Every finding on record at Taylor County Health and Rehabilitation

Based on observation, staff interviews, record review, and review of the facility's policy titled Food Preparation and Distribution, the facility failed to ensure proper thawing process was followed. In addition, the facility failed to sanitize food preparation surfaces in accordance with professional standards for food service safety as required in the facility's kitchen. These deficient practices had the potential to cause food-borne illness among all 67 residents who received meals from the facility kitchen. Findings include:Review of the facility's policy titled Food Preparation and Distribution, dated 12/27/2024, revealed that It is the intent of this center to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices by no bare hand contact with food items and work surfaces and equipment should be cleaned and sanitized as needed by appropriate sanitizer concentration of 150-400 parts per million (ppm). Thawing methods should be under refrigeration and food items should be in a drip-proof container and by submerging food under running water at a temperature no greater than 70 degrees Fahrenheit (F). 1. Review of the in-service documentation titled, Ready 365 Best Practice - Thawing Process, dated 8/2024, revealed that To reduce pathogen growth, never thaw food at room temperature and follow one of the four appropriate methods: refrigeration, running drinkable water at 70 degrees F or below, by microwave oven if it will be cooked immediately afterwards, and by cooking, as long as it reaches proper minimum internal temperature.During a tour of the facility kitchen on 1/7/2026 at 6:10 am, two ten-pound tubes of ground beef were observed sitting in a basin, while red and clear juices were dripping onto the bottom of the basin. The basin was observed sitting on top of the counter of the meat sink. During an interview on 1/7/2026 at 6:11 am, the Assistant Dietary Manager (ADM) was asked what time the two tubes of ground beef were taken out of the freezer. ADM stated, Today at three am. During an interview on 1/7/2026 at 6:35 am, the Dietary Manager (DM) was asked what the process was for thawing meat products, and she stated, Either thaw the meat in the refrigerator or leave it in a basin under running cold water. The DM stated she would re-educate the kitchen staff on the proper thawing process. DM was notified that the two tubes of ground beef in the basin were now being thawed under running water, but the number of hours these tubes have been thawing remains unknown. The DM discarded the two tubes of ground beef.During an interview on 1/8/2026 at 1:48 pm, the ADM stated, I knew that I was supposed to thaw the meat in the refrigerator or under running cold water.2. Review of the in-service documentation titled, Ready 365 Best Practice - Cleaning and Sanitizing Process, dated 4/2024, revealed that to clean and sanitize a surface appropriately, scrape or remove food bits from the surface by using the correct cleaning tool, such as a nylon brush or pad, or a clean cloth towel, wash the surface with the cleaning solution with an approved cleaner by using green buckets for this wash solution, rinse the surface with clean water, sanitize the surface using the correct sanitizing solution in the red bucket, and allow the surface to air-dry. During a tour of the facility kitchen on 1/07/2026 at 6:32 am, [NAME] 1 emptied seven liquid egg boxes onto a cooking pan. Each empty liquid egg box was placed back into its original storage box while liquid eggs dripped onto the food preparation surface. [NAME] 1 disposed of the empty liquid egg boxes outside to the main trash bin. [NAME] 1 returned to the food preparation surface, walked over to the handwash station, and, without donning (putting on) clean gloves, she pulled one paper towel from the dispenser and walked back to wipe the liquid egg spill on the food preparation surface. [NAME] 1 walked back to the handwashing station without clean gloves, pulled three paper towels from the dispenser, and returned to wipe the remaining liquid eggs from the food preparation surface. [NAME] 1 then walked to the walk-in freezer, brought out a box of frozen biscuit dough, and placed it on top of the spill site on the food preparation surface. [NAME] 1 then returned the box of frozen biscuit dough to the same location it was taken from in the walk-in freezer. During an interview on 1/7/2026 at 6:35 am, the DM was asked what the process for cleaning and sanitizing a food preparation surface in case of a spill was, specifically a spill with raw eggs. The DM stated, Staff is supposed to wipe the surface with the 'green bucket' solution, then sanitize the surface with the 'red' bucket solution and let the surface air dry. DM was notified of a liquid egg spill on the food preparation surface by [NAME] 1. The DM re-educated the kitchen staff.

Based on record review, resident and staff interviews, and review of the facility policy titled Dental Services/Oral Assessments, the facility failed to ensure routine or emergency dental services were provided for one of four residents (Resident (R) 22) reviewed for dental services. This deficient practice had the potential to place R22 at risk of pain and discomfort and to increase the risk of unmet nutritional needs.Findings include:Review of the facility policy titled Dental Services/Oral Assessments, last reviewed on 12/27/2024, stated, It is the intent of this center to promote person-centered care through appropriate oral care and facilitation of dental services. Under the facility's guideline, The center provides or obtains oral health care and dental services to meet the needs of each patient to the extent covered under State law. Under the facility's procedure, Dental Services, if necessary or if requested by the patient, the center will assist the patient in making appointments. Under the facility's procedure, Oral Assessments, oral assessment should be completed on admission, annually, and as needed.Review of the Minimum Data Set (MDS) assessment for R22, dated 11/28/2025, revealed a Brief Interview for Mental Status (BIMS) score of 9 (indicating moderate cognitive impairment). Review of the Change of Condition assessment for R22, dated 11/14/2025, located under the EMR Data Collection tab, revealed that R22 still had some pain in his tooth.Review of the Change of Condition assessment for R22, dated 11/14/2025, located under the EMR Data Collection tab revealed that R22 was asked what was going on with his mouth and R22 opened his mouth to show an area to his right upper gum that is reddened and noted trace edema to the area and stated that it was difficult to chew on his right side. Resident was encouraged to chew on the other side until issue was resolved. R22 stated that he will try to remember to do that. Pain rated at 5/10 [indicating resident was experiencing moderate pain at the time] to the right upper side of the mouth, scheduled Tramadol (narcotic pain medication) and Orajel.Review of the Change of Condition assessment for R22, dated 11/15/2025, located under the tab Data Collection, revealed that R22 complained of pain to right upper teeth and gum area; and had darkened areas to gums and teeth and broken teeth.Review of R22's Medication Administration Record for the dates of 11/01/25 - 11/30/25, provided by the Administrator, revealed R22 was administered the medication Orajel on 11/14/2025 and 11/15/2025. Review of a progress note written by the Social Service Assistant (SSA) on 1/6/2026 and located in the EMR Progress Notes tab, stated, . it was brought to our concern that [R22] may be having tooth pain. ADON [Assistant Director of Nursing] assessed and [R22] complained of pain when he eats. SSA scheduled an emergency dental visit. Mobile dentist provider will call with the time and date of the visit.During an interview on 1/5/2026 at 11:26 am, R22 stated, The care is alright. I don't like the food, because I have a bad tooth on my right upper side [pointing to the right cheek]. I have told the Scheduling Coordinator (SC), just the other day I told her. I have a hole in that tooth. I haven't seen the dentist.During an interview on 1/6/2026 at 2:05 pm, the SSA stated, I have not requested dental visits for [R22] for the last twelve months. We also changed to a new mobile dentistry provider last September. Don't quote me, but I believe he also doesn't have enough money left for dental premiums after he pays for his room and board. I have to confirm that with the financial controller .During an interview on 1/6/2026 at 3:41 pm, the Financial Controller (FC) stated, [R22] has Medicaid with Supplemental Security Income (SSI) benefits only, and $70.00 is all that is left after his room and board is paid to the facility. The dental insurance premium is $155.00. If the nurses let the Administrator know that the resident needs a dental visit, the SSA or SC are notified to make that appointment.During an interview on 1/6/2026 at 4:22 pm, the SC stated, When [R22] complained of a toothache, I told the nurse. I can't remember what day that was, but I told the nurse. I told the Licensed Practical Nurse Supervisor (LPNS). He was also eating a lot of chocolate and candy. I don't do the scheduling for the services that come to the facility. I only do transportation scheduling. SSA coordinates the dental services that come to the facility.During an interview on 1/6/2026 at 4:32 pm, LPNS stated, Any nurse can make appointments for the resident. If it's for a specialist, like a cardiologist or urologist, I usually make an appointment. For mobile dentistry, it is usually the SSA who sends out the referral. I only take care of the consents and orders to hold blood thinners, for example, if the resident is on a blood thinner. The order needs to be signed by the Medical Director. If the appointment is for anything dental, the nurses notify the SSA.During an interview on 1/7/2026 at 12:08 pm, LPN2 stated, I notified SSA that [R22] was referred to the dentist by [Nurse Practitioner (NP)1].During an interview on 1/7/2026 at 12:25 PM, with SSA, with Administrator present in room, the SSA stated, If a resident needs a dental visit, even if they don't have dental insurance, I make the referral for emergency dental services and the facility will provide it and we do it as a fee-for-service, the facility will pay for the dental services provided.

