Every finding on record at The Center At Val Vista, Llc

Based on facility observations, staff interviews, record review, and a review of facility policies, the facility failed to ensure that dumpsters were maintained in a clean and sanitary condition. This deficient practice has the potential to increase pest infestations and contribute to the spread of disease-causing microorganisms throughout the facility environment. Findings included: An initial observation was conducted on June 16, 2026, at 8:14 a.m. of the dumpsters located outside the facility. During the observation, one dumpster lid was observed to be left open. Sixteen pairs of used gloves were scattered on the ground around the dumpsters. Oil traps were covered with dirt and leaves. In addition, a bag containing eight (8) used IV bags with attached connectors and tubing, along with other medical supply items, was observed on the ground. A grease trap containing accumulated landscaping debris was also observed in the dumpster area.A subsequent observation conducted on June 17, 2026, at 8:14 a.m. revealed the presence of an IV flush syringe, IV tubing, used gloves, and landscaping debris around the dumpsters. At the time of the observation, Staff #119 was observed using a shovel to clean the area surrounding the dumpsters. Staff #119 stated that he would clean the debris around the dumpsters. A third observation conducted on June 18, 2026, at 2:59 p.m. revealed that the dumpster area had not been completely cleaned, as landscaping debris remained present and one dumpster lid continued to be left fully open.An interview with the Maintenance Manager, Staff #123, was conducted on June 18, 2026, at 11:57 a.m. Staff #123 stated that the maintenance department collaborated with the kitchen staff to clean the dumpster area. Staff #123 explained that, at times, refuse collection trucks spilled trash while emptying the dumpsters and that the drivers did not clean debris that fell onto the ground. Staff #123 stated that the maintenance team typically cleaned the spilled trash but acknowledged that the department did not maintain a cleaning log to document routine cleaning activities and ensure accountability.A subsequent interview with the Kitchen Manager, Staff #119, was conducted on June 18, 2026, at 1:54 p.m. Staff #119 stated that the dumpsters located behind the facility were used by the entire facility and further stated that individuals from outside the facility also disposed of trash in those dumpsters. Staff #119 stated that the kitchen staff were responsible for cleaning the dumpster area and that his kitchen staff members were routinely reminded to keep the dumpsters clean. Staff #119 further stated that the dumpster area was cleaned once per week and acknowledged that no cleaning log was maintained. Staff #119 stated that the used gloves and other medical supply items observed during the initial observation may have been discarded by overnight staff while leaving the facility. Staff #119 acknowledged that the unsanitary conditions observed around the dumpsters could attract pests and increase the potential for the spread of pathogenic microorganisms. Staff #119 further stated that dumpster lids should remain closed at all times, biohazardous materials should not be disposed of in the dumpsters, and the dumpster enclosure should be secured with a coded lock accessible only to facility staff.An interview with the Director of Nursing Services, Staff #113, was conducted on June 18, 2026, at 10:35 a.m. Staff #113 stated that IV bags were disposed of in the regular trash after they had been emptied. Staff #113 stated that IV bags should have been properly disposed of and expressed surprise that they had been found outside the dumpsters. Staff #113 explained that the facility maintained separate disposal procedures for different categories of waste, including designated containers for biohazardous materials, which were collected and disposed of according to facility protocol. Staff #113 stated that facility staff did not dispose of biohazardous materials in the dumpsters.A request for the facility's policy regarding environmental cleanliness was made on June 17, 2026. A review of the policy titled Cleaning Rooms Policy, revised in February 2021, revealed that it did not provide specific guidance regarding the cleaning, maintenance, or sanitation of dumpsters. A subsequent request for the facility's homelike environment policy was made on June 18, 2026, at 1:10 p.m. A review of the policy titled Homelike Environment, last updated on March 14, 2024, revealed that it did not include guidance regarding dumpster maintenance or a routine dumpster cleaning schedule. Although both policies emphasized maintaining a safe environment for residents and staff through the prevention of healthcare-associated infections, including MRSA, Clostridioides difficile (C. difficile), and device-related infections, neither policy specifically addressed dumpster sanitation or maintenance. The Homelike Environment policy further stated that the facility recognized the importance of providing residents with an environment that closely resembled normal community living.

Based on observations, staff interviews, and facility policy and procedure, the facility failed to ensure food items were properly stored, labeled, dated and handled in accordance with professional standards and sanitary food service practices. The deficient practice had the potential to result in food contamination and place residents at risk for foodborne illness.Findings include:An initial walk-through of the kitchen was conducted on June 16, 2026, at 8:20 A.M with the Dietary Manager (Staff #119). Observations were made in the large walk-in refrigerator, freezer, and dry storage. The following food items were observed to be improperly stored:- Approximately two pounds of Mozzarella cheese dated 5/31 with no use-by date.-One open package of ham with no use-by date.- One-eighth pan of carrots past due date.- One-eighth pan of green beans past due date.- One opened bag of lettuce exposed to air.- Three 8-ounce cartons of TruMoo milk with expiration date of June 15, 2026.- Ten Peeled hard-boiled eggs open to the air.- One Container of strawberries with mold and past the storage date.- Ten ground beef hamburger patties opened and exposed to air.- Open opened bag of French fries with no opened or use-by date.- One 70-ounce bag of hash browns with no opened or use by date.- Seven slider burgers opened to air and no open or use by date - Seven fish patties with no opened or use-by date.- Fourteen slices of garlic bread with no opened or use-by date.- Eight Chicken patties exposed to air with no opened or use by date.- Eleven Italian chicken breasts exposed to air with no use by date.- One Pan of apple crumble with no use-by date.- Approximately one-half pound of potato wedges exposed to air with no opened or use by date.- One 20-ounce package of Chuck Wagon corn with no opened or use by date.- Twelve Blueberry pancakes with no opened or use by date.- Twenty-five frozen Chicken Kiev breasts exposed to air with no opened or use by date.- Six Chicken tenders with no opened or use-by date.- One Tub of tapioca pudding with no opened or use-by date.- One container of Folgers coffee with no cover.- One case of No Preservative Fruit with dirt and plastic particles on the top of the lid.During a kitchen walkthrough on June 16, 2026, at 8:20 A.M., the Dietary Manager (Staff#119) stated that all food items should be dated upon opening. He emphasized that food kept past its use-by date could cause foodborne illness. Staff #119 stated he had previously discussed these protocols with staff members. He further stated that kitchen staff members possess food handler's cards and are aware of food storage policies. He stated that food left exposed to air develops frostbite, resulting in a bland taste and a leather-like texture. An Observation conducted on June 16, 2026, at 8:30 A.M., revealed that Dietary Aid (Staff #111) was preparing food with long braids outside of her hair net.An interview conducted with the Dietary Manager (Staff #119) on June 16, 2026, at 8:38 A.M. He stated that Dietary Aid (Staff # 111) should have braids secured within the hairnet. He further stated that staff #111's braids could contaminate the food.An interview with Dietary Aid (Staff #111) was conducted on June 16, 2026, at 8:40 A.M. who stated that the risk of having hair exposed while preparing food could introduce bacteria and contamination into the food. She further stated she was unaware that her braids were extending outside of the hairnet. Sanitary bucket testing was conducted on June 17, 2026, at 8:14 A.M. The kitchen had 9 sanitary buckets throughout the kitchen. Three of nine buckets tested did not meet safety guidelines for required parts per million (ppm) for sanitizer concentrations. Staff #119 tested the 3 of 9 buckets, revealing no parts per million (ppm). The Registered Dietitian (Staff #98) was observed emptying the other buckets while testing was in progress, after she was informed not to do so while the testing was in progress. Observation on June 17, 2026, at 12:18 PM, revealed Activities assistant (Staff#6) pulled the tray cart and delivered meal trays to residents without performing hand hygiene after touching the tray cart. Staff #6 stated she was not aware she needed to sanitize her hands after pushing the tray cart before delivering trays. She further indicated she works in the activities department and was just trying to help. An interview with the dietary manager, staff #119, was conducted on June 17, 2026, at 8:24 P.M. Staff #119 stated that staff #6 did not know she needed to sanitize her hands after touching the tray cart; she usually does not pass trays. He further stated that not sanitizing hands after touching the cart could lead to the introduction of bacteria to the food trays being delivered to residents.On June 18, 2026, at 9:30 AM, an interview was conducted with Dietary Manager staff #119, who stated he has been the dietary manager for the facility for four years. He emphasized the importance of dating food items when opened, as well as their use-by dates. He noted that dry storage should be rotated based on the dates and declared the need to discuss proper dating and labeling practices with his staff. The Dietary manager (#119) presented a staff meeting sign-in sheet dated June 6, 2026, to discuss the identified concerns, however the meeting was not conducted. He outlined expectations for the freezer, stating that staff should ensure all bags are closed and clearly marked with open and use-by dates to prevent cross-contamination, foodborne illness, and frostbite. He further stated that without proper labeling and dating, it would be difficult to determine whether food items remained within their use-by dates.A third observation was conducted on June 18, 2026, at 9:53 A.M. Three sanitary buckets were tested in the food prep area; two of the three buckets failed with a reading of 100 ppm and 200 ppm.An interview was conducted on June 18, 2026, at 1:10 P.M. with the Administrator (staff #117), who emphasized the importance of labeling and dating all food items. He further stated that the uncertainty of food items when opened could lead to spoiled food and potential health risks for residents. A review of the facility policy titled Food Storage Policy dated September 4, 2028, with a revision dated February 8, 2021, states that on the same day that food products are delivered to the facility, they are to be inspected for safety and quality. Each item is to be accurately dated upon receipt. When items are opened for use, use-by-dates are to be labeled upon them, followed by storing the item in the proper area, such as the Refrigerator, Freezer, or Dry Storage area located in the kitchen. All outdated, expired, or damaged food products are to be discarded immediately. Proper food sanitation guidelines are to be followed. Food from outside sources is to be stored in the refrigerators located on floors two and three with the correct date.

