Every finding on record at Terrace at Bishop's Glen, The

Based on observation, interview and record review, the facility failed to ensure that one (Resident #20) of seven residents receiving respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure there was a physician's order for oxygen therapy and care of oxygen supplies. The findings include: A rview of Resident #20's medical record revealed that she was admitted to the facility on [DATE], with diagnoses including cerebral ischemia, diabetes mellitus type II, chronic obstructive pulmonary disease (COPD), unspecified asthma, acute on chronic respiratory failure, morbid obesity, muscle weakness, other abnormalities of gait and mobility, congestive heart failure, cognitive communication deficit, generalized anxiety disorder, major depressive disorder, chronic kidney disease - stage 3, pneumonia, dependence on supplemental oxygen, and chronic pain syndrome. On 06/08/25 at 2:46 PM, Resident #20 was observed resting in bed receiving oxygen (O2) at a flow rate of 3.5 liters per minute (3.5 L/min) via nasal cannula that was connected to an oxygen concentrator. (Photographic evidence obtained) On 06/09/25 at 9:38 AM, a second observation was made of Resident #20 receiving oxygen (O2) at a flow rate of 3.5 liters per minute (3.5 L/min) via nasal cannula that was connected to an oxygen concentrator. (Photographic evidence obtained) The resident was interviewed, and she reported that she was supposed to receive oxygen at 3.5 L/min. She stated, I don't touch the oxygen concentrator., and the only people who monitored or touched her oxygen concentrator were facility staff. A review of Resident #20's Admission/Medicare 5-Day minimum data set (MDS) assessment, dated 05/27/25, revealed that the resident had a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. Section GG of the MDS (Functional Abilities and Goals), which focused on self-care and mobility, documented no impairment in upper or lower extremities, no use of a mobility device, eating ability was independent, oral hygiene and personal hygiene required set-up or clean-up assistance, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and putting on/taking off footwear required supervision or touching assistance. Section J of the MDS (pain assessment), noted the resident received scheduled, as needed (prn) pain medication and non-medication interventions for pain. The resident reported occasionally experiencing pain or hurting within the last five days of the assessment period. Pain rarely or not at all affected sleep or interfered with therapy activities and occasionally interfered with day-to-day activities. Pain intensity was reported at a level of 3 out of 10 with 10 being the worst possible pain. The resident experienced shortness of breath (SOB) or trouble breathing with exertion and while lying flat. The assessment noted the resident had a fall in the last 2-6 months prior to admission and had no falls while at the facility. A review of the resident's active physician's orders revealed no order for oxygen therapy or care of oxygen delivery devices, such as cleaning, maintenance, or monitoring of equipment, or the resident's response to oxygen therapy from her date of admission on [DATE] through 06/09/25. A review of the medication administration record (MAR) and treatment administration record (TAR) for June 2025 revealed no evidence that oxygen therapy or care of oxygen delivery devices, such as cleaning, maintenance, or monitoring of equipment, or the resident's response to oxygen therapy was provided/received. A review of Resident #20's patient-centered care plan, created on 05/21/25, revealed a respiratory focus noting the resident had the potential for difficulty in beathing related to chronic obstructive pulmonary disease (COPD), asthma and chronic respiratory failure. The care plan goal noted the resident's respiratory symptoms would be managed through the next review. Interventions included: Administer medications/treatments as ordered. Monitor oxygen saturation, monitor vital signs and lung sounds, administer oxygen as ordered, assess respiratory status: rate, depth, pattern and skin color. On 06/10/25 at 3:17 PM, an interview was conducted with Registered Nurse (RN) A, who reported that she had worked at the facility since August of 2024. She explained the process to ensure residents received the accurate O2 flow rate included receiving a report from the outgoing nurse, checking O2 flow rates while administering medications, and checking how many liters the resident should be on. The outgoing nurse would give a report on each resident and whether there were any changes with the residents. She further explained that when she entered a resident's room, she would look for kinks in oxygen tubing and look at the amount of water in the concentrator. She administered medications in the morning, early afternoon, late afternoon and evenings. RN A began her shift today at 7:00 AM. On 06/10/25 at 3:23 PM, she was accompanied to Resident #20's room and she checked for kinks in the oxygen tubing. RN A bent down to read the flow rate at eye level, and reported that the oxygen flow rate was set at 3.5 liters per minute (L/min.). On 06/10/25 at 03:25 PM, RN A was asked to locate the physician's order for Resident #20's oxygen. She checked electronic medical record (EMR) and stated she could not find an order for oxygen for Resident #20. She was asked to locate where the administration of O2 was documented on the medication administration record (MAR). RN A stated she could not find the administration of O2 on Resident #20's MAR. She explained that there would typically be an order for O2 tubing changes, which would be changed on Thursdays; however, she could not find an order for O2 tubing changes. On 06/10/25 at 3:32 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The Director of Nursing (DON) was on leave and not available for interview. The ADON explained that the process to ensure residents received the accurate oxygen flow rate began when the resident was admitted to the facility. She said that the resident would come into the facility with an oxygen order. If the resident came from a hospital, the nurses were to take the discharge order from the hospital and confirm the order. Once the nurse confirmed the order, they contacted the facility's Medical Director, and the physician would confirm the final order. The ADON further explained that when a nurse entered into a resident's room, they should look at the O2 tank, look at the flow rate, and verify the flow rate with the physician's order. She explained that occasionally a resident or their family would manipulate the flow rate, but the nurse was responsible for matching the O2 flow rate with the doctor's order. She further explained that when O2 was administered, it should be documented on the medication administration record (MAR). Nurses on each shift should mark on the MAR that oxygen was given according to the physician's order. Review of the facility's policy titled Oxygen therapy (clinical manual, dated 06/2015 and reviewed 09/2022, 10/2023 and 10/2024), revealed the responsible party: RN, LPN. Policy Guideline: 1. Residents who require oxygen therapy will have a physician order in their medical record which includes amount of O2 to be administered, route of administration and indication of use. 2. Residents who require O2 therapy will have an ongoing assessment of respiratory status and response to respiratory therapy. 3. Monitoring of spO2 levels and/vital signs as ordered will be documented in medical record . .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to remove grease from fryers and failure to clean grease build-up and food debris inside and around both fish fryers. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 06/09/25 at 11:35 AM. During the tour, it was observed that both fryers located between the ovens were filled with used grease and covered with a significant build-up of food grime and grease. Additionally, grease and food debris were splattered on both sides of the fryer and floor area in front of and around the fryer. (Photographic evidence obtained) On 06/10/25 at 1:42 PM, the same observations were made again of the fryers located between the ovens, filled with used grease and covered with a significant buildup of food grime and grease. Additionally, grease and food debris were splattered on both sides of the fryer and floor area in front of and around the fryer. New observations of grease build-up were made inside the front door area underneath the fryer. (Photographic evidence obtained) An interview was conducted on 06/10/25 at 1:46 PM with [NAME] B. She reported that the kitchen equipment was cleaned daily and kitchen staff had not used the fryer for over one year. An interview was conducted on 06/10/25 at 1:49 PM with Dietary Aide C who reported the cook was responsible for cleaning kitchen equipment after every meal and deep clean at the end of each day. An interview was conducted on 06/10/25 at 1:54 PM with the Dietary Director, who reported that all staff were responsible for cleaning kitchen equipment, including the fryer, which the kitchen had not used since 11/2024. A review of the facility's policy and procedure titled Cleaning Instructions: Fryers, chapter 5: 5-19 (undated), revealed: Fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production. Procedure: 1. Be sure the fryer has cooled completely prior to removing all oil from the fryer . 3. Scrub down the sides and bottom of the deep fryer according to manufacturer's directions . 4. Sanitize. 5. Check with maintenance department on the proper disposal of used oil. Cleaning Instructions: Floors, Tables, and Chairs, Chapter 5-15 (undated) revealed: Kitchen and dining room floors, tables, and chairs will be cleaned and sanitized regularly. Procedure: 1. Sweep and clean kitchen floors after each meal. Sanitize at least once daily. Move major appliances at least once a month (as appropriate) in order to facilitate cleaning behind and underneath them. (Copy obtained) Reference: FDA Food Code 2022, https://www.fda.gov/media/164194/download, (Accessed on 06/16/2025) Chapter 4. Equipment, Utensils, and Linens 4-6 Cleaning of Equipment and Utensils, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. .