Based on resident and staff interviews, record review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one of 18 residents (Resident (R) 48) reviewed for MDS in a total sample of 28 residents. This deficient practice increased the potential for missed opportunities for care or services. Findings include:Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, revealed the instructions for coding the tracheostomy care were to be coded . when performed while a resident of this facility and within the past 14 days . including if the resident performs the care.Review of R48's Face Sheet, undated and located in the electronic medical record (EMR) under the Face Sheet tab, indicated an admission date of 9/19/2022 and diagnoses included a permanent tracheostomy site. Review of R48's discharge, return anticipated MDS with an Assessment Reference Date (ARD) of 2/26/2025, located in the EMR under the MDS tab, revealed the tracheostomy care was not coded for special treatments/procedures. Review of R48's quarterly MDS with an ARD of 5/6/2025, located in the EMR under the MDS tab, revealed the tracheostomy care was not coded for special treatments/procedures.Review of R48's quarterly MDS with an ARD of 7/30/2025, located in the EMR under the MDS tab, revealed the tracheostomy care was not coded for special treatments/procedures.Review of R48's quarterly MDS with an ARD of 10/23/2025, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment). Further review revealed the tracheostomy care was not coded for special treatments/procedures.During an observation and interview on 1/6/2026 at 10:00 am, R48 was observed in her room, with her tracheostomy site clean, dry, and intact. R48 stated she was able to cover the opening of the tracheostomy to talk, and she did not require oxygen use with the tracheostomy.During an interview on 1/8/2026 at 11:00 am, Licensed Practical Nurse Assessment Coordinator (LPN) AC stated the MDS's on 2/26/2025, 5/6/2025, 7/30/2025, and 10/23/2025 were missed and should be coded to reflect R48's tracheostomy status. LPN AC stated the facility did not have a specific policy for following the MDS, and she follows the MDS manual for coding.

Based on interview, record review, and review of the facility's policy titled Fall Management, the facility failed to ensure residents were free from accidents and hazards as possible for one of three residents (R) (52) reviewed for accidents out of 21 sampled residents. Specifically, the facility assessed R52 required the assistance of two- staff persons for bathing; however, the resident was only assisted by one staff person when the resident fell from her bed. This failure caused R52 to sustain actual harm of a closed head injury with a laceration. Findings include: Review of the facility's policy titled, Fall Management review date of 12/29/2023, revealed each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). A plan of care is developed and implemented based on this evaluation with ongoing review. Review of R52's undated Face Sheet located in electronic medical record (EMR), under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, abnormalities of gait and mobility, and muscle weakness. Review of R52's annual Minimum Data Set (MDS), located in the EMR, under the MDS tab, with an Assessment Reference Date (ARD) of 4/17/2024, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. Additionally, R52 was assessed as being dependent (2-person assist) on staff for toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear, and required extensive/substantial assistance for all personal care. There were no falls noted prior to admission or after admission during this assessment. Review of R52's Comprehensive Nursing assessment dated [DATE], provided by the facility as evidence of a Fall Assessment prior to resident's fall revealed Functional Status: . Does the patient need assistance moving from sitting to lying position in bed? Yes. If the patient has difficulty from sit-lying [sic] in bed, answer the following. Staff completes all of the tasks .If the patient need assistance moving from lying to sitting position on the side of the bed, answer the following. Staff completes all of the tasks. If the patient needs assistance with toileting hygiene, answer the following. Staff completes all of the tasks .Care Plan consideration- all items checked below will trigger to care plan. Activities of Daily Living [ADLs]: Two people assist with transfers. Review of the Event Quality Assessment Performance Improvement (QAPI) Tool, dated 4/28/2024 and provided by the facility revealed Description of event: summoned to room per nursing assistant to assist with resident who had fallen off bed during bed bath. Entered room and noted resident lying on right side between bed and heating/cooling unit. Head to toe assessment revealed a one inch cut to right side forehead with moderate amount of bleeding noted. Pressure applied to control bleeding. Resident assisted off floor and onto bed. PERRL [pupils equal, round, reactive to light]. Alert and oriented times three. Resident stated that she got dizzy when she rolled during bath and resulted in fall. Review of the Emergency Department Record, dated 4/28/2024, located in the EMR under the Scanned Documents tab, revealed Clinical Impression: closed head injury, forehead laceration. During an interview on 8/27/2024 at 10:10 am, Certified Nursing Assistant CNA 1 was asked to describe the incident with R52. CNA1 stated she was giving her [R52] a bed bath, turned her towards the window, [R52] was holding onto the bottom of mattress, there were no fall mats, or siderails on the bed. CNA1 added R52 stated she couldn't hold onto the mattress any longer and rolled out of bed. When CNA1 was asked if she should have had additional assistance, CNA1 stated she normally gave R52 her bath herself, but she should have had another person to help. CNA1 further stated she was just trying to get done. During an interview on 8/27/2024 at 1:41 am, R52 was asked if she recalled falling out of bed? R52 stated Yes. Continued interview revealed the nurse's aide was giving her a bed bath, she became dizzy and fell out of bed and hit her head on the air conditioner. R52 also stated it did not help that there was no sheet on her bed, and the mattress was slippery without it (It should be noted resident is not on a specialized mattress). When asked how many staff members usually completed her bed bath, R52 stated, they always use two nurse aides to give me a bed bath. During an interview conducted on 8/27/2024 at 2:23 pm, stated she was familiar with R52. When asked how many staff members was needed to provide care for R52, CNA2 stated, we usually use two staff members for turning, and repositioning, and for her bed baths, because she [R52] has no use of her left arm, and her right arm is weak. During an interview on 8/27/2024 at 2:30 pm, the Director of Nursing (DON) confirmed R52 had been assessed as being an extensive assistance of two persons, per R52's MDS. The DON stated she would have expected two staff members would have given R52's bed bath based on the comprehensive assessments, and care plans. The DON agreed that CNA1 made a bad judgement call while giving R52's bed bath that resulted in the resident falling and sustaining an injury. During an interview on 8/27/2024 at 2:40 pm, the Administrator stated it was her expectation if R52 was assessed as needing two-person assistance, then she would expect that two staff members would give her the bath.