Based on observations, clinical record review, staff interviews, and facility policy and procedure review, the facility failed to ensure that medications were properly stored and not left unattended at the bedside for one of one sampled resident (Resident #35). The resident census (universe) was 62. This deficient practice had the potential to result in residents who are prone to accidents, as well as visitors, having unrestricted access to medications. Findings Include: Resident #35 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, acute pulmonary edema, generalized muscle weakness, dysphagia, oropharyngeal phase, and other comorbidities.A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.An observation was conducted of Resident #35's room on June 16, 2026, at 10:13 a.m. During the observation, two tablets were noted in a medication cup on the resident's bedside table. The resident stated that the tablets were vitamin C that the nurse had given him to take. The resident further stated that he had taken these medications independently since his admission.An immediate interview was conducted with Staff #500 (Licensed Practical Nurse, LPN), the nurse assigned to the resident at the time, on June 16, 2026, at 10:20 a.m. Staff #500 stated that the tablets were vitamin C for the resident to take. Staff #500 further stated that the resident was able to take the medications independently and that no incidents related to the practice had been reported. However, Staff #500 stated that she was unfamiliar with the facility's expectations regarding resident self-administration of medications because she was a registry nurse and indicated that she would verify the resident's self-administration status with the nurse leadership.A review of the resident's Order Summary on June 16, 2026, revealed no physician's order authorizing self-administration of vitamin C. A concurrent review of the resident's care plan revealed no evidence of a medication self-administration assessment or care plan. However, a follow-up review conducted during the investigation on June 17, 2026, revealed that a new care plan for self-administration of medications, excluding narcotics, had been initiated on June 16, 2026. This care plan was not present during the initial review conducted on June 16, 2026. An additional review of a care plan originally initiated on June 8, 2026, revealed that the resident was receiving speech therapy for swallowing deficits and pain when swallowing solid foods.An interview with Staff #15 (Registered Nurse, RN) was conducted on June 18, 2026, at 10:47 a.m. Staff #15 stated that she was familiar with Resident #35 and indicated that the resident often waited for his spouse before taking his medications. Staff #15 further stated that the resident was alert and oriented and had a care plan for self-administration of medications that was initiated on June 16, 2026.A subsequent interview was conducted with the Director of Nursing Services, Staff #113, on June 18, 2026, at 12:49 p.m. Staff #113 stated that she was familiar with Resident #35 because she routinely assisted with breakfast tray service in the mornings. Staff #113 stated that resident care was provided according to the care plan, physician's orders, and the outcomes of interdisciplinary team (IDT) meetings. Staff #113 further stated that nursing staff prepared Resident #35's medications in accordance with the physician's orders, left the medications with the resident, and later returned to verify that the medications had been taken. However, Staff #113 acknowledged that the physician's order authorizing self-administration of medications, excluding narcotics, was not entered until June 16, 2026. A review of the physician's order revealed that it was signed at 11:24 a.m. on June 16, 2026, approximately one hour after the medications were observed unattended at Resident #35's bedside. Staff #113 further stated that there were inherent risks associated with residents self-administering medications but believed Resident #35 was capable because he was alert, oriented, and willing to take his own medications.A review of the facility policy titled Medication Administration, last reviewed on March 14, 2024, revealed that medications were to be administered as prescribed by the attending physician. The policy further stated that medications must be administered in accordance with the written orders of the attending physician, may not be set up in advance, and must be administered within one hour before or after the prescribed administration time.

Based on observations, staff interviews, facility documentation, and review of facility's policy, the facility failed to ensure that infection control standards were followed during wound care for one resident (#157). The deficient practice could result in the spread of infection. Findings include: Resident #157 was admitted to the facility on [DATE] with a diagnosis that included acute on chronic systolic (congestive) heart failure and acute respiratory failure with hypoxia. Review of care plan initiated on April 26, 2025 revealed that resident #157 has an actual skin breakdown, present on admission, located in the coccyx related to general poor health. The interventions included to notify physician for any signs and symptoms of infections and wound nurse to evaluate and treat. A review of record titled, Wound Care Evaluation, dated April 27, 2025 at 09:53 AM revealed the resident has an unstageable pressure wound in the coccyx area measuring 10.5 centimeter (cm) in length by 14.5 cm in width by and depth is unable to determine (UTD). The record also revealed that the wound has a scant amount of serous sanguineous exudate, has a non-blanchable purple peri wound and redness. On May 1, 2025 at 08:52 AM, an interview was conducted with a Licensed Practical Nurse (LPN)/Wound Nurse/Staff #22. Staff #22 stated that as a wound nurse, she evaluates and performs treatments for wounds such as abrasions, blisters, surgical wounds, and pressure wounds. For a new resident, she stated that she performs a full head to toe assessment after the new resident had been admitted in the facility after 24 hours. Her assessment is documented in Point Click Care (PCC) in the skin evaluation, in the care plan, and in the treatment administration record. She stated that when a resident comes with a wound, it is documented as present on admission. She also stated that her work schedule is from Monday through Friday from 08:00 AM through 04:30 PM, and when she is not on schedule, there are several nurses that covers the wound care treatment, wound documentation, and head to toe assessment for new admissions during the weekend. She stated that she reviews and double check what the other nurses have done. She stated that as long as someone observed the wound, and documented the wound within the 24-hour period, she will follow up with the wound and document in more detailed. She stated that all nurses know how to do wound treatment because there is an order that they can follow. She also stated that she will contact the resident's provider or surgeon if she finds something is wrong with the wound. In addition, she stated that if a resident is at risk for pressure ulcer such as mobility issue, she will put in pressure prevention measures in place, which include the use of a skin barrier, offloading of heels, repositioning, and low air loss mattress (LALM). A wound care observation was conducted on May 1, 2025 at 10:54 AM with Staff #22 in Resident #157's room. The following were observed: -Staff #22 washed her hands in the sink; -Resident #157 has a personal caregiver at bedside; -Staff #22 and the caregiver put in new gloves; -Resident was repositioned to her left side; -Staff #22 removed a foam dressing from resident's back, then she removed her gloves; -Staff #22 put in new gloves, cleanse the wound with saline and gauze, then pat the wound to dry. She then removed her gloves and then put in another new gloves to place a pad on the bed, then opened a packet of tongue depressor, use the tongue depressor to apply Medihoney to resident's wound. After that, she removed her old gloves and then put on another new glove, then applied a new foam dressing to cover the right buttock wound site; -Staff #22 stated that the wound care dressing change was done, and stated that she will just help the caregiver with patient care before getting resident up out of bed. Right after Staff #22 stepped out of resident's room, another interview was conducted and Staff #22 described the resident's wound as improving pressure wound; it is unstageable; the wound bed has 20% adherence slough and 25 % granulating tissue; the peri wound and surrounding tissue were non-blanchable. She stated that she did not wear a gown because the wound is not draining. A review of treatment administration record (TAR) for May 1, 2025 revealed a treatment order for the coccyx to cleanse with normal saline, pat dry, apply medihoney, cover with secondary dressing every day shift and as needed for soiling/dislodgement for wound care. A review of nursing progress note titled, Skin/Wound Note, dated May 1, 2025 at 10:44 AM revealed a coccyx present on admission unstageable. The progress notes revealed resident at risk for delay in wound healing/at risk for skin breakdown due to comorbidities and past medical history. An interview was conducted on May 1, 2025 at 01:50 PM with the Director of Nursing/Staff #186. The DON stated that regarding the use of Enhanced Based Precaution (EBP), if resident has an indwelling device, or excessive wound drainage, her staff will gown up, use Personal