident #1's physician of the fall and resulting injuries. Resident #1's physician ordered neurological checks, a cool pack to be applied to the hematoma and monitoring for change in status. Employee A re-entered Resident #1's room and applied a cool pack to the hematoma and then notified Resident #1's family of her fall and resulting injuries. At approximately 0930, Employee A re-entered Resident #1's room to complete a neurological check. Resident #1 was noted making a moaning sound and displayed slightly labored breathing at that time. Resident #1 was positioned on her back with the head of her bed elevated. Resident #1's oxygen saturation was 67% on room air. Employee A stayed with Resident #1 and called for another nurse to bring the oxygen set up to Resident #1's room. Oxygen was applied at 3 liters per minute via nasal cannula. Resident #1's oxygen saturation level did not improve and the oxygen was increased to 4 liters per minute. The nasal cannula was placed in Resident #1's mouth due to her mouth breathing. Resident #1 was not as responsive as she had been earlier. Resident #1's pupils were slow to react. Employee A left the room to notify Resident #1's physician regarding Resident #1's change in status. The facility Director of Nursing and Employee G (Registered Nurse) remained in the room with Resident #1. Employee A received physician's orders [REDACTED].#1 to the hospital emergency room for an evaluation. At approximately 0950, Employee A telephoned emergency medical services to arrange for Resident #1 to be transported to the hospital emergency room . Employee A notified Resident #1's family of the physician's orders [REDACTED].#1 to the hospital emergency room for evaluation. Emergency medical services arrived at the facility at approximately 1005. Resident #1 suffered a steady decline while emergency medical services was on site at the facility. Record review of the hospital emergency department report (admitted /Time: 01/11/2019 / 10:58) documented Resident #1 had a pulse and was breathing at the facility but stopped breathing when she was put in the ambulance. The hospital emergency department report documented that cardiopulmonary resuscitation was initiated during transport to the hospital emergency room . The hospital emergency department report documented at 11:01 Resident #1 was unresponsive and her pupils were fixed and dilated with no respiratory effort. The hospital emergency department report documented that Resident #1 was intubated and displayed a pulse with compressions. The hospital emergency department report documented that Resident #1 was pronounced dead at 11:20. The hospital emergency department report noted that Resident #1's primary physician stated he would not sign the death certificate due to the trauma endured at the facility prior to arriving at the hospital emergency department. The hospital emergency department report noted Resident #1's primary physician requested the hospital call the medical examiner's office. The hospital emergency department report documented Resident #1 had suffered [MEDICAL CONDITION], respiratory arrest and head injury. Record review of a facility training documents related to proper use of bed rails and proper turning of a resident (Dated: 01/11/2019) specified: 1. The number one job of all staff members at the facility is the safety of the residents. 2. Per policy, bed rails should be raised for any resident requiring a bed bath, incontinent care procedures, etc. 3. The bed rail can be down on the side where the caregiver is positioned. This rail should be raised if the caregiver walks away at anytime. 4. The bed rail opposite the caregiver should be raised at all times. 5. TIME should be taken to ensure that the resident is safe at all times. DO NOT RUSH. 6. Following the completion of care, side rails are raised and the bed is placed in the low position. 7. Call light is placed within easy reach of the resident. Most accidents are the result of poor decision making. Always anticipate the worst and work to make every situation as safe as possible for your resident. During interview on 02/06/2019 at 12:32 PM, Employee H (Registered Nurse) stated that she was the facility Charge Nurse at the time of Resident #1's fall. She stated that Resident #1 had sustained a fall from her bed while she was getting a bed bath. She stated that Employee C rolled Resident #1 during the bed bath. She stated that Employee C had not raised the bed side rail and as a result Resident #1 rolled off of her bed. She confirmed that Resident #1 required extensive staff assistance for bed mobility. She added Resident #1 couldn't really move herself at all. Employee H stated that facility aides were supposed to have the residents' bed rails raised during a bed bath. She stated that Employee C had not offered an explanation as to why she had not raised Resident #1's bed rail. During interview on 02/06/2019 at 1:55 PM, the facility Director of Nursing stated that she believed Employee C had rolled Resident #1 away from her and Resident #1 had fallen off the far side of her bed. She added that the far side bed rail should be raised during residents' bed baths to prevent accidents.