Based on interview, record review, and facility policy review titled Patient's Plan of Care, the facility failed to ensure the development of care plans were person centered and detailed the care assistance residents needed for Activities of Daily Living (ADLs) for one of three residents (R) (52) reviewed for accidents and hazards. R52's care plan failed to indicate the amount of assistance needed to prevent falls. The facility assessed R52 to require the assistance of two staff persons for bathing; however, the resident's care plan did not indicate the number of staff the resident needed for bathing assistance. During a bed bath, R52 was only assisted by one staff person, even though the facility assessed the resident to need two staff persons. This failure caused actual harm to the resident, when the resident fell out of bed during the bed bath and sustained a closed head injury and a laceration. Findings include: Review of the facility's policy titled, Patient's Plan of Care dated 12/29/2023, revealed the facility's intent to promote person-centered patient care through a comprehensive care plan. Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, and mental and psychosocial needs. Review of R52's undated Face Sheet located in electronic medical record (EMR), under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, abnormalities of gait and mobility, and muscle weakness. Review of R52's Care Plan located in the EMR under the Care Plan tab, revealed the resident was a Fall risk, reviewed, and continued on 7/23/2024, as evidenced by always incontinent (urine) [dated 6/28/2023], transfer: total dependance, problem with balance, interventions included, but not limited to provide appropriate level of assistance to promote safety of resident. Review of R52's Comprehensive Nursing assessment dated [DATE], provided by the facility as evidence of a Fall Assessment prior to resident's fall revealed Functional Status: . Does the patient need assistance moving from sitting to lying position in bed? Yes. If the patient has difficulty from sit-lying [sic] in bed, answer the following. Staff completes all of the tasks .If the patient need assistance moving from lying to sitting position on the side of the bed, answer the following. Staff completes all of the tasks. If the patient needs assistance with toileting hygiene, answer the following. Staff completes all of the tasks .Care Plan consideration- all items checked below will trigger to care plan. Activities of Daily Living (ADLs): Two people assist with transfers. During an interview on 8/27/2024 at 10:10 am Certified Nursing Assistant CNA1 she normally gave R52 her bath without any other staff's assistance; however, she should have had another person to help. CNA1 further stated she was just trying to get the resident's bath done. During an interview on 8/27/2024 at 1:41 am, R52 stated she remembered falling out of the bed. When asked how many staff members normally assisted her with her bed bath, R52 stated, they always use two nurse aides to give me a bed bath. During an interview on 8/27/2024 at 2:23 pm when asked if she was familiar with R52, CNA2 stated, Yes. When asked how many staff members it took to provide care for R52, CNA2 responded we usually use two staff members for turning, and repositioning, and for her bed baths, because she [R52] has no use of her left arm, and her right arm is weak. During an interview on 8/27/2024 at 2:30 pm, the Director of Nursing (DON), confirmed the resident had been assessed as being an extensive assistance of two persons for bathing, per the resident's care plan. During an interview on 8/27/2024 at 2:40 pm, the Administrator stated she would have expected the staff to follow the plan of care in providing resident care. The Administrator also stated if R52 was assessed as needing two people to assist with bathing, then she should have had two staff members giving her the bath. Cross reference F689

Based on observation, interview, record review, and review of the facility's policy titled Skilled Nursing Services, Hand Hygiene, the facility failed to ensure an effective infection control and prevention program was implemented during medication pass for four of 11 residents (R) (43, 38, 17, and 57) reviewed for medication administration. Specifically, the nurse failed to ensure proper hand hygiene practices were implemented dur the administration of medication. This failure could promote the spread of multi drug resistant organisms (MDROs) throughout the facility. Findings include: Review of the facility's policy titled, Skilled Nursing Services, Hand Hygiene, revised on 12/29/2023, indicated, under the section Intent: It is the intent of this facility to promote and facilitate appropriate hand washing .GUIDELINE .Associates should use alcohol based hand rub or wash hands with soap and water for the following indications: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device or handling indwelling devices). Before moving from a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal, unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in absence of a sink, are an effective method of cleaning hands. Wash hands with soap and water when visibly soiled. After caring for someone with known or suspected diarrhea. After known or suspected exposure to spores (e.g. B. anthracis, C difficile). Gloves should not be used as a substitute for hand hygiene. lf your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves Review of the facility training document titled, Hand Hygiene Competency Validation, used revealed staff was evaluated monthly on the three areas of hand hygiene opportunities, performing hand hygiene with soap and water, and performing hand hygiene with alcohol-based hand rub (ABHR). Review of the facility training document titled, Hand Hygiene Observation Tool, revealed it was used to record the staff's skill check off performing hand hygiene using ABHR and washing hands with soap and water 1.Review of R43's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/2024, located in the EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R43 was severely cognitively impaired. During an observation on 8/26/2024 at 1:20 pm in R43's room, Licensed Practical Nurse LPN1 performed hand hygiene, donned gloves, administered Eye Drops, one drop to each of R43's eyes. LPN1 doffed the gloves, disposed of the gloves into R43's bathroom trash can, and left R43's room without performing hand hygiene prior to leaving room. Continued observation revealed LPN1 unlocked the medication cart, put R43's eye drops back into the cart, and logged into the laptop EMR to move onto the next resident preparing her medication. 2. During an observation on 8/26/2024 at 1:26 pm, LPN1 obtained one tramadol [medication used to treat pain] 50 milligram (mg) tablet from the narcotic box in med cart and poured a cup of water without performing hand hygiene first. LPN1 then knocked on R38's door, entered her room, and administered R38 her tramadol medication with the cup of water. R38 poured the medicine cup containing tablet into her mouth and took a drink of water. R38 gave an empty medicine cup and the cup with remaining water back to LPN1. LPN1 set the water cup down on R38's bedside table next to her, tossed the medicine cup in trash, and left R38's room without performing hand hygiene prior to leaving room. LPN1 was observed unlocking the medication cart and logging into laptop to move onto next resident preparing his medication. 3. During an observation on 8/26/2024 at 1:32 pm, LPN1 obtained a Sodium Bicarbonate (antacid that neutralizes stomach acid and relieves heartburn and indigestion) 650 mg tablet from the medication cart, crushed and mixed the medication with vanilla pudding in a medicine cup, and poured a cup of water without performing hand hygiene first. Continued observation revealed LPN1 knocked on R17's door, entered his room, administered R17 his mixture of medicine and pudding from a wooden depressor/spoon, and gave R17 a drink of water. LPN1 collected an empty cup from R17's bedside table, went to the bathroom, tossed the empty medicine cup and two water cups in the trash. LPN1 left R17's room without performing hand hygiene prior to leaving room. LPN1 was observed unlocking the medication cart and logging into laptop to move onto next resident preparing his medication. 4. During an observation on 8/26/2024 at 1:41 pm, R57 was lying in her bed. Continued observation revealed LPN1 obtained one hydrocodone (narcotic pain medication) 10 mg/acetaminophen 325 mg tablet from the narcotic box in medication cart and poured a cup of water without performing hand hygiene first. LPN1 then knocked on R57's door, entered her room and administered R57 her medicine in a medicine cup with the cup of water. R57 poured the medicine cup containing the tablet into her mouth and took drink of water. R57 gave an empty medicine cup and the cup with the remaining water back to LPN1. LPN1 removed a partially full water cup from her bedside table and tossed them all into the bathroom trash. LPN1 left R57's room without performing hand hygiene prior to leaving room. LPN1 was observed unlocking the medication cart and logging onto the laptop to move onto the next resident preparing his medication. During an interview on 8/26/2024 at 1:45 pm, when asked what step he forgot to do in between each resident, LPN1 stated, Oh I forgot to wash my hands. LPN1 also stated, And I always remember to do hand hygiene any other time. During an interview on 8/26/2024 at 2:35 pm, the Director of Nursing (DON) stated, Staff are expected to use hand sanitizer or wash their hands anytime they touch something dirty, before and after providing care of a resident, and when they don and doff gloves. I expect them to use soap and water after every third time unless they're visibly soiled or wet. During an interview on 8/26/2024 2:40 pm, the Infection Control Preventionist (ICP) stated, My expectation is that staff perform hand hygiene prior to care and every time they leave a resident's room from doing care. I expect them to use soap and water when their hands are visibly dirty, before and after eating and after using the restroom. I also train them to use soap and water after using hand sanitizer three times. During an interview on 8/27/2024 10:55 pm, the Administrator stated, The expectation is that staff use hand sanitizer or wash their hands between every resident and whenever providing care. They need to wash their hands after every third time using hand sanitizer or if they're visibly dirty.