Protective Equipment (PPE) during cares of high contact so not to transfer potential infection or not known infection to anyone. The DON defined an excessive drainage of wound as something splashable, or excessive amount of exudate/drainage. She stated that for pressure wound if no wound exudate, there is no indication of placing the resident on EBP. She stated that if a wound dressing change happens to be more than once a day that will constitute the use of EBP. She stated that exudate can be slough, and a wound that has a lot of exudate, the resident will be on EBP. And, if the wound is stable without gross amount of exudate and not constantly soiling the bandage, the resident will not be on EBP. The DON stated that some residents with wounds are on EBP and some are not. If a resident has an open pressure ulcer with scant or without drainage, the resident will not be on EBP. The DON stated that a stage 1 and stage 2 pressure ulcers will not be on EBP because there is no excessive drainage, not all wounds need enhanced barrier precaution. If there is no drainage that would splash on the staff, no EBP is needed. The DON stated that the facility follows the most current Centers for Disease and Control (CDC) EBP guidance which went into effect a year and half ago. The DON stated that a wound is subjective, and residents with an indwelling urinary catheter are on EBP. An interview was conducted on May 2, 2025 at 11:29 AM with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP)/Staff #187 in her office. Staff #187 stated that Transmission Based Precaution (TBP) is used for contact and droplet precautions such as COVID, Flu, and C Diff infections. She sets up the room to place signage and equipment. Regarding EBP, she stated that if a resident is coming in with an indwelling urinary catheter or an intravenous line, the admission staff or the charge nurse will initiate the EBP. A resident with a wound, the wound nurse will initiate EBP if meets the criteria. She stated that residents with wounds that are chronic, not intended to heal quickly, and has drainage are placed on EBP, and skin tears, sheering, surgical sites with staples are not placed on EBP. In addition, she stated that pressure sores if not draining are not on EBP. She stated that an open wound if not draining, projected to heal on a timely manner is not placed on EBP and that is what the guidance says. She also stated that if the wound team evaluates the resident and they feel that the wound is going to heal timely, no EBP is required. During the interview with the ADON/IP in her office, the wound nurse and the DON arrived outside her office waiting by the door. At 11:39 AM another interview was conducted with the wound nurse/Staff #22 and present during the interview is the DON. The wound nurse stated that a Medihoney is a wound ointment, use often for slough moist eschar, use for a stage 2 and stage 3 pressure wound if slough is present in the wound bed, to keep wound bed moist, dry, and clean, and it is an antimicrobial. Staff #22 stated that a Medihoney ointment would not be used on a close wound. A Medihoney ointment will be used on open wounds. Staff #22 stated that Resident #157 unstageable pressure wound means that resident has slough in the wound bed, a necrotic tissue, and that she has been working with the resident's wound since she arrived to the facility. A review of facility's policy titled, Infection Prevention and Control Program, reviewed and revised on May 18, 2022 revealed (4) Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services; and c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. A review of facility's policy titled, Enhanced Barrier Precautions, issuing date March 27, 2024 to be implemented by April 5, 2024 revealed that EBP are required for patients with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Wounds that are chronic with drainage, pressure ulcers, diabetic foot ulcers, unhealed surgical wound that have dehisced and have drainage, venous stasis ulcers will be considered for EBP.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure scheduled medications were administered accurately according to the physician's order for one resident (#156) for a sample of six residents. The deficient practice could result in medications not being administered according to physician's orders. Findings include: Resident #156 was admitted to the facility on [DATE] with a diagnosis that included acute kidney failure, hypertension, chronic obstructive pulmonary disease (COPD), depressive episodes, and generalized osteoarthritis. Review of admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13.0, indicating cognitively intact. Review of care plan dated April 8, 2025 revealed resident is at risk for muscular skeletal complications related to osteoarthritis. The interventions included to administer medications per physician's orders and assess for pain every shift. On April 30, 2025 at 08:06 AM, a medication administration observation was conducted with a Registered Nurse (RN)/Staff #45 for Resident #156. The following medications were prepared for the resident: -Lidocaine 4% two patches; -Vitamin D 25 mcg (microgram) two tablets; -Acetaminophen 325 mg (milligram) two tablets; -Bupropion HCl (hydrochloride) XL (extended release)150 mg one tablet; -Furosemide 20 mg one tablet; -Gabapentin 600 mg one tablet; -Sertraline HCL 100 mg one tablet; and -Potassium Chloride ER (extended release) 10 meq (milli equivalence) one tablet. At 08:13 AM, Staff #45 entered the resident's room with the resident's medications. After administering the medication tablets to the resident, Staff #45 applied the lidocaine patches. One lidocaine patch was placed on the resident's lower back and the other lidocaine patch was applied to the resident's upper back below the neck. Review of physician's orders conducted on April 30, 2025, revealed an order for Aspercreme Lidocaine Patch 4% (Lidocaine) apply to lower back topically two times a day for pain on at 0800 and off at 2000. However, during the medication administration observation, Staff #45 was observed preparing for two-Lidocaine 4% patch, and then applied one patch to the resident's lower back and the other patch was applied to the resident's upper back. An interview was conducted on May 1, 2025 at 10:15 AM with a Licensed Practical Nurse (LPN)/Staff #52. Staff #52 stated that regarding a lidocaine patch order lidocaine patch 4% apply to effective area 2 times a day, she stated that the order meant to put it on at 0800 AM and then take it off at 0800 PM. She added that the order should say one time a day, first touch is to apply it on the area and the second touch is to take it off, and that is how she understands the order. She also stated that the lidocaine medication will not be effective if taken off early. In addition, she stated that if she does not understand an order, she will ask assistance from her charge nurse. An interview was conducted on May 1, 2025 at 10:33 AM with Resident (#156) in the resident's room. Resident stated that most of the medications she is receiving at the facility she already knows because she has been taking the medications for a long time. She stated that the staffs are very efficient. Regarding the lidocaine patch medication, she stated that she gets one on the neck and one on the lower back. She gets two patches, applied at the same time, and the patches has to stay on for twelve hours. An interview was conducted on May 1, 2025 at 01:37 PM with the Director of Nursing (DON)/Staff #186 in the dining room. The DON stated that the process for medication administration is after her staff gets report and accepted the assignment, her staff will start going through the residents' medication record; follow the physician's orders for the right resident, right route, right time; gather supplies as needed like water, apple sauce, alcohol prep pad; do blood pressure checks so everything will be ready to give medications; and then sign the Medication Administration Record (MAR). Regarding physician's orders, the DON stated that the process is that the physician provides the orders, her staff transcribes the orders in PCC (Point Click Care), there is an agreement with the plan of care with the resident or family so they are aware of the plan; and then the order is automatically sent to the pharmacy. Her expectation with her staff is that her staff follows the physician orders and questions an order if the order is unclear for instance for potential allergy or contraindication. During the interview, the DON opened Resident #156's April 2025 MAR with her laptop to look at the Lidocaine medication order. After the DON read the order, to apply to lower back twice a day, the DON stated that to populate the order in the PCC, it will trigger a supplemental documentation for to be on at 0800 AM and off at 0800 PM. She stated that the dose for each lidocaine patch is 4%, and one patch comes in a foil package. She stated that the order for Resident #156 is one patch a day on in am and off at bedtime, and not applying two separate times. Her expectation for her staff is to follow the physician's order and question if there are concerns with the order. She stated that she will clarify the Lidocaine order with the resident's physician. Review of facility's policy titled, Medication and Treatment Orders, with a revised date of July 2016 revealed that medications and treatments will be consistent with principles of safe and effective order writing, and (1) administered only upon the written order of a person duly licensed and authorized to prescribe such medications.