Based on interviews, medical record review, facility documents review, and facility policy review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of three residents reviewed for medication administration. This action resulted in Resident #1 requiring a transfer to a higher level of care and hospital admission. The findings include: A review of Resident #1's medical record revealed she was a [AGE] year-old female admitted to the facility with a diagnosis of chronic obstructive pulmonary disease, morbid obesity, muscle weakness, transient ischemic attacks, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 8/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. A review of Resident #1's physician's orders revealed that on 10/19/24 at 9:00 AM, staff was to administer the following medications: Aricept 5 milligram (mg) tablet (to treat dementia caused by Alzheimer's) Calcium 600/Vit D3 20 microgram (mcg) (to increase low calcium levels) Furosemide 20 mg (to lower fluid levels) Lisinopril 10 mg daily (for hypertension) Namenda 10 mg (to treat dementia caused by Alzheimer's) Potassium 40 mili equivelants (mEq) (to treat low potassium levels) Artificial tears (to treat dry eyes) Docusate 100 mg (to soften stools) Further record review revealed that on 10/19/24, Resident #1 was administered Resident #2's medications (listed below) in error. Bupropion extended release 150 mg (extended release for treatment of depression) Citalopram 10 mg (for treatment of depression) Cranberry 450 mg daily (urinary tract infection prevention) Fenofibrate 160 mg (used to treat elevated cholesterol levels) Losartan Potassium-Hydrochlorothiazide 50-12.5 mg (used to treat high blood pressure) Metformin 500 mg daily (used to treat type 2 diabetes mellitus) Metoprolol extended release 2 5mg daily (used to treat high blood pressure) A review of Resident #2's medical record revealed she was the [AGE] year-old roommate of Resident #1. Her MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, indicating severe cognition deficit. A review of Resident #2's physician's orders revealed the following medications were to be administered on 10/19/24 at 9:00 AM: Bupropion extended release 150 mg (extended release for treatment of depression) Citalopram 10 mg (for treatment of depression) Cranberry 450 mg daily (urinary tract infection prevention) Fenofibrate 160 mg (used to treat elevated cholesterol levels) Losartan Potassium-Hydrochlorothiazide 50-12.5 mg (used to treat high blood pressure) Metformin 500 mg daily (used to treat type 2 diabetes mellitus) Metoprolol extended release 2 5mg daily (used to treat high blood pressure) A review of the October 2024 Medication Administration Record (MAR) revealed documentation of Resident #2 receiving her medications. A review of nursing progress note dated 10/19/24 at 12:14 PM read: Employee A, Licensed Practical Nurse (LPN)-at 10:00 am medication pass completed when patient was noted to be given wrong medications, patient alert, oriented to person and surroundings, the resident is not in acute distress at this time, vital signs 90/58- heart rate 60- respiratory rate 18- 95% oxygen (O2) saturation and temperature 98.5, recheck of blood pressure one hour after medication given 89/54-59 call to on-call for Doctor spoke with Nurse Practitioner (NP) on call who gave orders for resident to be sent to hospital for evaluation and possible intravenous (IV) fluids, call to daughter and son-in-law who agree patient should go to the emergency room (ER) for evaluation. Call to emergency medical transport (EMT) for transport to Hospital. EMT here to transport at 12:30 pm with son-in-law at bedside. Sent to hospital, call placed to hospital for report spoke with. Director Of Nursing (DON) aware. A review of nursing progress note dated 10/20/24 at 9:30 AM read: Employee B, Registered Nurse (RN)-Called hospital for report and was informed that patient is doing well and Blood Pressure is a little low and should be back tonight or tomorrow. Record review of Resident #1's Vital signs revealed: 09/01/2024 12:37 122 /68 mmHg Sitting left/arm 10/19/2024 12:17 89 /54 mmHg Lying left/arm 10/22/2024 20:43 98 /63 mmHg Lying left/arm Record review of Resident #1's O2 saturation/Respiratory Rate revealed: 09/01/24 96%/20 respirations per minute (RPM) 10/22/24 96%/18 RPM 11/04/24 97%/18 RPM A review of hospital note dated 10/22/24 read: Chief complaint: gave wrong medication at facility. [AGE] year-old female who came from facility for evaluation after she was given wrong medications from another resident. She received metoprolol, metformin and lisinopril. Facility notified family members and patient was sent to hospital for evaluation due to hypotension. During emergency she received IV fluids due to hypotension. Blood pressure improved. Also noticed increased oral secretions, Chest x-ray with small left-sided pleural effusion. Mild bilateral interstitial opacity, potentially representing chronic interstitial changes versus mild pulmonary vascular congestion. Family members at bedside. Reported the patient is bedbound. Laboratories with elevated [NAME] Blood Cells 13.6, glucose 160. Breath sounds with Bilateral (both sides) rhonchi (low pitched, coarse, loud lung sounds). Diagnosis: aspiration pneumonia (lung infection caused by inhaling food, liquid, or vomit), hypotension (low blood pressure) due to overmedication by mistake, history of hypertension (high blood pressure), chronic dementia. A review of investigation statements from facility staff revealed the following: Employee A, LPN -On Saturday 10/19/24, I came in to assist with Med pass while helping Employee B, I pulled medications for Resident #2, another nurse Employee C, asked to take them to the patient. and I handed them to her telling her room [ROOM NUMBER] (actual room number was 212), Resident #2. When the nurse returned, I was done pulling meds for the roommate Resident #1 and when Employee C was told who the meds were for she stated, Oh I already gave her (Resident #1) the other pills. Stating she thought it was for 112B bed (Resident #1)! This nurse did not see her give the medications. (Signed) Employee A, LPN. (Photographic evidence obtained) On 10/19/24 Saturday During med pass it was reported that (Resident #1) received her roommates' medications this nurse assessed the Resident and notified Doctor on-call and family. Patient sent to hospital for evaluation. (Signed) Employee A, LPN. (Photographic evidence obtained) On 10/19/24 Employee C, RN-This nurse offered assistance to nurse (Employee B) on the East cart. Employee A (wound care nurse) was pulling meds (Employee B was standing by passing meds as well). Employee A put some meds in a cup to be passed and this nurse repeated 212B to question and confirm the room I was to pass meds to. There was no contradiction to my statement, so this nurse passed the meds to 212B. This nurse explained that I gave them to 212B and Employee A stated, we have to do a med error. An incident report was done and Employee A showed me what was noted. Employee A later told me that upon recommendation of NP, resident was sent out to hospital. Employee B later told me the next day that resident would probably be coming back on Monday, but they were still monitoring her Blood pressure. (Signed) Employee C, RN. (Photographic evidence obtained) On 11/5/24 at 10:55 AM, an interview was conducted with Employee D, LPN. Employee D stated she would never give medications to a resident pulled by another nurse. She was unaware of an incident involving meds being pulled by one nurse and delivered to resident by another nurse. When describing the med pass process, she said, We get the cart from the other shift, then do the narc count and get the keys. I usually roll my cart to the room when I'm getting ready to give meds. I pull the meds from the cart, greet my resident, then either hand them to the resident or feed them to the resident, then go back and chart as given. When asked if meds are left at the bedside if the resident refused to take them at the time of delivery, Employee D replied, No, if the resident couldn't be coaxed into taking them, the meds would be discarded, and Medication Administration Record (MAR) marked as refused, and the Doctor or NP would be notified. On 11/5/24 at 11:05 AM, an interview was conducted with Employee E, Licensed Practical Nurse (LPN). Employee E stated she would only deliver medications to a resident that she actually pulled from the cart, that's one of the first things they teach in nursing school. She verbalized the facilities practice for medication administration as, using the MAR to pull the residents medications, delivering the medications to the resident, after verifying the resident, then documenting the resident took the medications. On 11/5/24 at 11:20 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who was also responsible for Staff development/Clinical Education. She stated she was aware of the incident involving Resident #1 receiving another residents' medications. She explained that Unit Managers can step in to cover a medication cart if there is a nurse who has called out, while they look for another nurse to come in. On this particular day, there had been a call out, Employee B, who was the Unit Manager (UM) for the 200 hall, started doing med pass. Employee A came in to relieve Employee B. A nurse from the other unit (100 hall) came over to assist which was when the error happened. The ADON stated, this was not a standard of practice for one nurse to pull medications and another nurse administer the medications. Adding, 1:1 education was done with Employee A and Employee C and she was in the process of conducting Read and Signs for the 11-7 shift, and education during huddles for the remainder of the nursing staff. On 11/5/24 at 11:35 AM, an interview was conducted with the DON. The DON stated that during the investigation they found Employee B who was the Unit Manager was on the med cart due to a callout. Employee A came in to relieve Employee B. Employee A put Resident #2's meds in a med cup, at that time Employee C came over from the 100 hall to assist. Employee A handed Resident #2's med cup to Employee C telling Employee C to give to 212A (Resident #2). DON added, Employee A was just trying to get the meds out and accepted Employee C's help. Employee C was just trying to help but did not know the residents on that hall. When asked if there had been any documented reprimands, DON replied, I haven't done any yet, still considering it. On 11/5/24 at 12:42 PM, a telephone interview was conducted with Employee A, LPN. Employee A said, I came in to relieve the Unit Manager (UM) Employee B, RN - I took over the cart from Employee B, RN. I was pulling Resident #2's meds, Employee C, RN came over to help, told her patient's name, she took the meds and walked away. I started pulling Resident #1's meds, Employee C, RN returned and said she had given the meds to B bed (Resident #1). I reported this to the NP, was told to send resident to the emergency room for evaluation. When asked if resident was assessed, Employee A replied, yes, her blood pressure was slightly low and she complained of nausea. When asked, how was the rest of the med pass completed, Employee A replied, Employee B and I completed the med pass pulling and passing. This was not a normal situation nor normal practice. A review of the facility's policy and procedure titled: Medication Administration-General Guidelines (May 2022); pages 152-158 revealed the following: Page 156, item B Administration: 7) The person who prepares the dose for administration is the person who administers the dose. 8) Resident are identified before medication is administered using two methods of identification. Methods of identification include: a. Checking photograph attached to medical record. b. Checking the resident's wristband. c. Calling resident by name (except with cognitive impairment). d. Having the resident verify his/her last name. e. If necessary, verifying resident identification with other facility personnel. (Copy obtained)