Based on observations, staff interviews, and a review of the facility policy titled Allocation of Human Resources Nursing Staff, the facility failed to have sufficient nursing staff in the secure unit during meals to ensure a resident (R) (R5) was not taking other residents' food or beverages and to ensure there was adequate staff to provide the residents with beverage refills. There were 11 residents residing in the secure unit. The deficient practice had the potential to place the residents at risk for unmet care needs. Findings include: A review of the policy titled Allocation of Human Resources Nursing Staff, with a review date of 12/29/2023, revealed the Intent stated: It is the intent of this center to allocate nursing staff to meet nursing needs of patients. During the lunch observation on the secure unit on 2/21/2024 at 12:43 pm, there was one Certified Nursing Assistant (CNA) supervising 11 residents who resided on the unit. There were two rooms across the hall from each other that were designated for dining. The CNA was in one room feeding a resident which also had five additional residents, and three residents were eating in the room across the hall. R5 was observed taking a cup of coffee from R3 and drinking from the cup as he left the room. The CNA had to stop feeding a resident to take the cup of coffee from R5 and open the door to the main portion of the building to request a cup of coffee for R3. At 1:15 pm, R5 once again took the second cup of coffee from R3. The CNA had to stop feeding the same resident to take the cup from R5 and place the cup on the tray cart. After the CNA sat down to start feeding the resident again, R5 took the dirty cup from the cart and walked down the hall. During the same observation, the residents were served one glass of tea with their meal. Nine of the residents consumed all their tea and were not offered refills. During the lunch observation on 2/22/2024 at 12:35 pm, four residents were eating in the secure unit. The Director of Nursing (DON) was observed feeding one resident and one CNA was assisting other residents. Three of the residents drank all their tea. The CNA left the secure unit, returned with a pitcher of tea, and refilled the resident's glasses. During an interview with CNA AA on 2/26/2024 at 3:55 pm, she stated since the DON was assisting with the lunch meal on 2/22/2024 she was able to leave the unit to get a pitcher of tea to refill the resident's glasses. During the lunch observation on 2/26/2024 at 12:45 pm, there was only one CNA in the secure unit supervising four residents in the dining area while feeding one of the residents. Three of the residents had consumed all their tea, but no refills were offered before the trays were removed. During an interview with CNA FF on 2/21/2024 at 1:20 pm, she stated that she used to work in the secure unit and that it was hard to keep eyes on all the residents because only one staff person was working on the unit. She stated when she would be feeding a resident, she would have to stop to prevent R5 and another resident from taking food and drinks off other resident's trays. During an interview with CNA AA on 2/21/2024 at 1:30 pm, she stated there was usually just one person working in the secure unit. She stated there used to be two staff in the unit but for the past few years, there had only been one person in the unit. She stated during meals it was just her, and she had to watch R5 and another resident because they took other resident's drinks and food from their trays. She further stated while she provided showers for the residents, there was no other staff to monitor the other residents in the secure unit. During an interview with the DON on 3/5/2024 at 1:40 pm, she stated for years they had two people working in the secure unit, but they have had problems with staffing for several months. She stated ideally, she would assign two staff in the unit.

Based on observations, staff interviews, and review of the facility policy titled Hydration, the facility failed to offer additional fluids to residents on one of three units, the secure unit, during two of three lunch meals observed. The deficient practice had the potential to prevent the maintenance of adequate hydration status of the 11 residents residing in the secure unit. Findings include: A review of the policy titled Hydration, with a review date of 12/29/2023, stated the policy Intent was: It is the intent of this center to provide patients with adequate hydration to assist in maintaining proper hydration and health, while honoring preferences. The Guideline section included: Hydration will be served on all meal trays and available throughout the day. Hydration will be consistent with the patient's needs and desires. A variety of items will be available to meet hydration needs and patient preferences. Nursing will provide ice water each shift, unless contraindicated. During an observation of the lunch meal served on the secure unit on 2/21/2024 from 12:43 pm to 1:30 pm, eight residents were observed eating lunch in the two designated dining areas on the secure unit and three residents ate in their rooms. The residents were only served one glass of tea with the meal. Nine of the residents had consumed all their tea and were observed attempting to drink more tea from the empty glasses. The residents were not offered refills of tea or additional fluids before removing the trays. During a subsequent observation of the secure unit on 2/26/2024 at 12:45 pm, four residents were eating in the secure unit while the remaining seven residents ate lunch in the main dining room of the facility. The four residents eating lunch in the secure unit were served one glass of tea. Three of the residents had consumed all their tea and were observed attempting to drink more from the empty glass. No refills or additional liquids were offered before the trays were removed. During observations of all the resident rooms on the secure unit on 2/21/2024 at 1:30 pm, 2/22/2024 at 12:35 pm, and 2/26/2024 at 12:45 pm, there were no cups or pitchers of water in the resident rooms. During an interview with Certified Nursing Assistant (CNA) AA on 2/26/2024 at 3:55 pm, she stated that the residents did not have water in their rooms because there were two residents in the secure unit who went into the rooms and took the cups of water and drink them all. During an interview with the Director of Nursing on 3/5/2024 at 1:40 pm, she stated they don't keep cups of water in the secure unit anymore due to infection control concerns. She stated there are residents in the unit who will take the cups of water out of resident rooms and drink them. She stated the staff should make sure the residents have water during the hydration rounds.