Based on clinical record review, observations, resident and staff interviews, and review of policy, the facility failed to ensure medications were not left in the room and resident was assessed to self-administration of medication for one resident (#148). The deficient practice could result in medications not being taken as ordered and residents unsafely administering medications. Findings include: Resident #148 was admitted to the facility on [DATE] with a diagnosis of encephalopathy, type 2 diabetes mellitus, anxiety disorder, depressive episodes, hypertension, and dementia. Review of care plan initiated on April 10, 2025 revealed resident has a risk for cognitive/neurological complications related to encephalopathy. The interventions included to administer medications as per physician's orders, allow resident time to communicate, allow resident to make as simple decisions regarding their care and activities. Review of another care plan revealed resident is confuse/forgetful at times. The interventions initiated on April 11, 2025 included to assist as needed, provide consistent caregivers, and remind and cue as needed. Review of admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10.0, moderately impaired cognition and resident required partial/moderate assistance with personal hygiene. Review of physician's order revealed that on April 24, 2025 an order for Hydrocortisone External Cream 2.5 % to be applied to the affected area topically every 4 hours as needed for itching eczema. During an observation conducted on April 29, 2025 at 09:19 AM, two medications were observed on the resident's bedside table. One medication was labeled Hydrocortisone 2.5% in a white container for eczema and the other one was labeled Vicks in a bluish small container. An interview was immediately conducted with the resident who stated that the Vicks is for breathing to open her sinuses. An interview was conducted on April 29, 2025 at 09:29 AM with a Licensed Practical Nurse (LPN)/Staff #62 in the resident's room. Staff #62 stated that she did not realized that the medications which she identified as hydrocortisone cream and Vicks were in the resident's room. She stated that she will take it with her, label it with the resident's name, and to get a physician's order. On April 29, 2025 at 17:11 PM, review of record revealed a Self-Medication Evaluation was performed for Resident #148 for the medication Vapor Rub. However, there is no Self-Medication Evaluation performed for the medication Hydrocortisone 2.5% external cream. Review of physician's order dated April 29, 2025 revealed an order for Vaporizing Chest Rub external ointment to be applied outside of nostril topically every 6 hours as needed, allowed to self-administer and keep at bedside, unsupervised self-administration. Review of care plan initiated on April 29, 2025 revealed a medication self-administration for vaporizing chest rub. An interview was conducted on May 1, 2025 at 2:06 PM with the Director of Nursing (DON)/Staff #186 in the dining room. The DON stated that regarding self-administration of medication, if a resident wants to self-administer, the process is that she will check with the resident's doctor, make sure resident is able and safely self-administer the medication, encourage the resident to keep the medication in a bag or in a drawer, she prefers that the medication is not laying out, and she added that their residents in the facility are in private rooms. In addition, the DON stated that if resident is deemed capable of self-administration, she will obtain an order for self-administration. The DON stated that assessment for self-administration is done as soon as possible when aware that the resident has the medication. The DON also stated that they have a process when visitors come in, their sign -in log has an acknowledgement not to bring in medication for the resident, and if they bring in medication to take it to the nurse. The DON stated that if she finds for instance a medication at the resident's bedside, she will start the process for self-administration of medication. Regarding hydrocortisone medication left at bedside, the DON stated that she expects her staff to get a self-administration order, do an evaluation and care plan. The DON stated that the goal is to do it right away. On May 1, 2025 at 14:29 PM, review of nursing progress note title, Daily Nursing Note, revealed that a nurse notified the resident's provider to approved resident's self-administration of hydrocortisone cream for eczema, and an evaluation and care plan was completed. An interview was conducted on May 2, 2025 at 10:34 AM with an LPN/Staff #85 in the third-floor nursing station. She stated that medication administration includes right dose, right route, right time and right resident. If there is a concern with a medication, for instant low blood pressure, she will notify the doctor. Regarding medication brought in from the outside for the resident, she stated that the process is that it has to be confirmed with the doctor, and the container has a label. She will add the medication in the medication list of the resident, and she will keep the medication inside her medication cart. She stated that she will not leave the medication at the bedside unless there is an order to self-administer because it is not safe, they might not take the medication as ordered, and she must have a visual for the resident taking and swallowing the medication because the medication might fall on the floor. She will not leave a medicated cream at bedside, she will return it in the treatment cart. She stated that for a hydrocortisone cream medication, she will not leave the medication at the bedside because the resident might put it in a body part that should not be on, or might put it on excessively, or if the resident is confuse, the resident might eat it. Review of facility's policy titled, Medication Administration, with a revised date of February 8, 2021 revealed that medications are to be administered as prescribed by the attending physician. Review of another facility policy titled, Self-administration of Medications, with a revised date of February 8, 2021 revealed that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for resident to do so.

Based on observations, resident and staff interviews, and facility documentation, the facility failed to ensure that one resident (#42) was free from the accident hazard of self-administering medications not ordered by the physician. This deficient practice could result in resident taking medications with contraindications. Findings include: Resident #42 admitted to the facility on [DATE] with a hip fracture, Deep Venous Thrombosis Prophylaxis, and history of breast cancer. She had a physician's order for an injection of the anticoagulant Enoxaparin 40 mg (milligram) one time a day dated [DATE], and supplement which included two 500mg Ascorbic Acid Tablets ordered [DATE] and two tablets of Cholecalciferol Oral Tablet 25 micrograms ordered [DATE]. Review of the Medication Administration Record for [DATE] showed she received all the above medications as ordered. According to the Minimum Data Set assessment conducted on [DATE] she scored a 10 on the Brief Interview for Mental Status, which indicates moderate cognitive impairment. In the care plan initiated on [DATE], Resident #42 has a goal for not having any complications due to not receiving cancer treatment during her stay at the facility. Resident #42 is also care planned for anticoagulant use. Interventions for these goals includes administer medications per physician orders and monitor frequently. On [DATE] at 10:01 AM, surveyor observed a pill box with medication on Resident #42's bedside table. On another counter in her room were medications including Triphala 1000 mg capsules, Vitamin D3, Vitamin K, and 800 mg calcium supplement. On a second observation on [DATE] at 2:22 PM, surveyor observed Registered Nurse (RN) Staff #210 inside Resident #42's room passing medication. On [DATE] at 2:27 PM surveyor entered the room to interview Resident #42 privately. Her husband was present. Resident #42 stated she did not recall doing a self-administration of medications assessment. She confirmed she does take the medications and the doctor is aware and had told her he is okay with it. Husband stated the pill box still had some days with pills in it and expressed upset that his wife had not been taking them as she should have been. In an interview with RN Staff #210 on [DATE] at 2:32 PM when asked how residents are assessed for whether they can self-administer medications or not, she stated the nurse will determine if the patient is eligible and if so, let the provider know so that they can input an order for self-administration of medications. If approved for self-administration of medications, then the resident will keep their medications in their room in the bedside drawer. When asked specifically about the medications in Resident #42's room, Staff #210 stated she would need to check in the EHR (electronic health record) for the orders and if she could self-administer medications. In a follow up interview with staff #210 on the same day at 3:01 PM, she clarified that before they could self-administer medications residents were required to demonstrate they could safely and properly administer medications, receive education about safety, verbalize understanding, and store medication in a cabinet. She stated that earlier she had not seen the pill box, only the pill bottles. She advised that the husband had brought the medications in and had now been educated about not bringing pills into the facility for his wife. During an interview on [DATE] at 3:02 PM with the Director of Nursing (DON) Staff #357, when asked if residents are able to bring in medications, vitamins, etc. and keep in room she stated they can if the facility knows about it. For even OTC (over the counter) medications the facility would need to call the doctor to make sure it is safe and okay. They then encourage residents not to leave medications out. For example, an inhaler would need to be in drawer or for allergy shots administered by a family member, they would need to demonstrate they could administer them without a nurse. The self-administration assessment process starts with the nurse completing the assessment. Then the provider will specify on the order if administration needs to be supervised or not. The DON stated that with regards to Resident #42, they had talked to the husband about bringing pills in. He had left the building at the time of surveyor requesting a list of the bedside medications and facility staff were not able to identify the pills. DON reiterated that RN Staff #210 had said husband brought them in from home today. In a follow up interview with the DON on [DATE] at 3:43 PM when asked about potential risks of Resident #42 being on an anticoagulant and taking Vitamin K, she stated in general it would probably be counterproductive but depended on the blood thinner. If coumadin, it would essentially be an antidote, but with Lovenox she would need to know exact dosage of the Vitamin K and would follow up with the pharmacist. DON confirmed they went through Resident #42's room and did not find any other medications. After following up with the pharmacist about the risks of Lovenox, DON returned on [DATE] at 8:15 AM to confirm there was no current risk for Resident #42 if she had taken or been taking Vitamin K. A review of physician orders and Resident #42's electronic chart on [DATE] revealed no self-administration of medications evaluation as well as no orders from the physician and no orders for any of the vitamins. In a clarifying interview with Resident #42 on [DATE] at 2:39 PM, she stated the doctor at this facility had been in her room to speak with her and seen the pill bottles she keeps on the countertop. According to her, he stated she could take them as they were just regular vitamins. She was adamant that she had been taking the medications since she arrived at this facility. In a final interview with the DON on [DATE] at 8:29 AM, she stated that while residents are encouraged not to bring medications from home, her expectations for her staff are to fill the requested medications from the pharmacy to ensure it is the same dose each time, that it is the actual medication that is listed on the bottle, and that the pills are not expired. She stated that this is important for patient safety. If staff does not know what a patient is taking and the patient were to become unresponsive, they would not be able to know if it was an allergic reaction or an interaction between medications. When emergency medical services arrive, they would need to be able to let them know about risks of contraindications, medication reactions, allergies, etc. Medications can also change from home to the hospital to the skilled nursing facility and patient may not be aware. For Resident #42 specifically, the DON stated she was not on Lovenox at home and would therefore have been unaware of any potential risk if she had taken Vitamin K. In facility policy titled Self-Administration of Medications last revised [DATE], it states the nursing staff will document their findings and the choices of patients who are able to self-administer medications . Self-administered medications must be stored in a safe and secure place which is not accessible by other patients .Staff shall identify and give to the charge nurse any medications found at the bedside table that are not authorized for self-administration.