Based on record review and interview, the facility failed to ensure as-needed (PRN) orders for psychotropic medications prescribed were limited to 14 days, except when extended by the physician beyond 14 days with documented rationale in the resident's medical record for 1 (Resident #1) of 1 resident reviewed for PRN psychotropic medication use, out of 5 sampled residents. Failure to obtain a 14-day stop order on PRN psychoactive medications presents a risk of overuse, and of improper monitoring by the prescribing practitioner for the appropriateness of that medication. The findings include: A review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with a readmitted [DATE]. Diagnoses included, but were not limited to, encephalopathy (a brain disorder caused by disease or damage that affects brain structure or function), non-Alzheimer's dementia, and cognitive communication deficit. A review of Resident #1's physician orders revealed an order started on 8/15/24 for an emergency order of ABH gel (a combination of Ativan, an anti-anxiety medication, Benadryl, an antihistamine, and Haldol, which is an anti-psychotic medication) 1/25/1 milligrams/milliliters (ml), apply 1 ml to wrist, alternation inner side of wrist every 4 hours as needed for unspecified dementia, unspecified severity with psychotic disturbance. The end date was noted as indefinite. Resident #1 was care planned on 8/22/24 for her multiple medical needs and for her behaviors of screaming and hollering. A review of Resident #1's quarterly minimum data set (MDS) assessment with a reference date of 8/25/24 revealed she was rarely, if ever, understood. She had short and long-term memory loss and moderately impaired cognition for daily decision making. The resident also received antipsychotic medications on 7 days over the assessment's lookback period. A review of the medication administration records (MAR) for Resident #1 revealed the following: ABH gel was applied in August 2024 on the following days: August 16th- 6 times and August 17th- 4 times. The order was held on 8/17/24, then re-ordered again 8/17/24 and used once daily on August 22nd, 24th, 25th, 28th and 30th, and two times each day on August 29th and 31st. In September 2024, the gel was applied once each day on the 2nd, 3rd, 5th, 6th, 7th, 8th and 10th, 14th, 16th, 21st, 22nd, 23rd and 30th and twice on September 1st, 11th, 17th, 20th and 26th. In October 2024, ABH gel was used once on the 1st, 4th, 5th and 9th and twice on the 6th. (Photographic evidence was obtained) An interview was conducted with Licensed Practical Nurse (LPN) A on 10/17/24 at 1:20 pm. She stated Resident #1 had been on the long-term care hallway for a little while. Her behaviors are more well-managed now. Resident #1 has a PRN order for ABH if she does not take her medication. PRNs are given only as needed. When asked about the stop orders for psychoactive PRN medications, LPN A stated Resident #1 takes Lorazepam (anti-anxiety) PRN, which has a stop order of 14 days. If it is still needed after that time, the physician reorders the medication. LPN A was shown the order for the ABH gel. She said she didn't realize it had no 14-day stop order. She stated the Director of Nursing (DON) usually catches that, but this job takes a village. LPN A acknowledged the requirements for a 14-day stop order on any prescribed PRN psychoactive medication. The DON was interviewed on 10/17/24 at 1:30 pm. He was asked about the ABH gel order for Resident #1. The DON reviewed the records and confirmed the lack of a 14-day stop order, calling it a miss. He stated he usually catches that and will notify the prescriber. The DON confirmed Resident #1 received this medication often.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility, by failing to 1) Seal and date mark open food products in the walk-in freezer, walk-in refrigerator, and open bundles of bread on the bread rack, and 2) Properly clean and sanitize the kitchen mixer, convection oven, fryer, oven tray lines and can opener pixel. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 3/18/24 at 10:45 a.m. During the tour, no date markings were observed on three open bags of French fries and one open bag of carrots in the freezer. The walk-in refrigerator had one open box of white potatoes, one open box of sweet potatoes, one open box of oranges, one open box of lemons, one open bag of onions, one open box of melons, one open box of cabbage, one open box of cantaloupe, one open package of strawberries, one open box of pineapples, one open box of tomatoes, one open box of parsley, one open box of squash, and one open package of shredded cabbage with no date marking. Four open bundles of bread with no date marking were observed on the bread rack located next to the prep table. At the time of the observations, the Certified Dietary Manager (CDM) was notified that one package of rolls was taken off the shelf and discarded by this surveyor due to an observation of mold. (Photographic evidence obtained) An interview was conducted with Dietary Aide D on 3/18/24 at 10:55 a.m., who reported opened and unused bread was used for puree and was not to be placed back on the bread rack. The CDM confirmed staff were to properly close and date all unused bread. A follow-up tour of the kitchen was conducted on 3/19/24 at 11:01 a.m. The mixer, located next to the bread rack and covered with clear plastic, had food debris stuck on and around the safety guard; the convection oven top and bottom doors were filled with grease buildup; the inside floor of the top and bottom convection oven was covered with food debris and dirty grime; grease buildup was observed on both sides of the fryer; the oven trays were filled with grease substances and food debris; and the can opener pixel holder was greasy and filled with food debris. During this time, the same observations were made in the walk-in refrigerator as were made on 3/18/24 at 10:45 a.m. of the open white potatoes, sweet potatoes, oranges, lemons, cabbage, onions, melons, parsley, and shredded cabbage with no date marking. New observations were made in the walk-in refrigerator of one open box of lettuce, one open package of tomatoes, and one open bag of mushrooms sealed with no date marking. Also, the same observations were made in the walk-in freezer of the three open bags of French fries with no date marking. (Photographic evidence obtained) An interview was conducted with Cook E on 3/19/24 at 11:01 a.m., who reported that she used ovens to prepare a la carte food items for the long-term care nursing home residents on the 2nd floor. During a second interview at 1:45 p.m., Cook E reported that each staff member was responsible for cleaning their area at the end of each shift. She confirmed that the facility policy for date marking food items was to wrap, date, and label once the food item was opened. An interview was conducted on 3/19/24 at 1:57 p.m. with Dietary Aide F, who reported that the staff member who used the kitchen equipment was responsible for cleaning the equipment. All open food was to be wrapped with plastic wrap, dated using a white sticker, or date marked on the actual product wrapping before placing the food item back on the shelf or in the freezer or refrigerator. An interview was conducted with the Dining Services Director on 3/19/24 at 2:04 p.m., who confirmed that all open food should be covered and labeled with a date. Each staff member was responsible for their station. Individual stations were wiped and sanitized each night; fryers were cleaned weekly; steamers and ovens were degreased and delimed monthly, and oven trays were cleaned monthly. The Dining Services Director was unable to provide cleaning schedules. A review of the facility's policy and procedure titled Labeling and Dating (undated), revealed: 1. Raw Foods . b. Once the raw package is open, it must be placed in a sealed container; c. Raw food package must be labeled and dated within 3 days of opening the package; d. Raw food can only be refrigerated for 3 days; and e. If the raw food is not completely used and needs to be put back into the freezer, the food must wrapped, sealed, labeled and dated . 3. Perishable Foods . b. If any perishable food is opened or cut, it must be sealed, labeled and dated 3 days from being used . 5. Bread . b. Once bread is opened, it must be used within 7 days. c. Once bread is opened, it must be placed in the original package or a sealed container, labeled and dated 7 days from the original date of being used. A review of the facility's policy and procedure titled Cleaning and Sanitizing Dietary Areas and Equipment (undated), revealed: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary food service that meets state and federal regulations. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 2/20/24) Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observations, a staff interview, and record review, the facility failed to ensure that one (Resident #39) of four residents who required oxygen administration, from a total sample of 21 residents, received such care, consistent with professional standards of practice (Oxygen was administered without a physician's order.) The findings include: On 3/18/24 at 3:19 p.m., Resident #39 was observed lying in bed. His oxygen flow rate was set at 2 liters per minute (L/min), his oxygen tubing was not dated, and the humidification bottle was on the floor. (Photographic evidence obtained) On 3/19/24 at 9:08 a.m., Resident #39 was observed lying in bed. His oxygen flow rate was set at 2 L/min, his oxygen tubing was not dated, and the humidification bottle was on the floor. There was no oxygen in use sign on the door. A review of the resident's medical record revealed that Resident #39 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) with exacerbation, acute and chronic respiratory failure with hypoxia, generalized anxiety disorder, and heart failure. A review of the active physician's orders revealed orders to change the resident's nebulizer tubing weekly and as needed every night every shift. Ipratropium - Albuterol solution 0.5-2.5 mg/ml (milligams per milliliter), inhale 3 milliliters (ml) orally three times a day for COPD was ordered. [NAME] Ellipta inhalation powder, breath-activated, 200-25 micrograms (mcg), 1 inhalation orally in the morning for COPD and rinse and spit after using to decrease the risk of infection was also ordered. There were no orders for oxygen. (Copy of the physician's orders obtained) A review of the Admission Minimum Data Set (MDS) assessment, with an assessment reference date of 12/29/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 possible points, indicating severe congitive impairment. There were no behaviors documented. The resident required supervision with eating. He was dependent with bed mobility, transfers and toileting. He was documented with diagnoses including anxiety disorder, depression, COPD, acute and chronic respiratory failure with hypoxia, heart failure and he required oxygen use. A Care Plan initiated on 2/7/24, revealed that the resident required oxygen therapy related to COPD, chronic respiratory failure and heart failure. Interventions included administration of medication as ordered by the physician. In an interview on 3/20/24 at 9:54 a.m. with Licensed Practical Nurse (LPN) A, she stated Resident #39 was receiving oxygen at 2 L/min PRN (as needed) for COPD. She was accompanied to the resident's room and confirmed that the resident was receiving oxygen. She also confirmed that the humidification bottle was on the floor. She said, The humidification bottle should never be placed on the floor. She picked it up and attached it to the oxygen concentrator. When she was asked to review the resident's orders for oxygen administration, she confirmed that there were no orders for oxygen. A review of the facility's policy and procedure titled Oxygen Administration and Use (revised 8/2022), revealed that the facility will ensure that oxygen therapy will be administered in compliance with current standards of practice. The policy interpretation and implementation indicated that: 1. Oxygen should be administered in accordance with the physician's order. 2. Oxygen will be administered by physician's order; however, in an emergency situation, oxygen may be applied and the physician will be contacted as soon as possible to obtain appropriate directions. 3. An Oxygen in Use sign should be placed outside of the room on the entrance door or door frame. .