Based on observation, staff interviews, record review, and review of an instructional document titled Enhanced Barrier Precautions, published by the Center for Disease Control and Prevention (CDC), the facility failed to ensure that nursing staff wore Personal Protective Equipment (PPE) following recommended practice and failed to ensure Activities of Daily Living (ADL) care was provided in a sanitary manner for one resident (R) (R15), from a sample of 16 residents. These deficient practices had the potential to increase R15's risk of infection. Findings include: A review of R15's clinical record revealed diagnoses included but were not limited to, neurogenic bladder and quadriplegia. A review of the 12/8/2023 Quarterly Minimum Data Set (MDS) assessment revealed that R15 was assessed as having an indwelling urinary catheter and being incontinent of bowel. A review of the care plan revealed a care area of a self-care deficit and needed assistance from staff with ADL care. Interventions assigned to the Certified Nursing Assistant (CNA) and Nurse included PPE when providing care. The care plan also revealed that R15 had a suprapubic catheter. During an observation of ADL care on 3/5/2024 at 1:55 pm, an instructional sign titled Enhanced Barrier Precautions, published by the CDC was posted on the door to R15's room. The directions on the sign included that everyone must clean their hands, including before entering and when leaving the room. The sign also alerted providers and staff to wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care. During the 3/5/2024 1:55 pm observation, CNA DD donned a gown and gloves upon entering the resident's room. CNA CC did not put on a gown. When CNA DD asked CNA CC if he was going to put a gown on, he stated no, that he thought that was just for wound care. Both CNAs then assisted R15 with personal hygiene tasks, emptying the suprapubic catheter drainage bag, dressing, bowel incontinence care, and a transfer out of bed to the wheelchair. In addition, during the provision of bowel incontinence care, CNA CC removed old barrier cream and feces from R15's buttocks with disposable wipes. However, he failed to change his soiled gloves before picking up a clean adult brief, picking up the tube of barrier cream from a shelf, and applying a new coat of barrier cream to R15's buttocks. During an interview on 3/5/2024 at 3:40 pm, the Director of Nursing (DON) stated that R15 was on enhanced barrier precautions because of her suprapubic catheter. During an interview on 3/5/2024 at 4:02 pm, the DON stated she would address the infection control concerns.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled Suprapubic Catheter Care, the facility failed to ensure that nursing staff provided routine indwelling urinary catheter care for one resident (R) (R15), from a sample of 16 residents. This deficient practice had the potential to increase R15's risk of urinary tract infection. Findings include: A review of the policy titled Suprapubic Catheter Care, with a review date of 12/29/2023, revealed the intent of the policy was to provide guidelines for the care of new and established suprapubic catheters. The Guideline section included a line that stated: Clean the insertion site and catheter daily with soap and water. A review of R15's clinical record revealed that she had diagnoses that included but were not limited to, neurogenic bladder, and quadriplegia. A review of the 12/8/2023 Quarterly Minimum Data Set (MDS) assessment revealed that R15 was assessed with a Brief Interview for Mental Status (BIMS) of 11 (indicating moderate cognitive impairment) and having an indwelling urinary catheter. A review of the care plan revealed a care area of a suprapubic catheter, with an intervention dated 10/6/2022 to monitor and clean skin under and around the external catheter and check for redness/skin breakdown. The intervention was assigned to the Nurse and Certified Nursing Assistant (CNA). A review of physician's orders revealed orders to change the suprapubic catheter every month on the 28th day and as needed when it was clogged. A review of the February 2024 Medication Administration Records (MAR) and February 2024 Treatment Administration Records (TAR) revealed that the suprapubic catheter was most recently changed as ordered on 2/28/2024. However, there was no evidence in the clinical record that daily catheter care was provided. During an interview on 3/5/2024 at 10:30 am, when R15 was asked if anyone cleaned her urinary catheter tubing, she stated no, but that it was changed once a month. During an observation of Activities of Daily Living (ADL) care on 3/5/2024 at 1:55 pm, CNA CC and CNA DD assisted R15 with personal hygiene tasks, emptying of the suprapubic catheter drainage bag, dressing, bowel incontinence care, and a transfer out of bed to the wheelchair. However, catheter care was not provided. During the observation, when questioned about who cleans RA's urinary catheter tubing, CNA CC stated that the nurses do and that he only empties the catheter bag. During an interview on 3/5/2024 at 3:40 pm, when questioned about when the suprapubic catheter was cleaned, the Director of Nursing (DON) stated that it was cleaned with perineal care. When asked if it was the Nurse's or CNA's responsibility, the DON stated it was the CNA's. During an interview on 3/5/2024 at 3:45 pm when RA's nurse, Licensed Practical Nurse (LPN) EE, was asked who cleans R15's urinary catheter tubing, she stated she was unsure.

Based on observation, staff interviews, and a review of the facility policy titled, Information Technology - Safeguarding and Storage of Protected Health Information (PHI), the facility failed to ensure resident medical records for disposal were kept securely for 57 residents. Findings include: A review of the facility policy, Information Technology - Safeguarding and Storage of Protected Health Information (PHI), policy number HIPAA 164.530, dated 2021, revealed the facility was to maintain PHI in a safe and secure location that is easily accessible for authorized use, limit unauthorized access, and safeguard against loss and tampering of PHI. A further review revealed that records/PHI would not be kept in public areas, and when unattended, PHI would be stored in a locked office or storage. A review of the facility's shredding service invoice, ticket number 450221, revealed that the company picked up documents from the facility on 1/16/2023 at 10:05 a.m. and was scheduled to service the facility again on 4/10/2023. An observation of the document disposal containers on 1/29/2023 at 8:49 a.m. revealed four large blue containers stored outside the facility's rear entrance. All four containers were labeled with the name of the company that provided shredding service to the facility. All four containers were open and without a locking mechanism. Inside the containers were copious amounts of resident medical record information and medication labels with names, dates of birth, and medical record numbers. A further observation of the area revealed an approximately four-foot-tall chain link fence surrounded the back of the facility property, with housing noted beyond the fence. Interview on 1/29/2023 at 8:51 a.m. with the Assistant Director of Nursing (ADON), she stated that FT AA would come by weekly and pick up any documents from all the offices and dispose of them into the shredding containers, which were stored outside. Interview on 1/29/2023 at 8:55 a.m. with the Maintenance Supervisor (MS), he acknowledged that all four document containers were unlocked and stated they were supposed to be locked. He noted that the shredding service would come to the facility every three months and remove the documents from the shredding containers and ensure the containers were locked after removing the documents. The MS stated he should have checked the containers to ensure they were secured, and he just assumed they were locked. He explained that FT AA collected the documents from individual bins in each office and deposited them into the shredding containers, which were stored outside. Interview on 1/29/2023 at 9:10 a.m. with the Administrator, he stated the document containers were supposed to be locked and acknowledged the containers were not locked. The Administrator explained that FT AA and the Maintenance Supervisor picked up any documents from each office every week and then deposited the documents into the shredding containers outside.

