Every finding on record at The Gardens of Taylor Glen Retirement Community

Based on observation, staff interview, and record review, the facility failed to ensure resident privacy and confidentiality by allowing protected health information (PHI) to remain visible on an unattended medication cart computer screen for 1 of 1 medication cart observed for medication administration (The health care unit medication cart). The findings included: A continuous observation was conducted on 12/30/2025 from 8:28 AM until 9:04 AM. At 8:28 AM Nurse #1 walked away from a medication cart located on the health care unit. Although the cart was locked, the computer screen remained visible and displayed the electronic charting system. The screen visibly listed five resident's names and one resident's medication information, including insulin pen details. A group of residents were noted to be around the medication cart at the time of the observation. At 8:34 AM the computer screen saver came on, and the resident information was no longer on the screen. Nurse #1 returned to the medication cart and continued her medication pass. At 8:54 AM Nurse #1 walked away from the medication cart a second time while a residents' personal and medical information remained displayed on the screen. The observation ended at 9:04 AM when Nurse #1 returned to the medication cart. On 12/30/25 at 10:06 AM an interview was conducted with Nurse #1. During the interview she stated she would typically shut the entire computer down when she walked away but acknowledged on this occasion that she did not shut down the computer or use the walk away feature. She stated she was nervous because of the surveyor observing her medication pass and had just made a mistake. On 12/30/25 at 10:00 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON was notified of the observations made by the surveyor and stated all nurses on the health care unit were supposed to use the walk away feature in the electronic charting system. She stated it was a button located at the top of the Medication Administration Record that would hide the screen if the nurses walked away from the medication cart. She stated at all times residents' privacy and personal information should be protected by using the walk away feature on the computer screens. On 12/30/25 at 11:54 AM an interview was conducted with the Administrator. During the interview he stated he would expect nursing staff to follow facility protocol and to keep all resident information confidential.

Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use and failed to discard a dented can stored for use. These practices occurred in 1 of 1 walk-in cooler and 1 of 1 dry goods storage area and had the potential to affect food served to the residents who resided in the facility. The findings included: An initial tour of the kitchen occurred on 11/5/24 at 9:54 AM. The following concerns were identified: a. Items in the walk-in cooler that were labeled with a preparation date, but no use-by date included: -a resealable container of sliced red onion dated 11/1/24. -a resealable container of scallions dated 11/1/24. -a bag of shredded carrots, opened and resealed with plastic wrap dated 11/1/24. -a bag of cheddar cheese cubes, opened and resealed with plastic wrap dated 11/1/24. -a bag of shredded white cheddar cheese, opened and resealed with plastic wrap dated 11/1/24. b. An unopened bag of chopped cabbage dated 10/25/24 was observed in the walk-in cooler with a manufacturer's use-by date 10/29/24. c. A 6-pound, 12 ounce can of sweetened applesauce dented on the bottom seal was observed in the dry goods storage area ready for use. An interview with the Executive Chef on 11/5/24 at 11:39 AM was conducted. The Dietary Manager was out on vacation. He stated the facility used a three-day system for food storage. The Executive Chef indicated the date on the label was a preparation date and the staff needed to fill out the entire label, to include the use-by date on opened and prepared items. He stated cans with a dent on the edge or seal should not be used. An interview with the Administrator on 11/6/24 at 3:50 PM revealed he expected staff to follow the policy and procedures for labeling food items and proper storage for canned goods. He added the Dietary Manager typically checked the dates for stored food and stated when she was not working, the staff needed to follow the policies and procedures.