Based on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed for one (Resident #32) who was diagnosed with a mental disorder, from 21 residents in the total sample. Failure to accurately complete a Level I PASRR results in the facility's inability to determine whether a resident requires specialized services. The findings include: A medical record review indicated that Resident #32 was admitted to the facility on [DATE]. Her diagnoses included traumatic subdural hemorrhage with loss of consciousness of unspecified duration, expressive language disorder, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, depression and anxiety disorder. A review of a Quarterly minimum data set (MDS) assessment with an assessment reference date of 2/25/24, revealed that a Brief Interview for Mental Status (BIMS) score could not be obtained. The assessment further indicated that the resident had depression, a psychotic disorder (other than schizophrenia), dementia and a traumatic brain injury. She was also documented with hallucinations, delusions, and wandering behaviors. The Level I PASRR, dated 5/27/22, Section A, was incomplete as it did not indicate Resident #32's pertinent diagnoses. Section II indicated that the resident did not have a diagnosis of dementia. In an interview with the Director of Nursing 3/20/24 at 1:29 p.m., he was asked about the facility's process for PASRR review. He stated when residents were admitted , he reviewed all documentation including the PASRR. If the PASRR was incorrect for a new admission, he would have to send it back to the place the resident was admitted from to have it corrected. When he was asked the facility's process for review of new conditions for residents already in the facility that might require an update of the PASRR, he said, I have not had that happen while I was at the facility. He stated he would have to review that with Social Services. He added that the new psychiatric diagnosis would not warrant a new level one PASRR. He stated there was no one who reviewed the PASRR for residents who were already in the facility. He was then asked about Resident #32's PASRR. He confirmed that the resident had diagnoses including dementia, psychosis, and depression, and that these diagnoses were not checked on the Level I PASRR. He added that it was not a provisional admission and therefore it would not change anything. A review of the facility's policy and procedure titled PASRR (revised 6/2023), revealed that the facility admits only residents whose medical and nursing care needs can be met. The policy interpretation and implementation noted that all new admissions and readmissions were screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. a.) The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD. .