Based on observations, staff interviews, and a review of the facility policies titled, Storage Areas and Cleaning and Sanitizing, the facility failed to securely close open food items in the dry storage; remove dented cans from potential use; and demonstrate proper sanitizing practices with the three-compartment sink for 54 of 57 residents consuming an oral diet. Findings include: Review of the policy titled Storage Areas revealed that items should be covered, sealed, labeled, and dated appropriately. Dry storage and dented cans should be stored separately in a clearly labeled area. Review of the policy titled Cleaning and Sanitizing revealed that three-compartment sink items should be fully submerged in the sanitizer solution according to the manufacturers' guidelines. Observation on 1/27/2023 at 8:55 a.m. of the dry storage area revealed an opened 22-ounce bag of orange beverage drink mix that was not securely closed. Continued observation revealed a plastic bin with dried pasta, this bin contained an open bag of elbow macaroni and two bags of spaghetti noodles that were opened and were not securely closed or wrapped. Further observation of the dry storage area revealed two large cans of diced green chiles with large dents on the side. Both cans were located on a shelf with other canned food items. Interview on 1/27/2023 at 9:08 a.m. with the Dietary Manager (DM) confirmed that the orange drink mix, elbow macaroni, and two bags of spaghetti noodles were all opened and not securely closed/wrapped. The DM revealed she expects staff to properly close opened items before storing. The DM also confirmed that the two large cans of diced green chilies were dented on the shelf. The DM stated that staff should have placed the dented cans in a separate bin and away from the other food cans. Review of the Manufactures' product specification for multi-Quat Sanitizer revealed: expose all surfaces to the sanitizing solution for a period of not less than 1 minute. Observation on 1/28/2023 at 10:45 a.m. of Cook BB using the three-compartment sink revealed she washed dishware items with soapy water, rinsed with running water, then submerged in sanitizing solution for ten seconds and placed them on a surface to air dry. Interview on 1/28/2023 at 10:45 a.m. with Cook BB confirmed that she only had the dishware in the sanitizing solution for ten seconds. Cook BB revealed that she usually has the dishes in the sanitizing solution longer. Interview on 1/28/2023 at 10:45 a.m. with DM confirmed that the facility uses a quaternary sanitizing solution in the three-compartment sink. In addition, the DM revealed that she expects staff to leave dishware items in the sanitizing solution for at least 60 seconds for proper sanitizing.

Based on observation, record review, staff interview, and review of facility policy titled, Medication Administration - General and Enteral Tube Medication Administration, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 28 medication opportunities were observed, and there were six errors for one of five residents (R) (R #5), for an error rate of 21.43%. Findings include: Review of the facility policy titled Medication Administration - General dated 2019 revealed the intent of the policy is to ensure medications are administered as prescribed, in accordance with good nursing principle. Medications are administered in accordance with a valid prescriber order. Prior to medication administration: the nurse should read the administration directions on the MAR (medication administration record) and verify correct medication, dose, and directions for use. Review of the facility policy titled Enteral Tube Medication Administration dated 2019 revealed it is recommended that crushed medications not be combined and given all at once via feeding tube in order to avoid obstructing the tube and to ensure the complete delivery of each medication. On 1/28/2023 at 8:15 a.m., Licensed Practical Nurse (LPN) CC was observed giving R#5 their 9 a.m. medications which included Baclofen 10 milligrams (mg) 1 tab (tablet), amlodipine 10 mg 1 tab, carvedilol 25 mg 1 tab, famotidine 20 mg 1 tab, and Eliquis 5 mg 1 tab given via gastrostomy tube (g-tube). LPN CC crushed each medication separately and then combined in a cup. LPN CC also prepared Lactulose 30 milliliters (ml) (10 gram/15 ml) and combined in the same cup. Further observation revealed LPN CC disconnected the g-tube from the water flush, poured the mixture of medications in the tube, then reconnected the water flush. Record review of R#5's January 2023 Physician Orders revealed the following orders: Baclofen 10 mg 1 tablet g-tube every 4 hours; amlodipine 10 mg 1 tablet g-tube one time per day; carvedilol 25 mg 1 tablet g-tube two times per day; famotidine 20 mg 1 tablet g-tube two times per day; Eliquis 5 mg 1 tablet g-tube two times per day (DO NOT CRUSH, MAY DISSOLVE IN 60 ML OF WATER); and lactulose 10 gram/ 15 ml 30 grams g-tube one time per day. LPN CC failed to administer the crushed medications separately, failed to administer the correct dose of lactulose, and failed to follow the instructions for dissolving the Eliquis in water. Interview on 1/28/2023 at 8:45 a.m. with LPN CC, revealed she is an agency nurse. She stated she does not receive education through the facility but through her agency. She revealed the facility does have them sign off on policies. She stated she has always crushed the medications separately but administers them all together as one through the g-tube. Interview on 1/29/2023 at 11:40 a.m. with the Director of Nursing (DON), revealed the nurse administering the medications is responsible for giving the medications appropriately and verifying the physician orders.

Based on record review, staff interviews, and review of the facility document titled, Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to ensure a bed hold notice was provided at the time of transfer to a hospital for one of three residents (R) (R#16) reviewed for hospitalization . Findings include: Review of the facility document titled Bed Hold During Hospital Stays and Therapeutic Leaves dated 2020 revealed that it is the intent of this nursing center to offer all patients . the choice of either paying the appropriate amount to hold the bed when the patient goes to the hospital .or releasing the bed and being readmitted to the first appropriate available bed . A letter must be mailed to the patient and/or responsible party within 24 hours of the patient's admission to the hospital . Record review for R#16 revealed no evidence of a bed-hold notice for this resident when she was hospitalized on [DATE] through 3/25/21. During an interview on 5/20/21 at 10:51 a.m., R#16 revealed that the facility did not notify her of the Bed Hold policy when she was admitted to the hospital on 3/16/21. She stated the facility did call her family to let them know that she was going out to the hospital. The 4/29/21 Quarterly Minimum Data Set Assessment revealed R#16 had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition intact. Interview with the Social Service Director on 5/20/21 at 9:30 a.m. revealed nursing is responsible for sending out Bed Hold policies with residents upon transfer to the hospital. Interview with the Financial Controller on 5/20/21 at 10:00 a.m. revealed nursing is responsible for filling out the Bed Hold form and sending it with the residents when they are sent to the hospital. Further interview with Financial Controller revealed she fills out a Bed Hold During Hospital Stays and Therapeutic Leaves form after seven days of the resident being in the hospital. She stated the bed hold policy is in the admission packet and residents and/or representative signs it on admission. Interview with Licensed Practical Nurse (LPN) GG on 5/20/21 at 11:00 a.m. revealed a Bed Hold policy should be sent out with each resident upon transfer to the hospital, and it is part of the transfer paperwork. Interview with the Administrator on 5/20/21 at 11:25 a.m. revealed that most of the time residents go out to the hospital and return but even if they do not return, they do not give their beds away. During an interview on 5/20/21 at 11:33 a.m., the Regional Vice President confirmed that the Bed Hold policy should have been sent with the resident to the hospital. She stated the Bed Hold policy is in the admission packet and is signed by resident/representative on admission.