Based on observations, clinical record review, staff and family interviews and facility policy review, the facility failed to ensure reasonable care for the protection of the resident's medical assistive property from loss or theft for one resident (#219). The deficient practice could result in resident not provided with a homelike environment. Findings include: Resident #219 was admitted on [DATE] with diagnoses of laceration without foreign body of other part of head, hypo-osmolality and hyponatremia, syndrome of inappropriate secretion of antidiuretic hormone, muscle weakness, difficulty in walking, essential (primary) hypertension, dysphagia, oropharyngeal phase, cognitive communication deficit, hypokalemia, long term (current) use of anticoagulants, encounter for surgical aftercare following surgery on the circulatory system, personal history of transient ischemic attack, and cerebral infarction without residual deficits. Observation and resident interview conducted on December 26, 2023 at 10:03 AM the resident stated, My hearing aids were lost when I got here, both sides are missing, I just had them adjusted and they can take up to two weeks to get new ones. I could cry! I had them when I came in. I told the nurses and all they say is, oh dear how terrible. Observed the resident's hearing aid case with no hearing aids but a package of batteries was found in the residents hearing aid case. Observed the resident in having difficulty hearing and resulted in nearly shouting to resident in order to hear questions. Observed the resident tearfully distraught in describing her missing hearing aids. The Resident Dashboard (December 24, 2023) reports a BIMS (Brief Interview for Mental Status) score of 8 indicating the resident had moderately impaired cognition. Review of Nursing Comprehensive Admission Data Collection V8 document (December 21, 2023) and revealed that a Licensed Practical Nurse (staff #60) annotated the resident to use hearing aids on admission. Review of resident Care Plan and revealed the Focus statement (December 26, 2023), Patient's is hard of hearing Patient has hearing aid in both ears. The Goal states, Patient's needs will be met every shift X 90 days. The Interventions states, Eliminate distractions or background noise. Give clear & simple directions. Staff to adjust tone and volume of voice as needed. The resident Care Plan was initiated 12/26/2023 and created by a Registed Nurse (staff #421), MDS Coordinator and revised on 12/27/2023 by (staff #421), MDS Coordinator. Review of Case Management Progress Note (December 21, 2023 at 4:24 PM) and revealed admission was conducted with the resident expressing verbal understanding and all questions were answered at this time. Note Text: [NAME] arrived safely to the facility via stretcher with AZ Patient Transport. This writer welcomed & greeted patient upon her arrival to the facility and provided the room number she will be going into. This writer spoke with the resident's daughter in law at [PHONE NUMBER] and informed her of patient's safe arrival to the facility & reiterated visiting policy & procedure. This writer explained that any scheduled appointments do need to pertain to admitting diagnosis and it is important that family meet them at the appointment to provide proper insurance cards and identification. Care Plan meeting with IDT members, patient & family was offered at this time, but declined. The daughter in-law was informed to contact case management to arrange per request and she expressed verbal understanding & all questions were answered at this time. Family interview conducted on December 27, 2023 at 12:45 PM via phone with the resident's son and he stated, She got in there on Thursday and it was Saturday that we discovered it was no longer there and they stated they have no idea what idea what happened to them, spoke with staff #521 one of the nurses. She had her hearing aids at the time of admission. I am in the process of getting her hearing aids replaced at Costco and making appointments to have her hearing tests done for her hearing aid replacement. Interview conducted on December 27, 2023 at 1:07 PM with a Registered Nurse (staff #210) and the , Staff Development Coordinator (staff #740). Staff #210 stated, I was told that that we can't find her hearing aids. I started her care on December 24, 2023. I wasn't here during her admission.Staff #740 stated, For facility policy in regards to missing property, case management completes a grievance. When patient arrive, they sign consents for their own property, they are responsible for their own items, we recommend that they send valuables homes, we do have a policy for reimbursing. During an interview conducted on December 27, 2023 1:34 PM with a Licensed Practical Nurse,(staff #50) Director of Case Management. Staff #50 stated, Her son called yesterday to find out why she was at the facility and I was informed about her missing hearing aids yesterday. The resident was admitted on [DATE], Thursday and was interviewed by the case manager, on Friday and she didn't mention anything about the hearing aids. For residents with cash we do an inventory for their cash and put into a safe, we don't inventory personal property, we suggest to the family to take their property home and for those who refuse we say we are not responsible for lost or stolen property. The policy that address this might be in the admission packet. Medical assistive devices are documented in the care plan, we've had residents who have lost dentures and we've replaced them depending on the situation. Reviewed facility policy PATIENT RIGHTS: PLANNING AND IMPLEMENTING CARE and revealed the statement Personal clothing and effects including personal property are patient responsibility per admission agreement. The Patient agrees to take reasonable precautions to safe keep this property by indelibly marking personal belongings at or before time of admission. The Patient shall be responsible for providing any desired insurance protection covering loss of property. Reviewed facility policy ADMISSION CRITERIA and revealed the statement 2. Residents (and potential residents) will not be asked or required to: c. waive facility liability for losses of personal property . Interview conducted on December 27, 2023 at 2:26 PM with the Executive Director (staff #235). Staff #235 stated, When they admit, we ask family members to take valuables home we don't do the personal property inventory because patients are in and out in a short time and when family would often bring items and it was hard to keep up inventory and corporate changed the policy on personal inventory. For medical assistive devices we keep in the room and keep an eye on it, like for hearing aids and dentures. When they come up missing we typically replace them and work with the family. For missing items, I didn't think we had to do a facility report if it was rectified but it if was stolen then we would report. I'm understanding if it something is lost then we do a grievance and replace if needed. I expect my staff to report missing items pretty quick because it can be time sensitive. I expect my team to call me at any time and I have a charge nurse to begin to look for it. I do have leadership here seven days a week to report as needed. In regards to the risk of missing medical assistive devices, the Executive Director (staff #235 stated), There are safety concerns, a resident cant' eat if dentures are lost, for hearing aids .we want to replace quickly. The Director of Nursing (DON, staff #357) entered the facility meeting room with the surveyors on December 28, 2023 at 9:05 AM and presented her staff interviews and Nursing Comprehensive Admission Data Collection documentation in regards to the resident's missing hearing aids. The DON (staff #357) explained that after nine staff interviews, all staff interviewed stated that the resident did not admit to the facility with her hearing aids. The DON (staff #357) further explained that the Nursing Comprehensive Admission Data Collection V8 document (December 21, 2023) completed by a Licensed Practical Nurse (staff #60) was not completely charted and omitted the comment that the resident did not have her hearing aids upon admission and the LPN (staff #60) was educated by the DON (staff #357) to add comments like this to the comment or additional information section. After review of the submitted documentation by the DON and consideration of the collected interviews, record review, and observation it was explained to the DON that this would be a potential citation. The DON's loud and abrasive response was You're going to take the word of a [AGE] year-old woman? as she left the facility meeting room.