Based on observations, record reviews, and staff interviews, the facility failed to implement infection control policies and procedures when the Nurse did not don a gown to provide wound care for a resident on enhanced barrier precautions (EBP). In addition, Nurse #1 failed to follow the facility's policy and procedure for clean dressings which included changing gloves and performing hand hygiene after removing the old dressing. The deficient practice occurred for 1 of 3 staff observed for infection control practices. The findings included: Review of the facility's policy for Enhanced Barrier Precautions (EBP) dated 04/01/2024 revealed the EBP will be implemented for the prevention of transmission of multidrug-resistant organisms. EBP employs gown and glove use during high resident care activities such as: Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube and tracheostomy, Wound Care: any skin opening requiring a dressing. Review of the facility's policy and procedure on clean dressings last revised in March 2022 revealed the following procedure: - Use disposable cloth (paper towel is adequate) to establish a clean field on residents' overbed table. Place all items to be used during the procedure on the clean field. - Wash and dry your hands thoroughly. - Position resident. Place disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen. - Put on gloves. Loosen tape and remove dressing. - Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. - Put on new gloves. - Pour liquid solutions directly onto gauze sponges on their papers. - Wear gloves while holding gauze to catch irrigation solutions that are poured directly over the wound. - Apply treatments as indicated. - Dress wound. - Discard disposable items into the designated container. Discard all soiled laundry, linen, towels and washcloths into the soiled laundry container. Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. Review of the facility's policy and procedure on handwashing last revised in August 2022 revealed the following procedure: - Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: - Before and after coming on duty. - Before and after direct contact with the residents - Before performing any non-surgical invasive procedures - Before handling clean or soiled dressing, gauze pads, etc. - After handling used dressing, contaminated equipment, etc. On 11/06/24 at 12:04 PM an observation was made of Nurse #1 entering Resident #3's room to provide wound care. Resident #3 was under EBP for a wound located on his left heel. The EBP signage located on Resident #3's door instructed staff to wear a gown and gloves during high contact resident care activities such as wound care for chronic wounds. Gowns were available directly outside of the resident's door in the hall in a three-compartment container. She was observed entering the resident's room, performing hand hygiene and applying gloves. Nurse #1 had Resident #3's wound care supplies in a container placed on the resident's bedside dresser. Resident #3 was observed sitting in a recliner chair and he placed the footrest up so his heels were in the air. Nurse #1 removed the old dressing and discarded the dressing in the trash can. The Nurse was observed using the same gloves to cleanse the wound with normal saline, paint the wound with betadine and apply calcium alginate (used in wound care to absorb drainage and promote wound healing). Nurse #1 was then observed wrapping Resident #3's heel with gauze. Nurse #1 then removed the gloves and discarded them into the trash can. She gathered the supplies and returned to the medication cart where she sanitized her hands. An interview on 11/06/24 at 12:15 PM with Nurse #1 revealed the facility did not have a wound nurse, it was up to the nurses working on the hall to complete and provide wound care. She stated she worked 4 days a week and every other weekend, so she changed Resident #3's dressing frequently. Nurse #1 was asked if Resident #3 was under any kind of precautions and replied yes, Enhanced Barrier Precautions which meant she needed to wear a gown and gloves before entering the resident's room. Nurse #1 stated she would typically wear a gown while providing wound care however it had just slipped her mind to put it on. She stated she would normally put on a gown while providing any wound care in the building. Nurse #1 stated she had also forgotten to wash her hands and change gloves in between removing the soiled dressing and applying new treatment to the wound and, after removing her gloves in the room. She stated she had just become nervous during the encounter and had forgotten. She stated she knew the policy and knew the process of wound care. An interview on 11/06/24 at 12:43 PM with the Director of Nursing (DON), who was also the Infection Preventionist (IP), revealed it was her expectation for the Nurse to follow infection control guidelines and wound care guidelines while providing wound care. She stated they were auditing staff to ensure they were following infection control guidelines and procedures and said she would be adding the Nurse and wound care to the auditing tool. She stated Nurse #1 should have worn a gown during the wound care for Resident #3. An interview on 11/06/24 at 12:50 PM with the Administrator revealed Nurse #1 should have followed the infection control policy and guidelines regarding wound care and Enhanced Barrier Precautions.

Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor these interventions the committee put into place in [DATE]. This was for 1 re-cited deficiency which was originally cited on [DATE] (F812) and on the current recertification/complaint survey on [DATE] (F812). The continued failure of the facility during the two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This tag is cross referred to: F812: Based on observation, staff interviews and record review the facility failed to remove expired food stored for use from the walk-in refrigerator, failed to date meat that was thawing, failed to allow clean dishes to air dry before they were stacked (placed on top of each other while still wet). The failures had the potential to affect food served to residents. During the Federal Monitoring Comparative Survey conducted on [DATE], the facility failed to ensure sanitary practices were carried out in the kitchen. The facility failed to discard buttermilk by its use by date; failed to perform hand hygiene to prevent cross contamination of clean dishes during dishwashing and while plating food; failed to ensure gloves used while temping and plating food, were not cross contaminated by the food thermometer which had been improperly stored in a staff members pocket; and failed to allow clean dishes to air dry when they were wet stacked (placed on top of each other while still wet). The failures had the potential to affect three (3) of three (3) residents. The Administrator was interviewed on [DATE] at 1:57 PM and she explained the facility conducted quarterly QAPI meetings that included the dietary director. The Administrator reported staff turnover in the dietary department was the cause of the breakdown in the system related to sustaining the corrective actions that were put in place in [DATE].