Based on record review and staff interview, the facility failed to update care plan interventions to include a nutritional supplement to address weight loss for one resident (R) (R#45) of 10 residents receiving a dietary supplement. Findings include: Record review revealed R#45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#45 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Section G-Functional Status documented the resident required one person supervision with eating. Section K- Swallowing and Nutritional Status revealed no significant weight loss. Review of the May 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for R#45 last reviewed on 4/13/2021 revealed the resident has altered nutritional status related to fair appetite, medications, and history of COVID-19. The care plan was initiated on 1/27/2021 with interventions including to allow to eat at own pace, allow extra time during meals, monitor weight, observe for dehydration, observe oral intake of food, provide daily multivitamin with minerals as ordered, provide diet as prescribed, provide favorite foods and beverages, provide necessary assistance with food and fluids, and update patient's food preferences. The care plan was updated on 4/10/2021 to include the need for a mechanically altered diet. There were no other updates to the care plan and no evidence that the care plan was updated to include the use of a House Supplement. During an interview on 5/20/2021 at 9:04 a.m., the Interim Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that interventions for weight loss, including dietary supplements, should be addressed on the resident's care plan. An interview on 5/20/2021 at 11:10 a.m. with the MDS Coordinator revealed she conducts MDS Assessments and updates the care plans as needed. If a problem arises, she will update the care plan as needed. She attends the daily clinical meetings and gets information she may need to update the care plan. She confirmed that the supplement to address weight loss was not added to the care plan for R#45. Cross refer to F692.

Based on observation, record review, staff interview, and review of the facility policy titled Nutrition Screening, Assessment, and Monitoring the facility failed to ensure the Registered Dietician's (RD) recommendations were implemented for one resident (R) (R#45) of 10 residents receiving a dietary supplement. Findings include: Review of the undated facility policy titled Nutrition Screening, Assessment, and Monitoring revealed: 2. The Registered Dietician will complete a nutritional assessment after admission, annually, and as determined by the patient's needs and plan of care. b. The Registered Dietitian will make nutritional recommendations to the attending Physician. Record review revealed R#45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#45 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Section G-Functional Status documented the resident required one person supervision with eating. Section K- Swallowing and Nutritional Status revealed no significant weight loss. Review of the weights for R#45 revealed the following: 1/8/2021 (on admission) - 115.4 pounds (lbs.) February 2021 - resident refused weight. 3/2/2021 - 105 lbs. 4/1/2021 - 103 lbs. May 2021 - resident refused weight. Review of the medical record for R#45 revealed multiple Nurses Notes related to refusing medications, refusing meals, and refusing to put in hearing aids. An RD Note dated 4/19/2021 revealed notes including but not limited to the following: a significant change; mechanical soft diet with ground meats; House Supplement 90 milliliters (ml) by mouth three times per day; appetite fair (25% - 50%) to poor (less than 25%); resident has low body mass index (BMI) of 20, current weight of 103 lbs., resident with trending weight loss. Recommendation was to increase House Supplement to 150 ml three times per day. Review of the Physician Orders for May 2021 for R#45 revealed: multivitamin with minerals tablet take one tablet by mouth one time per day for supplement; [MEDICATION(S)] 15 milligrams (mg) tablet half tablet by mouth daily, take half tab (7.5 mg) for appetite stimulant; House Supplement 90 ml by mouth three times per day. There was no evidence that the RD recommendation to increase the House Supplement to 150 ml three times per day on 4/19/2021 was communicated to the Physician. Review an RD Note for R#45 dated 5/19/2021 (during the survey) revealed notes including but not limited to the following: a significant change; mechanical soft diet with ground meats; supplement order; multivitamin with minerals tablet one tablet by mouth daily, House Supplement 90 ml by mouth three times per day; appetite fair (25% - 50%) to poor (less than 25%); resident has low BMI of 20, weight 103 lbs., trending weight loss, stable for 120 days. Recommendations included to increase House Supplement to 120 ml (now 120 instead of the original recommendation of 150) three times per day. An observation of R#45 on 5/20/2021 at 8:00 a.m. revealed resident in bed and had refused her breakfast tray. An interview on 5/20/2021 at 8:35 a.m. with Certified Nursing Assistant (CNA) AA revealed R#45 usually does not eat any breakfast. An interview held on 5/20/2021 at 8:37 a.m. with Licensed Practical Nurse (LPN) BB revealed R#45 usually accepts her supplements if she is awake. If she is asleep, she will offer it to her later. She loves anything sweet and has snacks brought in by her family. Three of her grandchildren work at the facility and bring her food to eat that she likes. An interview was conducted on 5/20/2021 at 9:04 a.m. with the Interim Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON stated her expectations were that any recommendations the RD makes should be brought to the Physician's attention and orders written if needed. The ADON revealed she was aware of the resident weight loss. She indicated the resident has had weight loss, refuses food, and has refused to be weighed. She usually prints the RD notes and looks for recommendations, informs the Physician and family and writes orders as needed. She verified the RD recommendation to increase the supplement dated in April 2021 were not ordered. She noted the recommendation from RD visit on 5/19/2021 and had a note to go over with the Physician or Nurse Practitioner (NP). She indicated the resident had the initial weight loss after admission but has stayed stable. The resident has refused to be weighed at times. She was started on a multivitamin and was put on 90 ml supplement three times per day after admission.