Based on observations, staff interviews and policy and procedures, the facility failed to ensure the daily nursing staffing information posted was accurate. The deficient practice could result in residents and/or resident representatives not being informed of accurate and current staffing information. Findings include: An observation of the Daily Staff Posting located at the counter on the second floor was conducted on June 21, 2021 at 8:32 a.m. The posting had a census of 52, was dated June 17, 2021 and did not include the actual hours worked by staff directly responsible for resident care per shift. On June 21, 2021 at 8:45 a.m., an observation of the Daily Staff Posting located at the counter on the third floor was conducted. The posting had a census of 48, was dated June 7, 2021 and did not include the actual hours worked by staff directly responsible for resident care per shift. At 8:47 a.m., the scheduler (staff #56) removed the old Daily Staff Posting that was posted and replaced it with a new posting that had a date of June 21, 2021. The new posting included a census of 59; however, the actual hours worked by staff directly responsible for resident care per shift was not included in the new posting. During an interview conducted on June 22, 2021 at 1:35 p.m. with the scheduler (staff #2), she said the Daily Staffing Posting shows resident family and visitors that the facility had enough staff and had a safe staffing ratio. Staff #2 said she was responsible for ensuring that the Daily Staff Posting has the correct information, is completed and posted. Staff #2 also said the admissions or weekend receptionist is responsible for doing this task when she is not at the facility. Staff #2 said the Director of Nursing (DON/staff #51) is responsible for sending her the posting information through an email each morning and for reviewing the posting. Staff #2 stated she updates the posting when staffing changes occur prior to 9:00 a.m. and she tries to update the posting if changes occur after 9:00 a.m. Staff #2 said the following information are included in the posting: patient care nursing hours, number of nurses and certified nurse assistants (CNAs) scheduled to work on each shift, the census, the date, and the total number of staff scheduled to work that day. However, staff #2 said she had never documented the actual hours worked by staff on the Daily Staff Posting. An interview was conducted with the (DON/staff #51) on June 23, 2021 at 10:37 a.m. The DON stated that staff #2 is responsible for doing the Daily Staff Posting; and that, she and staff #2 are both responsible for ensuring the posting is correct. The DON stated the posting was supposed to have the facility census, date, the number of nurses and CNAs, the number of hours each staff is working and the total number of hours worked by staff. The DON said each morning when she arrives for the shift she reviews the actual hours worked by staff the day before; and, based on the information she knows what staffing changes needs to be done. The DON stated that she documents the changes made on the Daily Staff Posting form the following morning. Regarding the Daily Staff information posted at the second and third floor, the DON said she and staff #2 were at the facility over the weekend on Saturday (June 19) and Sunday (June 20). The DON said that she and staff #2 walked around the facility and posted the Daily Staffing Postings on both days. The DON further stated that staff #2 must have printed the wrong date for the postings. The facility's policy on Daily Staffing Post dated February 1, 2016 stated that the facility will post the daily nursing staffing hours according to number of each discipline and amount of hours scheduled to work along with the daily census. Staffing post will be for all staff, visitors, patients and vendor to view easily in plain sight.

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure one resident's (#3) medical record was accurate and complete. The deficient practice could result in the medical record not reflecting the resident's condition and the care and services provided across all disciplines. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (antihypertensive) 100 milligrams (mg) tablet by mouth two times a day for hypertension and to hold medication if systolic blood pressure (SBP) is less than 130 millimeters of mercury (mmHg) or heart rate (HR) is less than 60 beats per minute (BPM); and, -[MEDICATION(S)] (antihypertensive) 25 mg tablet by mouth two times daily for hypertension and to hold for SBP less than 120 mmHg. Review of the Medication Administration Report (MAR) for June 2021 revealed the following: -June 17 at 8:00 p.m.: [MEDICATION(S)] and Losartan were administered; and, -June 18 at 8:00 p.m.: [MEDICATION(S)] was administered. However, the Weights and Vitals Summary report revealed the following: -June 17, 2021 at 6:45 p.m. the resident's blood pressure (BP) was 117/75 mmHg; and, -June 18, 2021 at 7:26 p.m. the BP was documented as 125/67 mmHg. There was no evidence found that the resident's blood pressure was rechecked and its rechecked value was documented in the clinical record. Further review of the clinical record revealed no evidence of the reason why the medication was administered outside of the ordered parameter; and that, the physician was notified. During an interview on June 23, 2021 at approximately 9:45 a.m. with a Licensed Practical Nurse (LPN/Staff #133) she stated if a medication was held or not given, this is documented in the MAR where the staff can pick an option from a list to best describe why the medication was held or not given. The checkmark in the boxes in the MAR indicates that the medication was given to the resident. An interview was conducted with the charge nurse (staff #124) at approximately 10:45 a.m. on June 23, 2021. Staff #124 said the nurse should call the doctor if the blood pressure was low or outside parameters, document in a progress note, and enter the correct code in the MAR corresponding to the reason why it was not given or held. An interview with the Director of Nursing (DON/staff #51) was conducted on June 23, 2021 at approximately 11:30 a.m. with the Executive Director (staff #67) present. The DON stated medications should be administered following the ordered parameters by the physician. If the value is outside the ordered parameters, the physician is notified depending on how far the value is from the set parameters. The DON stated that when a nurse documents that an antihypertensive medication was administered, the electronic record software would ask for the blood pressure value and would pull the information from the system. However, she said it may not be the most recent one. During the interview, a review of the clinical record was conducted with the DON who said that a registry nurse administered the medications outside the ordered parameters on June 17 and June 18; and that, these are medication errors. On June 23, 2021 at 1:43 p.m., the DON provided the survey team an untitled document that had resident #3's name, room number, diagnoses, code status, name of the nurse and a date of June 17. On the farthest right of the sheet was handwritten circled note that read BP at 7:00 p.m. 132/65. On June 23, 2021 at 2:05 p.m., the DON provided another untitled document that was dated June 18 and had the name of a different nurse. On the farthest right of the sheet was a a handwritten note that read Recheck BP 134/70 at 7:45 pm. The DON stated the two untitled documents showed that the resident's blood pressure were rechecked on June 17 and 18 and the values were within the ordered parameter for the medications administered. However, the DON stated these documents were found and taken from the bin which were ready and scheduled to be collected for shredding that day. The facility policy titled, Medication Administration, included that medications must be administered as prescribed by and in accordance with the written orders of the attending physician. All current drugs and dosage schedules must be recorded on the patient's medication administration record (MAR and TAR as appropriate). Should a drug be withheld, refused, or given other than at the scheduled time it should be appropriately documented as such on the MAR. The facility assessment dated [DATE] and reviewed by the QAPI (Quality Assessment and Performance Improvement) committee on April 1, 2021 stated that the facility uses a clinical record software for their electronic health record and all paper documents are scanned and uploaded to the patient's medical record.