Based on record review and staff interview, the facility failed to ensure that one (Resident #9) of three residents with pressure ulcers, from a total of 21 residents in the sample, received treatment and services consistent with professional standards of practice, to promote wound healing, by failing to follow the wound care physician's recommendations. Failure to follow physicians' recommendations could result in delayed healing. The findings include: A medical record review indicated that Resident #9 was admitted to the facility on [DATE]. Her diagnoses included aftercare following joint replacement surgery, unspecified protein-calorie malnutrition, muscle weakness (generalized), difficulty walking, dysphagia, cognitive/communication deficit, elevated white blood cell count, fracture of unspecified part of neck of right femur, adult failure to thrive, Alzheimer's disease, and essential hypertension. A review of the resident's Physician's Orders revealed the following: 1/1/24: Weekly skin check on every day shift every Monday for skin care. 2/22/24: Wound care specialist may evaluate and treat as needed. 3/6/24: Cleanse wound to the right hip, left hip and left ankle with Dakin's solution. Apply skin prep to surrounding tissue, apply Santyl and calcium alginate to wound bed and cover with dry dressing daily. 3/11/24: Cleanse right ankle wound with normal saline, apply skin prep to surrounding tissue, apply Medi-honey and collagen powder to wound bed, and cover with dry dressing daily. A review of the 5-day Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/8/23, revealed that the Brief Interview for Mental Status (BIMS) score was left blank. The resident was documented as always incontinent of bowel and bladder and required extensive assistance for bed mobility, toileting and transfers. There were no pressure ulcers documented on this assessment. A review of the Significant Change MDS assessment with an ARD of 3/5/24, revealed that the resident had three stage IV pressure ulcers, one unstageable, one deep tissue injury (DTI), and moisture-associated skin damage, that were not present upon admission. The care plan updated on 3/12/24 read, Resident on hospice for end-stage dementia, eats 25% or less of meals, assist with all care, and at risk for new or worsening skin breakdown. A review of the Wound Care Specialist's notes dated 2/26/24, revealed the following: Stage IV right lateral ankle measuring 1.4 cm (centimeters) x 1.3 cm x 0.5 cm; Stage IV right hip 3.3 cm x 2.4 cm x 1.6 cm; Unstageable DTI left lateral foot 1.3 cm x 1.4 cm, and Stage IV left hip 1.5 cm x 1.7 cm x not measurable due to necrosis (dead tissue obstructing the wound bed). Recommendations included Zinc sulfate 220 milligrams (mg) for 14 days; Vitamin C, 500 mg two times a day (BID) and Multivitamin daily. On 3/11/24, the wound measurements were as follows: Stage IV right hip 3.3 cm x 1.6 cm x 1.6 cm, wound has decreased in size. Stage IV right lateral ankle 1.2 cm x 1.3 cm x 0.5 cm, unchanged in size; Stage IV left lateral foot 3/11/24: 0.7 cm x 0.7 cm, decreased in size; Stage IV left hip 1.2 cm x 1.4 cm x 1.7 cm, decreasing in size. Recommendations included Zinc sulfate 220 milligrams (mg) for 14 days; Vitamin C 500 mg two times a day (BID), and Multivitamin daily. On 3/20/24 at 3:43 p.m., Licensed Practical Nurse (LPN) C was observed providing wound care to Resident #9. She dressed the wounds to both of the residents hips and ankles per the orders. LPN C stated the resident was followed by a wound care physician weekly and the wounds had improved. LPN C was asked about the wound care physician's recommendations. She said, When the wound care recommendations are made, I notify the resident's attending physician and then add to orders to the Treatment Administration Record (TAR) and also document a progress note about the new recommendations. She added that she had never had the attending physician say no to any recommendations from the wound care physician. She was then asked about the recommendations for Resident #9. She confirmed that recommendations for Zinc sulfate 220 milligrams (mg) for 14 days; Vitamin C, 500 mg two times a day (BID), and a Multivitamin daily from the wound care physician had not been carried out since 2/26/24. She mentioned that she had just started rounding with the wound care physician and she was still learning the process. She mentioned that she would add the recommendations. A review of the facility's policy and procedure titled Pressure Ulcer Treatment (undated), revealed the following: 1. The pressure treatment program should focus on the following: a. Assessing the resident and the current status of the pressure ulcer(s). b. Current support surfaces. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Education and quality improvement. Interventions/care strategies - Pressure ulcer treatment requires a comprehensive approach including: 1. Debridement. 2. Managing infections. 3. Managing systemic issues ( edema, venous insufficiency etc). 4. Maximizing the potential for healing. 5. Pain control.

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5%, based on 37 opportunities for error with three errors identified, resulting in an error rate of 8.11%. Two (Residents #31 and #23) of six residents observed during medication administration were involved. Failure to administer medications as ordered could result to side effects leading to serious harm to residents. The findings include: During medication administration observation on 3/18/24 at 11:34 a.m., Registered Nurse (RN) B was observed preparing medications for Resident #31. She gathered supplies for blood glucose monitoring. She performed hand hygiene and donned gloves. She cleansed the resident's right ring finger with alcohol, obtained a drop of blood on the test trip and received a blood glucose reading of 160 milligrams per deciliter (mg/dl). She reviewed the Medication Administration Record (MAR) and stated Resident #31 required three units of Novolog insulin coverage. She obtained the Novolog Flex Pen, opened 3/12/24. She dialed the pen to three units, donned gloves and administered the insulin in the resident's right lower abdomen. RN B did not prime the pen before dialing the dosage. An interview was conducted with RN B on 3/18/24 at 11:52 a.m. When she was asked about the proper way to use insulin Flex Pens, she stated, I should have primed the pen with two units then dialed per sliding scale. On 3/20/24 at 9:28 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #23. She reviewed the MAR, obtained medications one at time and put them in a medication cup. She then poured the contents of the cup into a pill crushing pouch and crushed the medication. She mixed all of the medications with pudding and administered them to the resident. In an interview on 3/20/24 at 9:35 a.m., LPN A confirmed that this resident had no order to crush medication. A review of the facility's policy and procedure titled Administering Medication (reviewed on 02/2024), revealed: Medications shall be administered in a safe and timely manner and as prescribed. According to the National Library of Medicine at www.Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations - PMC (nih.gov) (Accessed on 4/9/24 at 9:05 a.m.): Mixing multiple crushed medicines may also be unsafe or make them less effective. People in hospitals and long-term care settings who have a hard time swallowing pills should have an individual plan in place for taking medicines. Physicians, pharmacists, speech-language pathologists, and front-line care staff should work with patients and caregivers to make the plan. The plan should be written down in their patient record. Although medication crushing is common, prescribing information may not include details on acceptability of crushing medications or how to administer once crushed, and inappropriate medication crushing can have unintended or adverse effects. According to the American Association of Post-Acute Care Nursing at www.Avoiding a Citation When Crushing Medication - AAPACN (Accessed on 4/9/24 at 9:00 a.m.): Best practice for administering crushed medication is to crush and administer each medication separately. Crushing and combining medication may result in physical and chemical incompatibilities, leading to an altered therapeutic response; it can also cause a feeding tube occlusion. There may be times when crushing and administering each medication separately is not appropriate for a resident. When this is the case, facility staff should actively involve the resident, the resident's representative, the attending physician, the consultant pharmacist, and the medical director, as needed, to ensure that there is a person-centered, individualized approach to administering each medication.

Based on observation, interview, record review, and facility assessment tool review, the facility failed to ensure a registered nurse (RN) worked at least 8 consecutive hours a day, seven days a week on four separate occasions. Registered nurses provide assessments, care to clinically complex patients and supervision to licensed practical nurses. The findings include: During a tour of the facility on 4/4/22 at 9:17 AM, the daily staffing sheet was observed posted at the nurse's station. There were no Registered Nurse (RN) hours listed on the daily staffing calculations. Review of the Calculating State Minimum Nursing Staff for Long Term Care Facilities form provided by the facility dated 3/20/22 through 4/2/22 revealed on 3/20/22, 3/21/22, 3/26/22, 3/27/22 and 4/2/2022 there were 0 hours documented in the RN hours column. (Copies obtained) During an interview with the Staffing Coordinator and Interim Director of Nursing (IDON) on 4/6/22 at 1:10 PM, they confirmed there were less than 8 RN hours on the days in question. The Staffing Coordinator stated the shortage was a result of staffing changes. The IDON acknowledged, she was an RN but had not served as a charge nurse in the facility. She stated that she was unaware of the wording in the regulations permitting her to serve as a charge nurse when the facility census was less than 60. A review of the Facility Assessment Tool updated on 4/1/2022, identified the Interim DON, as a RN and read: To determine if they facility has sufficient staffing the following should be considered: Review expectations for federal minimum staffing requirements at the federal and state level. Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week 483.35(b)(1) and must designate a licensed nurse to serve as charge nurse on each tour of duty 483.35(a)(2).