Based on observation, record review and interview the facilty failed to label medication with an expiration date on one of three medication carts, failed to discard expired medication in one of one medication storage rooms and failed to administer medications in a safe manner due to leaving one medication cart unlocked and leaving medication unattended on the medication cart, by one of two licensed practical nurse (LPN), on one of three halls. The sample size was 35. Findings include: 1. Observation on 8/14/18 at 10:03 a.m. of medication administration with Licensed Practical Nurse (LPN) AA the surveyor inquired as to the expiration date for a medication, Oxycod/APAP 10 milligrams (mg)/325 mg (1) by mouth, because the expiration date could not be located on the pill card. LPN AA stated that she could not see where the expiration date was and she was not sure what pharmacy the facility used but stated she thought that it looked like a local pharmacy pill card. LPN AA confirmed that it was the last pill in the card for the resident and stated that she would not know how to know if the medication was expired. An interview on 8/14/18 at 10:30 a.m. with the Director of Nursing (DON) reported that the medication came from the local pharmacy and it would be labeled and have an expiration date when it came from the pharmacy. However, on the the pill card there was not an expiration date. Observation and interview on 08/16/18 at 11:14 a.m. with the Director of Nursing (DON) in the medication room revealed that the medication room was untidy and cluttered. A plastic box with Intravenous lines and [MEDICATION NAME] and saline flushes was observed. Inside the box contained expired drugs that included two (2) [MEDICATION NAME] 5 milliliter intravenous flush that expired (MONTH) (YEAR) and one (1) [MEDICATION NAME] 5 milliliter intravenous flush and saline flush that expired (MONTH) (YEAR). The DON confirmed that the syringes of [MEDICATION NAME] and saline were expired and stated that the nurses are responsible to check and discard the expired drugs. Review of the facility policy, Medication Storage in the Care Center: Procedural Guidelines: Medications and biological are stored safely, securely and properly. 1. The provider pharmacy dispenses medications in containers that meet legal and manufacturers requirements. 3. Medication storage areas are kept clean, and free of clutter. 18. Outdated medications are immediately removed from stock, disposed of according to procedures for medication destruction. Review of the facility policy Medication Administration-General Guidelines: Procedural Guidelines; 14. The expiration date of the medication should be checked prior to administering a drug. 2. Observation on 8/14/18 at 9:54 a.m. of Licensed Practical Nurse (LPN) AA on the 100 hall medication cart, revealed that she walked across the hall to room [ROOM NUMBER], entered the resident's room and closed the door, leaving the medication cart unlocked and the surveyor standing by the medication cart. Observation at 9:56 a.m. that LPN BB came to the medication cart, and observed the surveyor standing in the hallway by the unlocked 100 hall medication cart. LPN BB inquired as to where LPN AA and noted that the medication cart was unlocked which she promptly locked. On 08/14/18 at 10:30 a.m. in an interview with LPN AA she reported that she normally locks her cart before walking away. An interview on 8/16/18 at 10:45 a.m. with Registered Nurse Education Coordinator revealed that it was not acceptable for a nurse to leave the medication cart unlocked and be out of view of the cart while administering medications. An interview on 8/16/18 at 10:53 a.m. with LPN DD and LPN EE revealed that they received training regularly with the nurse consultant on correct medication administration and that it was not ok to leave the medication cart unlocked at anytime and especially if it is not in view. Review of the facilty Medication Administration-General Guidelines intent; page 77. #18. During routine administration of medications, the medication cart is kept in the doorway of the patient's room, with open drawers facing inward and all other sides closed. The cart must be clearly visible to the personnel administered medications, and all outward sides must be inaccessible to patients or others passing by.

Based on observation and interview the facility failed to prevent possible contamination during medication administration with one of two Licensed Practical Nurses (LPN). The sample size was 35. Findings include: Observation on 8/14/18 a.m. at 10:25 a.m. of LPN AA who was observed to walk away from the medication cart with R#55 medications in gloved hands, enter the resident's room, placed the medications on the bedside table, repositioned the resident in the bed, then was observed to walk out of the residents room. LPN AA was observed to return to the medication cart opening and closing the mediation cart drawers, then came back in the room with Kleenex, wearig the same gloves on her hands. On 08/14/18 at 10:30 a.m. an Interview with LPN AA reported she would normally take her gloves off but that it did not really matter because she was going back into the same room to the same resident. Also stated that she had only been out of the resident's room a minute. On 8/16/18 at 10:45 a.m. an interview with the Registered Nurse Education Coordinator reported that it was not acceptable to come out of a resident's room wearing gloves and then return into a resident's room wearing gloves, that would be an infection control concern.

Based on observation, record review, review of the facility policy titled Pest Control, review of the pest control service records, resident and staff interviews, the facility failed to help reduce flies and the potential for other pests in the facility. The facility census was 35 residents. Findings include; Review of the facility policy titled Pest Control dated (MONTH) 2013 documented, Procedural Guidelines state; This center maintains an on-going pest control program to promote that our building is kept free of insects and rodents. Observation on 8/14/18 at 11:44 a.m. noted a fly on resident (R)# 47. R#47 had a [MEDICAL CONDITION] (trach) open to air (not covered). The fly was noted approximately five inches from [MEDICAL CONDITION]. Resident unable to communicate effectively. When asked if there are flies in her room often, resident nodded her head. Resident had not brief interview for mental status score (BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding Observation on 8/14/18 at 1:53 p.m. during a medication administration of his roommate, noted R #11 with two flies on his person. R #11 was sleeping during the observation. Observation on 8/15/18 at 9:05 a.m. during a wound treatment observation for her roommate, noted fly landing on and off R#50. Per most recent annual Minimum Data Set ((MDS) dated [DATE], R#50 receives tube feedings and requires extensive assistance with all areas of activities of daily living. When asked if she often experiences flies in her room, resident stated yes. R#50 has a BIMS of 15. A BIMS score of 13-15 indicates resident is cognitively intact. On 8/15/18 at 11:00 a.m. during tour of the facility's perimeter noted the back of the air condition in room [ROOM NUMBER] was off and laying on the ground. An interview and observation on the same day at 11:30 a.m. with the Maintenance Director, he was asked how often does he make rounds around the outside of the facility, he stated he makes rounds daily. When asked how long the back of the air condition in room [ROOM NUMBER] had been off he stated he was not aware that it was off. Further tour and interview with the Maintenance Director validated there was approximately an inch gap between the door and the threshold on the egress door on the A hall. When asked if he was aware there was a gap, Maintenance Director stated that the vendor would usually address those type of concerns and they haven't. Maintenance Director could not state how long the gap has been there.

Based on observation, staff interview and record review, the facility failed to ensure that the monthly infection control rate was accurate for one month, and failed to ensure that licensed nursing staff washed or sanitized their hands between resident contacts during medication administration. Findings include: 1. A review of the infection control logs revealed an infection rate of 1.4%, documented on the Infection Rate Report for June 2017. The rate included one Community Acquired Infection (CAI) and no Healthcare Associated Infections (HAI). However, a review of the handwritten Line Listing of Resident Infections forms for June 2017 revealed three infections were determined to be CAI's and two infections were determined to be HAI's. There was no evidence the infection control rate included the accurate number of infections. During an interview on 8/10/17 at 1:20 p.m., Licensed Practical Nurse (LPN) AA confirmed that the June 2017 handwritten line listing was correct, that there were three CAI's and 2 HAI's. She stated that the infection information was logged in to the computerized line listing system but that an error had caused them not to be included in the infection rate calculation of 1.4% 2. Observation of medication pass on 8/9/17 at 4:44 p.m. revealed that licensed practical nurse (LPN) CC was observed to not wash or sanitizer her hands prior to or during medication administration of four (4) residents. LPN CC was observed to go in and out of the medication cart, knock on residents doors, touching the medication cart, touch cups and pour water into cups for residents to take medications orally. Interview 8/9/17 at 5:01 p.m. with LPN CC she reported and confirmed that she did not wash or sanitizer her hands between administering the medications to residents R#12, #29, #70, #74 and she also reported that she should have used a Sani wipe to clean the pulse oximetry before and after using it on R#29 to check the pulse prior to administering the medication. Interveiw on 8/13/17 at 4:00 p.m. with the Administor and DON their expectations are for staff to wash their hands between residents and especially when passing medications.