Based on an observation, staff interviews, policy and procedures and Centers for Disease Prevention and Control (CDC) guidelines, the facility failed to ensure infection control protocol was implemented related to improper donning of the face mask for one staff. The deficient practice could result in the spread of infections to residents. Findings include: On June 22, 2021 at 9:15 a.m., a wound care treatment observation was conducted with the wound care nurse (staff #106) who was wearing gown, gloves and a white face mask with a navy blue/black curvy design on it when she entered the resident room. The top edge of the face mask was resting on the tip of her nose. During the observation, the face mask slipped further down under her nose. Staff #106 did not correct the placement of her face mask and proceeded to complete the wound care for the resident. Staff #106's nose was exposed and was not covered the entire time. An interview was conducted immediately after the observation with staff #106 who exited the room. Staff #106 touched her nose and stated her mask was below her nose and was not being worn correctly. Staff #106 further stated this created a risk of passing COVID infection to residents. An interview was conducted with the (DON/staff #106) on June 23, 2021 at 9:22 a.m. The DON stated that a surgical mask is to be worn at all times in the facility; and that, the person's mouth and nose must be covered. The DON also said she had seen staff #106 wore the mask with the top edge of the mask located right at the tip of her nose. She also stated the mask should be above the tip of the nose; and, the mask has a metal clasp that can be pressed around the bridge of the nose to hold the mask in place so it stays on. The DON further stated staff are mandated to wear a surgical mask as a COVID-19 precaution even if staff had been vaccinated. The CDC guideline on Using Personal Protective Equipment (PPE) updated August 19, 2020 included that facemask should be extended under the chin. Both mouth and nose should be protected. The facility's policy, PPE During the COVID-19 Pandemic with a revision date of May 1, 2021 stated that masks must be worn continuously until visibly soiled or damaged throughout shift. The CDC guidance on How to Wear Mask for Unvaccinated People updated on June 11, 2021 included that masks are a critical step to help prevent people from getting and spreading COVID-19. A cloth mask offers some protection to you as well as protecting those around you. Wear a mask and take every day preventive actions in public settings and mass transportation, at events and gatherings, and anywhere you will be around other people. It also included to put the mask over your nose and mouth and secure it under your chin. Fit the mask snugly against the sides of your face, slipping the loops over your ears or tying the strings behind your head. Wear a mask over your nose and mouth to help prevent getting and spreading COVID-19; and, to wear a mask correctly for maximum protection.

Based on observations, facility documentation, staff interviews, review of the Center for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure that infection control standards were maintained. The deficient practice could result in the spread of infection to residents and staff, including COVID-19. Findings include: -On October 6, 2020 at 10:48 a.m., a housekeeper (#76) was observed spraying a yellow colored disinfectant on a resident's wheelchair and walker. At 10:53, she was observed wiping the disinfectant off with a cloth. She stated that she was using the 764 Lemon Quat Disinfectant Cleaner and that the contact time was 10 minutes, but if she wiped off the surface immediately after spraying, the surface was still clean. An interview was conducted on October 6, 2020 at 2:04 p.m. with the Director of Housekeeping (staff #20), who stated the 764 Lemon Quat Disinfectant Cleaner has a 10-minute contact time. He said this means the surface should be left to air dry for 10 minutes or can be wiped with a cloth after 10 minutes to ensure the surface is clean. He said that it was his expectation that durable medical equipment, such as a wheelchair and walker should be sprayed and left to air dry. The facility's policy titled Medical Devices/Equipment-Disinfection dated March 27, 2020 revealed the center is dedicated to protecting all residents and staff. The center will follow CDC guidelines for disinfection of medical devices/equipment. The Center will use the CDC recommended cleaning products for disinfection. The policy included all non-dedicated non-disposable medical equipment used for patient care is cleaned and disinfected per manufacturer's instructions/CDC guidelines and recommendations. Review of the 764 Lemon Quat Disinfectant product spec sheet, revealed that the disinfectant has a contact time of 10 minutes for virucidal activity. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic updated July 15, 2020 stated all non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. Ensure environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings. -On October 6, 2020 at 11:07 a.m., a Certified Nursing Assistant (CNA/staff #51) was observed on the observation floor, donning a gown in in a resident's room. She exited the room wearing the gown and stuck her arm into the resident's room next door and grabbed some gloves. She then donned the gloves and re-entered the first resident's room. An interview was conducted on October 6, 2020 at 11:57 a.m. with staff #51, who stated that she had received training on donning and doffing PPE (Personal Protective Equipment). She said that the residents on that floor are being quarantined. She said there is a gown hanging in each resident's room and that she is supposed to wear the gown each time she enters that room. The CNA further stated that she is to doff the gown before exiting the room because the gown could be contaminated and she could spread infection. She said that she went to the resident's room next door to get bigger gloves. The CNA stated that she should have asked another staff to hand her some gloves instead of exiting the resident's room wearing the gown. An interview was conducted with the Infection Control Preventionist (ICP/staff #42) and the Director of Nursing (DON/staff #77) on October 6, 2020 at 1:40 p.m. Staff #77 said there is a gown hanging in each resident's room for staff. The DON stated that staff should don the gown when entering the room and doff the gown before leaving the room. Review of the facility's policy, Isolation Gown and Extended Use for Facilities in Crisis Capacity dated May 15, 2020, states a gown will be issued to every healthcare professional responsible for caring for patients on transmission-based isolation or quarantine with full PPE. One gown per staff, per patient. The gown should be left in the patient's room and placed on a hook. The CDC Strategies for Optimizing the Supply of Isolation Gowns states that the risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Gown reuse has the potential to facilitate transmission of organisms (e.g., C. auris) among patients. Repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. If reuse is considered, gowns should be dedicated to care of individual patients. Any gown that becomes visibly soiled during patient care should be disposed of or, if reusable, laundered. -On October 6, 2020 at 11:29 a.m., a Licensed Registered Nurse (LPN/staff #31) was observed sticking both of her hands into the back of her pants (scrubs) with palms facing outwards and thumbs resting over the top outside of the pants. She was then observed to take a meal tray out of the warming cart without sanitizing her hands. The LPN handed the tray to another staff who served the meal to a resident. An interview was conducted on October 6, 2020 at 11:45 a.m. with staff #31, who stated that staff should sanitize their hands before touching a meal tray, between serving each meal tray, and if staff touches anything else while serving meal trays to residents. She acknowledged that she had been assisting another staff with serving meals and probably was pulling down her shirt and she did not sanitize her hands before handling the meal tray. An interview was conducted with the ICP (staff #42) and the DON (staff #77) on October 6, 2020 at 1:40 p.m. Staff #42 stated that staff should sanitize their hands before serving meal trays. Staff #42 also stated that if staff touch anything while serving meal trays, they should sanitize their hands. The facility's handwashing policy stated that at the center, all staff are expected to wash their hands when visibly soiled or dirty and after removing gloves and providing patient care. Use of sanitizer is acceptable in all other circumstances. Review of the facility's educational in-service information for infection control included hands should be washed or sanitized prior to passing a meal tray and after passing a meal tray. The CDC's Introduction to Hand Hygiene states that multiple opportunities for hand hygiene may occur during a single care episode, which includes after contact with blood, body fluids or contaminated surfaces.

Based on observations, staff interview and policy review, the facility failed to ensure that expired medications were discarded and not available for use on one of three medication carts. The deficient practice could result in residents receiving medication which is less effective. The facility census was 92 residents. Findings include: During an observation conducted on (MONTH) 21, 2019 at 12:47 p.m. with the Assistant Director of Nursing (staff #48), eight prefilled [MEDICATION NAME] Lock syringes were found in medication cart 3-A. The [MEDICATION NAME] syringes had an expiration date of (MONTH) 1, 2019. At this time, staff #48 stated that the medications should not have been on the medication cart, as they were expired. Review of a policy regarding the Storage of Medications revealed that the facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.