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #5) of two residents sampled for a review of range of motion services from a total of 16 sampled residents. The findings include: A review of Resident #5's medical record revealed he was admitted to the facility on [DATE], with the most recent readmission on 3/23/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly minimum data set (MDS) assessment, dated 1/12/22, revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating cognitively intact. He also required 2-person assist with bed mobility, dressing and personal hygiene and required 1-2 person assist with transfers and toileting. Resident #5 had a contracture to his upper left hand. A review of the resident's care plan revealed the resident had impaired mobility and was at risk for contractures. He was observed removing his splints. Interventions included to splint as tolerated, notify physician if range of motion (ROM) deteriorated, keep call light, bedside table, and telephone within reach. A review of Resident #5's restorative care plan dated 11/27/21 thru 11/26/22, revealed resident was to receive restorative nursing program (RNP) splint application to right hand utilizing a right resting hand splint to decrease extension tone in the third and fourth digits. Splint was to be applied at bedtime and removed in the morning before breakfast or as tolerated by resident. On 4/4/22 at 11:38 AM, Resident #5 was observed without a splint on is right hand. When asked if he wears a splint. The resident stated, he wears a splint on the right upper extremity (RUE) at night during the week when Employee D a Certified Nursing Assistant (CNA) was assigned to him, but on the weekends, no one applied the splint. On 4/5/22 at 9:01 AM, Resident #5 was observed with a rolled-up wash cloth in his left hand. The splint for his right hand was sitting on a stack of pillows. (Photographic evidence obtained) On 4/6/22 at 8:05 AM, the resident was observed eating breakfast in his bed. When asked if the splint was applied last night. The resident replied, yes, Employee D, CNA, Always puts it on me at night. When asked if anyone else applied the splint, he replied, No. On 4/6/22 at 8:10 AM, Resident #5's restorative nursing logs for the months of February, March, and April 2022 were reviewed with the Director of Nursing (DON). The logs revealed only one set of initials (Employee D, CNA) signing off for the application of the splint to the right hand. The logs revealed no documentation of splint application for Feb. 6, 12, 13, 19, 20, 25, 26, 27, 28; March 3, 8, 14, 21, 26, 27, 28, 31; and April 4, 2022. (Photographic evidence obtained) The DON confirmed the missing documentation. When asked who was responsible for applying the splint when Employee D, CNA was not working. The DON stated, The CNA assigned to the resident is responsible for the task and if it was not documented it was not done. When asked who was responsible for the follow up on the status of the Restorative program. The DON stated no one was assigned responsibility to provide oversight of the program. On 4/7/22 at 8:43 AM, an interview was conducted with Employee E, CNA. When asked if there were residents that needed splints, she replied, yes, a couple. When asked if CNAs could apply splints, she stated only, if they were on the Restorative Program. She explained that if a resident was getting therapy services, then the task was performed by them. When asked if the CNAs received training on the application of the splints, she stated, yes. When asked if they had to document the application of a splint, she stated yes, in the Restorative book. On 4/7/22 at 8:55 AM, Resident #5 was observed sitting in bed. When asked if his splint was applied last night, he replied, No, Employee D, CNA was off last night. A review of the Restorative log for 4/6/22 revealed no documentation to indicate splint was applied. On 4/7/22 at 9:10 AM, an interview was conducted with Employee F, CNA. When asked if there were any residents who wore splints, she replied, Yes. When asked if CNAs could apply splints, she replied, Yes. When asked if she received training on the application of splints, she replied, Yes. When asked if CNAs documented the application of splints, she replied, Yes, in the Restorative Book. On 4/7/22 at 10:15 AM, a follow up interview was conducted with the DON. When asked who was responsible for the Restorative program, she stated, No one is in charge of the program it is a shared responsibility with the nurses. When asked how many residents were receiving Restorative Nursing Services, she stated, she did not know. When asked if anyone followed up on whether the services were being performed, she stated, the logs make it evident if the services are being performed. On 4/7/22 at 10:40 AM an interview was conducted with Employee G, a Physical Therapy Assistant (PTA). When asked if Therapy was responsible for the oversight of the Restorative Nursing Services program, she stated no, it is completely turned over to nursing. When asked who trains the CNAs on the application of splints, she stated, they can do the initial training and periodically if staff ask. Further record review for Resident #5's revealed a Discharge Summary by Physical Therapy that read, Goals met. Recommend restorative treatment to maintain progress made with functional mobility. On 1/14/22, the physician wrote an order to discharge from skilled therapy to Skilled Nursing Facility with RNP. A review of the facility's policy and procedure for Restorative Nursing Services (Revised July 2017) read: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabiliative care. 3) Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. (Copy obtained)

Based on record reviews, observations and interviews, the facility failed to provide services to maintain personal hygiene (grooming) for one (Resident #12) of 16 sampled residents. The resident's fingernails were not cleaned or trimmed. The findings include: A review of Resident #12's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) assessment dated [DATE] indicated that the resident required extensive assistance with personal hygiene and total assistance with bathing. A review of the brief interview for mental status (BIMS) revealed a score of 99, indicating Resident #12 had unclear speech. A review of the care plan updated on 2/22/22, noted personal hygiene required extensive assistance and total assistance with bathing. (Photographic evidence obtained) An observation of Resident #12 on 4/4/22 at 12:33 PM, revealed the fingernails on his right hand were long, jagged, and unclean. When asked about his fingernails, Resident #12 reported the guy that gave him his shower said he was coming back and would cut them, but he never returned. A second observation of Resident #12 on 4/5/22 at 1:23 PM, revealed the fingernails remained long, jagged, and unclean. A third observation of Resident #12 on 4/6/22 at 8:45 AM, revealed the fingernails remained long, jagged, and unclean. An interview was conducted with Employee H, Licensed Practical Nurse (LPN) on 4/6/22 at 1:40 PM. When the LPN was asked who was allowed to cut and clean the resident's nails. She reported the nurses or CNA's can complete the task. The LPN entered Resident #12's room and observed his nails. She confirmed the nails on his right hand were long and full of black substance underneath, and thumb on left hand was long and all nails had black substance underneath. The LPN reported the staff would take care of it. On 4/6/22 at 1:48 PM, Employee E, Certified Nursing Assistant (CNA) was interviewed. She stated the nurses usually cut fingernails especially if the resident is diabetic. The CNA acknowledged, she could cut resident fingernails if they were not diabetic. Employee E confirmed Resident #12's nails were long and full of black substance and stated she would be cleaning and cutting his nails.

Based on a review of resident records and interviews with staff, the facility failed to notify the resident and the resident's representative(s) of the transfer in writing, and include all required information related to the emergent transfer for two (Residents #12 and #23) of three residents reviewed for transfer/discharge from a total of 22 residents in the sample. The findings include: 1. A closed record review for Resident #12 revealed an admission to the facility from an acute care hospital on [DATE], with discharge on 9/14/20. [DIAGNOSES REDACTED]. Resident #12 had a friend designated as her care plan consultant and guardian. A Patient Transfer form, dated 5/13/20, revealed Resident #12 was transferred to the hospital for a blood transfusion due to low hemoglobin and hematocrit levels. An AHCA (Agency for Health Care Administration) Nursing Home Transfer and Discharge Notice was initiated for the hospital transfer. It documented the date the notice of transfer was given on 5/13/20. Further review of the form found the following required information was omitted: The effective date of the transfer, the hospital address and phone number, and the date the information was sent to the Long-Term Care Ombudsman. (Photographic evidence obtained) 2. A closed record review for Resident #23 revealed she was admitted to the facility from an acute care hospital on [DATE]. [DIAGNOSES REDACTED]. A Patient Transfer Form dated 8/15/20 noted Resident #23 was transferred to the hospital on [DATE] after restarting diuretic medication and complaining of chest pain. An AHCA Transfer Discharge Form was initiated for the transfer that documented the date the notice of transfer was given on 8/15/20. Further review of the form found the following required fields were left blank: The effective date of the transfer, the hospital's address and telephone number, and the reason for the transfer. In addition, the form omitted the date the notice was given to the local Long-Term Care Ombudsman. (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on 09/23/20 at 2:59 PM. She was asked who was responsible for completing the Transfer and Discharge Forms when a resident was sent to the hospital. She stated the floor nurse was responsible for completing all required paperwork upon transfer. When asked who was responsible for forwarding the form to the proper individuals for signatures, the DON replied, Nope, I can tell you now we have never done that. Upon review of the forms, she confirmed they were incomplete and were missing the the required information.