Based on observation, staff interviews and record review the facility failed to remove expired food stored for use from the walk-in refrigerator, failed to date meat that was thawing, failed to allow clean dishes to air dry before they were stacked (placed on top of each other while still wet). The failures had the potential to affect food served to residents. The findings included: 1. An initial observation of the walk-in refrigerator conducted on [DATE] from 11:25 AM to 11:50 PM with the Dietary Director (DD) revealed the following food items stored past the use by date and/or without a date to indicate how long the item was good for: - A 10-quart container of bean soup which was ,d+[DATE] full dated [DATE]. - 20 ham slices in a zip lock bag dated [DATE]. - ,d+[DATE] of a 2-pound pre-packaged ham was wrapped in plastic wrap without a date. - A metal container of ham slices with an unreadable date. The DD confirmed this was unreadable. - A plastic container containing approximately 2 cups of egg salad dated [DATE]. - A plastic container containing approximately 5 cups of tuna salad dated [DATE]. - A 12-quart container of cooked meatballs in sauce dated [DATE]. - Canned peaches in a plastic container dated [DATE]. - A metal pan of 12 thawed chicken breast with no date on the pan. The DD stated the chicken breast were served on Saturday [DATE]. - A 10-pound box of mushrooms which had ,d+[DATE] remaining that were covered in brown spots and were dated [DATE]. - A 10-pound thawed, uncooked pork roast with no date. The DD stated the pork roast had been pulled from the freezer on Friday [DATE] and pork roast was served on Sunday [DATE] and this was pork was not used. - 5 pounds of thawed ground beef with no date. During the initial tour the DD stated that all food without an expiration date such as cooked food is kept for three days, and frozen food is pulled from the freezer to thaw in the refrigerator 48 hours prior to being cooked. A follow-up interview was completed with the dietary director on [DATE] at 3:16 PM who stated that she did not know why there had been expired food in the walk-in refrigerator. The DD stated that food that was cooked should have had a label with the day it was made and a use by date. The DD director explained that items like the raw ground beef should have had a date it was put in the refrigerator to thaw. An interview was completed with Cook #1 on [DATE] at 3:34 PM who stated that the process for labeling food was for example, if the food had been mixed vegetables he would have put a date the mixed vegetables were put in the refrigerator with plastic wrap over them. Cook #1 stated for ham slices he would had put the date of prepping and for raw chicken he would have put the date it had been put in the metal bin and placed in the refrigerator. Cook #1 stated that the policy is prepared food is thrown out after 3 days. 2. During a follow up visit to the kitchen of the dishwashing area on [DATE] at 3:40 PM revealed four, 4-quart plastic containers were stacked inside each other and 3 of the containers had noticeable condensation (water) inside the containers. The DD was made aware of the plastic containers at 3:46 PM and stated these were wet nested (containers stacked inside each other while still wet) and should have been left to air dry on the dish rack. An interview was completed with Dishwasher #1 on [DATE] at 3:50 PM who stated that dishes were to be put on a rack to air dry. Dishwasher #1 was shown the wet containers and he stated that some containers may be a little wet and he would still stack them or would get a clean towel to dry them off. An interview was completed with the Administrator on [DATE] at 2:42 PM who stated that it would be her expectation that food is labeled and dated and thrown away if expired and dishes are dry when stacked.

Based on record review and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for 1 of 1 sampled resident reviewed for discharge (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Record review revealed Resident #1 had discharged return not anticipated to the assisted living section of the facility on 11/4/22. Review of Resident #1's medical record revealed a discharge return not anticipated assessment dated [DATE] had been started but not completed. During an interview with the Administrator on 2/15/22 at 12:36 PM, she stated their MDS assessments were contracted from an outside agency. She explained they realized on 2/12/23 the discharge assessment for Resident #1 had not been completed. She stated she would expect the MDS assessments to be completed timely. A telephone interview was conducted with the contracted MDS nurse on 2/15/23 at 1:12 PM. She stated that she had thought the MDS discharge assessment had been completed. She explained she was not a Registered Nurse (RN) so once she completed the assessment, she would send an email to the facility to notify them the MDS assessment was ready to be closed and transmitted by a Registered Nurse at the facility.

Based on observations, staff interview and review of required posted nurse staffing sheets revealed the facility failed to post the actual hours worked by nursing staff for 15 of 15 days reviewed for nurse staffing information. Findings included: A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/21, 4/20/21, 4/23/21, 4/24/21, 4/25/21, 4/28/21, 4/29/21 and 5/3/21 (8 days) the posted staffing sheet revealed a RN had worked the night shift from 7:00 PM to 7:00 AM however the schedule revealed there was not an RN scheduled during the night shift. On 4/21/21, 4/22/21, 4/26/21, 4/27/21, 4/30/21, 5/1/21 and 5/2/21 (7 days) the posted staffing sheet revealed a RN had worked the day shift from 7:00 AM to 7:00 PM however the schedule revealed there was not an RN scheduled during the day shift. A joint interview was completed on 5/4/21 at 1:42 PM with the Minimum Data Set/Staff Development Nurse (MDS) and the Director of Nursing (DON). The DON stated they are both sharing the scheduling responsibility as the facility does not have a scheduler at this time. The DON stated the night shift supervisor posts the census and fills out the posted staffing for the entire day. A review of the staffing daily schedules and posted staffing sheet from 4/19/21 to 5/3/21 was reviewed with the DON and MDS nurse. The DON stated the RN coverage was off. The DON stated that it is her expectation that the posted staffing be accurate and reflects the daily schedule. An interview was completed with the administrator on 5/4/21 at 2:46 PM who stated we want to make sure they put down everyone that is there, and it is done correctly.