Based on observations, staff interviews and policy and procedures, the facility failed to ensure that multiple food items in the kitchen were sealed and/or dated. The deficient practice could result in a potential for food borne illnesses. Findings include: An observation of the kitchen was conducted on (MONTH) 21, 2019 at 8:30 a.m., with the Dietary Manager (staff #72). In the refrigerator, there was one slab of uncut and uncooked Rib Eye steaks on a metal tray and one metal tray with a large mound of cooked rice, and both were uncovered and not dated. Just below the tray of rice, there were two metal trays of pork steaks, which were not covered or dated. Directly below the pork steaks, there was one metal tray of pre-cooked chicken pieces which were also uncovered and not dated. The chicken pieces appeared to be dried out. During the observation, staff #72 stated that an employee had just cut a steak off of the slab and had not covered it yet. He stated the meat should have been covered. He stated that the rice was served to the residents yesterday ([DATE]), and that he was going to use the rice in a soup for the staff. He said that he did not think the rice needed to be covered or dated, because the rice was for staff use only. He stated that the pork steaks had been precooked for the residents and were going to be served today. He said the chicken had just been prepared for the resident's meal and was to be used today. During the same observation, there were two frozen gallon size bags of pasta with red sauce in the walk-in freezer and neither bag was dated. Staff #72 stated the bags were pasta and were to be used for the staff's meal. An observation of the dry storage room was also conducted at this time. On a shelf, there were two gallon size bags of wild rice mix and two gallon size bags of red rice, with no dates. He stated that he opened the wild rice mix and the red rice yesterday, and should have put a date on the bags. There was also a large rack which contained two bags of pasta, which were open and not dated. Staff #72 stated that the pasta was going to be used for staff meals and that he always orders extra to cook for the staff. He said any pasta and rice for the residents was also stored on this same rack. He said he just knew that he was going to use the two open bags of pasta for the staff, and that is why the two bags were not closed or dated. He further stated that did not know if facility policy required him to cover and date food that was precooked and was going to be served on the same day. A review of the Food Storage Policy dated (MONTH) 4, (YEAR), revealed that food items within the building are to be stored properly to ensure they are optimal for safe consumption by patients and staff. Storing foods properly helps to prevent food borne illnesses and maintains the food's peak qualities such as flavor, texture, color and aroma. The policy included that when food items are opened or in use, the use-by-dates are to be labeled, followed by storing them in the proper area such as the refrigerator, freezer or dry storage area in the kitchen. All outdated, expired or damaged food products are to be discarded immediately. Proper Food sanitation guidelines are to be followed. When storing meat, it must be properly sealed and separated from all other foods during storage. Items stored in the dry storage area are to be tightly sealed, free of debris and properly labeled/dated. All frozen food items are to be properly sealed and dated. Review of the Leftover Food Policy dated (MONTH) 4, (YEAR), revealed the dietary department is able to prevent unnecessary waste of food products by providing staff a meal. Leftover foods may be used and handled by the dietary department to feed staff, in accordance with food safety guidelines. The policy included that after food service is complete, leftover foods should be placed in a properly sealed or well wrapped containers or bags, with a label and date and then placed in the refrigerator/freezer, as indicated.

Based on clinical record review, observation, resident and staff interviews, and facility policy, the facility failed to ensure one resident (#34) received outside specialized rehabilitation services in a timely manner. Findings include: Resident #34 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of physician's orders [REDACTED]. A care plan problem initiated on December 20, 2017 included the resident used a TLSO brace when out of the bed and the interventions included: -To encourage the use of the appliance to maintain/increase compliance per patient's tolerance; -Make sure the appliance is being used per physician's orders [REDACTED]. -Monitor skin under the appliance daily and as needed; -Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat as necessary. A Physical Therapy note dated December 21, 2017 revealed the resident reported discomfort with the TLSO brace and that the therapist adjusted the brace to fit properly which decreased discomfort. A Daily Skilled Nurse's Note dated December 22, 2017 revealed the resident had the TLSO brace on and there were no signs or symptoms of skin breakdown under the brace. A Physical Therapy note dated December 23, 2017 revealed the resident stated the TLSO brace is very uncomfortable and pinching her arms. A Physical Therapy note dated December 24, 2017 revealed the resident reported discomfort with the TLSO brace and that the therapist attempted to adjust and add padding where the resident complained of discomfort. The note also included PT was to notify the TLSO brace manufacturer about making adjustments to the TLSO brace. A Physical Therapy note dated December 26, 2017 revealed the resident reported feeling uncomfortable while wearing the TLSO brace. Review of the physician's orders [REDACTED]. A Physical Therapy note dated December 28, 2017 revealed the resident continued to complain of the TLSO brace being uncomfortable. The note also included that the therapist consulted with the Supervisor and the Director of Rehab to have the orthotist adjust the resident's TLSO brace for a better fit. A Daily Skilled Nurse's Note dated December 29, 2017 revealed the TLSO brace was uncomfortable and that the resident was waiting to have the brace refitted. A Physical Therapy note dated December 29, 2017 revealed that during therapy the TLSO brace was donned, however it was positioned too high on the resident and caused discomfort to the resident's bilateral axilla. The note also revealed the resident was educated to have her family member purchase sheep's wool and bring it to rehab so that the therapist can cut the sheep's wool to fit the area of the TLSO brace that is not comfortable to prevent discomfort, redness, and skin breakdown. The note further revealed the TLSO brace was adjusted to a lower position to improve fit and stabilization of the spine. A late entry physician progress notes [REDACTED]. The note also included therapy or orthotics would be notified to evaluate the TLSO brace for adjustments. Another late entry physician progress notes [REDACTED]. The note further revealed therapy or orthotics would be notified to evaluate the TLSO brace for adjustments. Review of the Treatment Administration Record (TAR) for December 2017 revealed the resident had the TLSO brace on when out of the bed on all shifts except the day shift on December 28, 2017. Further review of the TAR revealed no documentation that the skin was monitored daily under the TLSO brace. A physician order [REDACTED]. During an observation conducted on January 2, 2018 at 9:22 a.m., the resident was observed sitting in a wheelchair in her room wearing a TLSO brace that covered her chest and abdomen in the front and [MEDICATION NAME] and lumbar spine in the rear. The TLSO brace was held together at the sides. The TLSO brace was observed to be up to the clavicle level in the front and pushing into the axilla on both the right and left sides causing the skin tissue to bunch up. An interview was conducted with resident #34 on January 2, 2018 at 9:22 a.m. Resident #34 stated that she was admitted with the TLSO brace and that the therapy staff were trying to find someone from a Durable Medical Equipment (DME) company or the hospital to evaluate the TLSO brace for a better fit. She further stated that when the TLSO brace is first put on it is not uncomfortable, but when she sits down the TLSO brace starts riding up and puts pressure on her armpits which hurts. Resident #34 stated there is no sore on the areas of her skin where the TLSO brace hurts. A Physical Therapy note dated January 3, 2018 revealed the resident had an uncomfortable feeling in her armpits from the TLSO brace and that the PT Supervisor contacted the orthotist to adjust the TLSO brace for a better fit. The note further revealed the orthotist was expected to come January 3, 2018 to adjust the TLSO brace. In an interview conducted with the Director of Rehab (staff #32) on January 4, 2017 at 12:49 p.m., staff #32 stated when a resident is admitted with a TLSO brace that fits to high on the resident or is too big or small; PT or OT would evaluate the TLSO brace for comfort and pressure points. Staff #32 further stated for problems identified, whoever issued the TLSO brace would be contacted promptly to make the TLSO brace correction so that the TLSO brace would fit the resident better. She also stated there was a delay having someone come to the facility to evaluate the TLSO brace for resident #34. During an interview conducted January 4, 2018 at 12:53 p.m. with the Physical Therapist (staff #58), staff #58 stated she initially evaluated resident #34 on December 20, 2017. She further stated resident #58's TLSO brace never fitted correctly, that she did not like the way the TLSO brace rode up around the resident's neck. Staff #58 further stated there was a delay getting the TLSO brace adjusted to fit better. In a follow-up interview with resident #34 conducted on January 4, 2017 at 1:25 p.m., resident #34 stated the TLSO brace was adjusted on January 3, 2018 and that the TLSO brace fits better. The facility policy DME, Splints, Orthoses, Braces Protocol included a procedure for the physical therapists and/or occupational therapists regarding the application and usage of DME, splints, orthoses, and braces for residents which included physical therapists and occupational therapists will follow-up as necessary if concerns arise.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#7) received a pain medication as ordered by the physician. Findings include: Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A review of the resident's care plan initiated on November 16, 2017, revealed the resident was to be administered an opioid medication as needed for pain relief status [REDACTED]. Review of the Medication Administration Record [REDACTED]. An interview was conducted January 5, 2018 at 1:24 p.m. with a Licensed Practical Nurse (LPN/staff #150). Staff #150 stated that the as needed pain medication should be administered according to the physician's orders [REDACTED]. During an interview conducted January 5, 2018 at 1:43 p.m. with a LPN (staff #70), staff #70 stated as needed pain medication is to be administered according to the ordered parameters. She also stated she should have administered one [MEDICATION NAME] tablet on November 17, 2017 instead of two [MEDICATION NAME] tablets. An interview was conducted January 5, 2019 at 2:09 p.m. with the Director of Nursing (staff #1). Staff #1 stated the expectation is that staff administer as needed pain medication according the parameters ordered by the physician. The policy Administering Medications included that medications must be administered in accordance with the orders.