Based on observation, review of facility records, and interviews with staff, the facility failed to post daily staffing information on four of four days of the survey, that included the name of the facility and the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs). The findings include: Observations of the nurse staffing information was conducted daily between 9/21/20 and 9/24/20 during the survey. The information was prominently displayed at the central nurses' station, as required. Closer inspection of the information on 9/21/20 at 2:53 PM, found the form included the number of RNs, LPNs, and CNAs on each of the following shifts; Day Shift, P.M. Shift, and Night Shift. The form did not include the name of the facility or the actual number of hours worked by each licensed staff member on each shift. (Photographic evidence obtained) Observations conducted on 9/22/20 at 1:33 PM, on 9/23/20 at 9:12 AM, and on 9/24/20 at 1:22 PM, found the form had been updated to reflect the current day, but still omitted the facility name and the actual number of hours worked by each licensed staff member on each shift. (Photographic evidence obtained) An interview was conducted with the Unit Manager on 9/24/20 at 1:27 PM. She was asked about the omitted information. She reviewed the regulation and acknowledged the requirements for actual staff hours and the name of the facility to be on the form. She stated she would need to re-do the form.

Based on observations, review of grievances, staff interviews, and review of the Grievance Policy and Procedure, the facility failed to ensure prompt efforts to resolve grievances for two (Residents #1 and #8) of three sampled residents. The findings include: A review of the grievances for (MONTH) (YEAR) through (MONTH) 2019, revealed a grievance for Resident #1, dated 3/19/2019, concerning missing clothing. The resident's daughter filed the concern on 3/19/19. There was no resolution to the grievance documented on the form. An interview was conducted with Social Services at 9:45 AM on 5/15/19. The Social Services designee reported that she spoke with the daughter about replacing the items, but had not followed up. The process for missing items included notification of missing items, a search for them by staff, and if unable to find them, the facility was to replace the missing items within one week. The family had the option of replacing the items and submitting receipts, or to look through the facility's catalog and order items to be replaced. The Social Services designee called the resident's daughter after the 5/15/19, 9:45 AM discussion related to the resolution of this grievance. The staff member returned at 10:03 AM and stated, The daughter is going to come look at our catalog and order the missing items. The Social Services designee confirmed that neither a resolution not a summary of the investigation had been documented. A grievance concerning missing clothes, dated 4/2/19 and filed by Resident #8's the resident's son, was reviewed. No resolution was documented. A 5/15/19 interview concerning the two grievances with no documented resolution or summary of the investigation for Resident #1 and #8 was conducted with the Director of Nursing (DON) at 1:50 PM. She stated her expectation was for the grievances to be documented and resolved. She confirmed the missing information on the two resident grievances. An interview was conducted on 5/15/19 at 2:26 PM with the Social Services designee. She confirmed the two grievances for Resident #1 and #8 were not resolved. She stated she had spoken with both families today (5/15/19) and a resolution was in progress. The procedure for filing a Resident Grievance/Complaint was reviewed. Number five noted that within three working days of the day the grievance was filed, the person with the concern would receive a written summary of the results of the investigation. The policy and procedure, revised 10/1/17, on Resident Rights-Grievances and Resolution, noted under E: Ensure all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.

Based on observations and staff interviews, the facility failed to prepare and serve foods in accordance with professional standards for food service safety. The findings include: On 11/14/18 between 11:50 AM and 12:30 PM during a tour of the kitchen, the cook was observed taking food temperatures before service resumed at 12:15 PM. She touched her face and glasses many times, and rubbed her gloved hands on her clothes. She was not wearing an apron. When she was asked why she was not wearing an apron, she put one on. On 11/14/18 at 11:53 AM. a cart containing cold desserts, yogurt and milk was observed in the kitchen without a cooling device. At 12:28 PM, the temperature of a carton of milk was taken and was 51.7 degrees Fahrenheit (F). The cook confirmed the cart had been brought into the kichen at the tray line at 11:45 AM without proper refrigeration or ice baths. Fourteen overhead, rectangular light shades were observed to be discolored; some with food stains and others with dead bugs. All of the shades were covered with dust. The kitchen walls were observed with splashes of food debris and dust. Stove tops and grills were heavily impacted with food debris and burnt grease. Grease traps were impacted and burnt. The stove top grease trap was stuck with debris and could not be pulled out. Ovens and two deep fat fryers were heavily soiled with grease and grime. The tray line was observed with hanging dust overhead. The kitchen floor was observed with a pool of oil around the deep fat fryer. One of the deep fat fryers was leaning towards the stove. The dishwashing room walls were observed with a black substance along the wall joints, and the back door was soiled. (Photographic evidence obtained of all above-mentioned concerns) During an interview with the kitchen aide on 11/14/18 at 12:45 PM, he stated that one of the casters supporting the fryer had been broken for some time. He asked whether he should report the broken castor to the maintenance director. He confirmed that it was a hazard when in use with hot oil. He further stated that he was always careful when he was using that fryer. During an interview with the Kitchen Manager/Food service Director on 11/14/18 at 4:15 PM, he stated that he had not formulated a cleaning schedule for the facility yet. He had been employed at the facility for six months. He confirmed that there was no system in place to maintain a clean kitchen.

Based on observation and staff interview, the facility failed to maintain the kitchen equipment in safe operating condition. The findings include: On 11/14/18 between 11:50 AM and 12:30 PM during a tour of the kitchen, the stove top and grills were observed to be heavily impacted with food debris and burnt grease. The ovens and two deep fat fryers were heavily soiled with grease and grime. The kitchen floor was observed with a pool of oil around the deep fat fryer, and one of the two deep fat fryers was leaning towards the stove. The fryer was full of cooking oil. At the time of the observation, a kitchen aide who was cleaning the stove confirmed that the facility used the fryer. During an interview with the kitchen aide on 11/14/18 at 12:45 PM, he stated that one of the casters supporting the fryer had been broken for some time. He asked whether he should report the broken castor to the maintenance director. He confirmed that it was a hazard when in use with hot oil. He further stated that he was always careful when he was using that fryer.

Based on observations and staff interviews, the facility failed to ensure the privacy of residents receiving insulin injections (Residents #6, #37, and #38), and failed to promote respect for residents requiring staff assistance for feeding (East dining room, hallways, and at nursing station). The findings include: 1. a. On 12/19/17 at 12:03 pm, during medication administration observation for Resident #37, Employee A (staff nurse) performed blood glucose monitoring to determine the need for insulin coverage. The results of the test indicated the resident would receive [MEDICATION NAME] insulin, 2 units. The nurse prepared the insulin injection at the medication cart outside of the room. When she entered the room, Resident #37 was asked their location preference for the insulin injection. The resident indicated the abdomen. The nurse, without pulling the privacy curtain or closing the door of the room, lifted the resident's shirt and exposed the resident's abdomen to administer the insulin. Interview with Employee A at 12:10 pm confirmed that she did not pull the curtain or close the resident's door. b. On 12/19/17 at 11:25 am during medication administration observation for Resident #6, Employee A performed blood glucose monitoring to determine the need for insulin coverage. The results of the test indicated the resident would receive [MEDICATION NAME] Regular insulin, 3 units. The nurse prepared the insulin injection at the medication cart outside of the room. When she entered the room, she asked Resident #6 their location preference for the insulin injection. The resident indicated the abdomen. Employee A, without pulling the privacy curtain or closing the door of the room, lifted the resident's shirt and exposed the resident's abdomen to administer the insulin. An interview with Employee A at 12:10 pm confirmed that she did not pull the curtain or close the resident's door. c. On 12/19/17 at 11:14 am during medication administration observation for Resident #38, Employee A performed blood glucose monitoring to determine the need for insulin coverage. The results of the test indicated the resident would receive [MEDICATION NAME] insulin, 4 units. The nurse prepared the insulin injection at the medication cart outside of the room. When she entered the room, she asked Resident #38 their location preference for the insulin injection. The resident indicated the abdomen. The nurse, without pulling the privacy curtain or closing the door of the room, lifted the resident's shirt and exposed the abdomen in order to administer the insulin. An interview with the nurse at 12:10 pm confirmed that she did not pull the curtain or close the resident's door. FACILITY 2. On 12/19/17 at 07:50 am, Employee Q (staff nurse), was overheard as she was walking down the North hallway asking for the tray for Resident #38, and calling the resident a feeder to another staff member. An interview was conducted on 12/19/17 at 07:58 am with Employee Q. The employee was asked if Resident #38 was receiving a tray and eating in the room, and she replied, Yes, (resident)'s a feeder. An interview was conducted with the Director of Nursing (DON) on 12/19/17 at 08:17 am. The DON was asked why some of the residents on the North Hallway had not received a breakfast tray, as it was 30 minutes later than other residents who had received their trays. The DON replied, The ones that are left are feeders. We keep the trays on the food cart to keep the food hot, and they get delivered last since they have to be fed. 3. An observation was conducted of the lunch meal on 12/19/17 at 12:07 pm. The Advanced Registered Nurse Practitioner (ARNP), along with a second ARNP in training, was observed conducting assessments on two residents in the dining room. There were nine other residents, two staff members, and two state surveyors present in the dining room while the ARNP was conducting assessments. On 12/19/17 at 12:35 pm, an interview was conducted with the hospice Certified Nursing Assistant (CNA) regarding the ARNPs completing resident assessments in the dining room. The CNA stated, They are not supposed to do assessments in the dining room, and I offered to take the residents back to their rooms. However, the ARNP said 'no, it was okay', and continued with completing assessments. The CNA stated, It was not my place to say anything to them because I might get in trouble.

Based on observations and staff interviews, the facility failed to protect residents' dignity while receiving insulin injections (Residents #6, #37, and #38), and failed to promote respect for residents requiring staff assistance for feeding (East dining room, hallways, and at nursing station) for a total 54 residents residing in the facility. The findings include: 1. On 12/19/17 at 12:03pm during medication administration observation for Resident #37, Employee A performed blood glucose monitoring to determine the need for insulin coverage. The results of the test indicated the resident would receive [MEDICATION NAME]2 units. The nurse prepared the insulin injection at the medication cart outside the room. When she entered the room, she asked Resident #37 at what site was the injection was preferred. The resident indicated to the abdomen. The nurse, without pulling the privacy curtain or closing the door of the room, lifted the shirt exposing the abdomen to administer the insulin. Interview with Employee A at 12:10pm confirmed that she did not pull the curtain or close the resident's door. 2. On 12/19/17 at 11:25am during medication administration observation for Resident #6, Employee A performed blood glucose monitoring to determine the need for insulin coverage. The results of the test indicated the resident would receive Humolin R 3 units. The nurse prepared the insulin injection at the medication cart outside the room. When she entered the room, she asked Resident #6 at what site the injection was preferred. The resident indicated the abdomen. The nurse, without pulling the privacy curtain or closing the door of the room, lifted the shirt exposing the abdomen to administer the insulin. Interview with Employee A at 12:10pm confirmed that she did not pull the curtain or close the resident's door. 3. On 12/19/17 at 11:14am during medication administration observation for Resident #38, Employee A performed blood glucose monitoring to determine the need for insulin coverage. The results of the test indicated the resident would receive [MEDICATION NAME]4 units. Employee A prepared the insulin injection at the medication cart outside the room. When she entered the room, she asked Resident #38 at what site the injection was preferred. The resident indicated the abdomen. Employee A, without pulling the privacy curtain or closing the door of the room, lifted the shirt exposing the abdomen to administer the insulin. Interview with Employee A at 12:10pm confirmed that she did not pull the curtain or close the resident's door. 4. On 12/19/17 at 07:50 AM, Employee Q was overheard as she was walking down the North hallway asking for the tray for Resident #38, and calling the resident a 'feeder' to another staff member. An interview on 12/19/17 at 07:58 AM was conducted with Employee Q. She was asked if Resident #38 was receiving a tray and eating in the room, and she replied, Yes, he's a feeder. An interview was conducted with the Director of Nursing (DON) on 12/19/17 at 08:17 am. She was asked why some of the residents on the North Hallway had not received a breakfast tray, as it was 30 minutes later than other residents who received a tray. The DON replied, The ones that are left are feeders. We keep the trays on the food cart to keep the food hot, and they get delivered last since they have to be fed.

Based on observations, record reviews, and resident and staff interviews, the facility failed to take prompt action to resolve grievances related to a lost item and meal preferences for 1 of 1 sampled residents (Resident #44). The findings include: 1. During an interview with Resident #44 on 12/19/2017 at 7:47 AM, the resident stated that the loss of laundry at the facility was unacceptable. Resident #44 stated the facility policy was that you were to report to the Social Service Director (SSD) the loss of an item and then give them a receipt, and they would replace your item. The resident stated the son had given her a twin set as a gift and half of it disappeared. The resident had reported the item missing several weeks ago, and hoped someone would look for it. The resident stated the facility did not attempt to recover missing items. Record review of the 12/5/2017 quarterly Minimum Data Set (MDS) assessment for Resident #44 found a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment. During an interview with the SSD on 12/21/17 09:34 AM, she stated that when someone reported something missing, they would look for it. If it was not found, they would replace it. She stated she had worked at the facility during the period of time Resident #44 had been at the facility, and Resident #44 had not reported anything missing. She provided the Grievance Log and there was no record of Resident #44 reporting missing items. Record review of the Grievance policy found under proceedures that employees are required to file a written missing items report to the Administrator or designee. During an interview with a laundry attendant (Employee J) on 12/21/17 12:42 PM, she stated the last time Resident #44 mentioned something missing to her was several weeks ago. She stated Resident #44 informed her of a missing hot pink shirt to match an over shirt. Employee J stated that she had not located it. She stated she would continue to look for it until she found out what happened to it. She stated if she did not locate it, she would tell the SSD or the Housekeeping and Security Director. She stated she would look in the rooms on the other hallways and in the rooms of residents with similar names. She stated she kept an eye out when putting things away. She stated there were also other employees that may have put it on the lost and found rack, but that it was not there now and that it was about time to do a grievance. She stated that she would normally do a sticky note downstairs for other staff to keep an eye out. She stated she had not done that yet. On 12/21/17 at 12:57 PM, Employee J brought a pink shirt to the surveyor. She stated she found the item in another resident's room and would bring it to Resident #44. 2. During an interview with Resident #44 on 12/19/17 08:01 AM, she stated she did not get what she ordered at the evening meal. She stated the Certified Dietary Manager (CDM) (Employee M) was aware and that it had just gotten worse. During a visit to see the resident in the room on 12/21/2017 at 8:45 AM, the resident stated she received a ham and cheese sandwich for dinner last night. The resident had to ask for mayonnaise. It would be nice if I did not always need to ask for something. During an interview with the SSD on 12/21/17 at 09:34 AM, she was asked about food complaints from Resident #44. She stated the CDM (Employee M) was in to see the resident all the time and would fix any food related issues. Record review of the Grievance Log found no complaints for Resident #44. In an interview the CDM on 12/21/17 at 9:47 AM, she stated Resident #44 had a selective menu that started on Sundays. The resident requested bread and butter at each meal and a soup spoon, so she wrote it on the menu. She stated she found the next day did not follow the menu. She stated she addressed it with the kitchen. The CDM stated the resident was correct. It was very often the kitchen did not send what the resident requested. She further stated she did not know what to do about it. She was asked if there was a way to see how the kitchen did not follow the resident's requests. She stated she did not keep a record. Employee M provided the menus for the resident 12/21/17 at 10:38 AM for Week 3. Bread and butter was written on the menu for dinner. During a visit to see Resident #44 on 12/22/17 at 09:00 AM, she was asked about dinner the night before. The resident received what was ordered, but the bread was missing. The resident stated that even the dietary slip had bread on it. The resident had to call for someone to get the bread. Record review of the progress notes for Resident #44 found the resident and son attended a 12/11/2017 care plan meeting. Food preferences for the evening meal were discussed and the notes documented the resident wanted bread and butter on the tray every evening and the Dietician was aware.