Based on record review and staff interview the facility failed to accurately code the Minimum Data Set Assessment (MDS) in the areas of type of assessment and discharge location for 1 of 3 sampled residents (Resident # 9) and failed to accurately code the MDS in the area of Range of Motion for 1 of 3 sampled residents (Resident # 8). The findings included: 1. Resident #9 was readmitted [DATE] and had [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set (MDS) Assessment section A dated 1/18/17 revealed the following was coded: -Discharge Return Not Anticipated and Discharge to the Community. Review of the facility census for 1/24/17 at 11:00 AM revealed Resident #9 was on the active census for the facility and in a skilled nursing bed. During interview with the Director of Nursing on 1/24/17 at 11:15 AM she stated that Resident #9 was in the facility and in a Skilled Nursing bed from 12/27/16 through 1/24/17. She added that Resident #9 was discharged from Medicare Part A on 1/18/17 but they were still working with him to get him back to his apartment. Review of the Nursing Notes on 1/24/17 at 12:15 PM revealed Resident #9 was sent to the hospital. He was admitted and discharged from the facility later on 1/24/17. Interview with the Social Worker on 1/25/17 at 5:50 PM revealed that she had done the discharge coding for the I/18/17 MDS. She acknowledged that until the afternoon of 1/24/17 Resident #9 had been in a Skilled Nursing Bed. She stated that it was unusual at their facility for a resident to be discharged from Medicare Part A and remain in a skilled bed and she had not known how to accurately code it. She acknowledged that she should have coded the MDS as not and entry or discharge MDS. She stated that she would make the correction and also complete the Discharge MDS for 1/24/17since Resident #9 had been admitted to hospital. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse ' s note dated 10/17/16 was reviewed and the note stated the resident had [DIAGNOSES REDACTED]. A physical therapy (PT) noted dated 10/18/16 was reviewed and it was noted the resident ' s bilateral lower extremity strength and the right side 4/5 and the left 2/5 . This note was uploaded into the document system on 10/26/16. A nurse ' s note dated 10/23/16 documented the resident required extensive assistance with all activity of daily living (ADL) and 2+ assistance with ambulation on the unit and with therapy and was not tolerating weight well on the left hip. An admission Minimum Data Set (MDS) assessment was completed on 10/24/16 and assessed Resident #8 to be severely cognitively impaired and required extensive, two person assistance with transfers, toileting, bathing and dressing. The resident received Physical and Occupational Therapy, but had difficulty achieving goals due to her cognitive status. The admission MDS was completed with Question G0400 Functional Limitation in Range of Motion , B. Lower extremity (hip, knee, ankle, foot) answered 0, no impairment. A PT note dated 10/24/16 was reviewed and documentation was noted to include yelling with movement of left lower extremity and is unable to bear weight on it. This note was uploaded into the document system on 10/26/16. An interview was conducted with the Director of Nursing (DON) on 1/25/17 at 5:14 PM. She stated she was responsible for the completion of the MDS for the facility. She reported she was in training the date the admission MDS was completed and did not complete the assessment. The DON stated that it was her expectation that MDS be completed on time, as well as accurate and complete upon submission. An interview was conducted with the Corporate Clinical Director on 1/25/17 at 5:47 PM and he stated he was training the current DON on 10/14/16 and he completed the admission MDS. He further stated the start of care notes from PT dated 10/24/16 had not been uploaded into the document system and he did not have access to those notes for the completion of the admission MDS and the information that was available did not seem to indicate the resident had limited ROM or that the [MEDICAL CONDITION] had limited her function.

Based on observations, staff interviews and facility policy the facility failed to disinfect 2 glucometers prior to use for 2 of 2 sampled residents observed getting blood glucose checks. (Resident #3 and Resident #5) The findings included: The facility policy effective July 30, 2011, entitled, Blood Glucose Monitoring read in part : Procedure-The Blood Glucose Monitoring Device will be disinfected both prior to testing and post testing per the FDA (Food Drug Administration) recommended cleaning solution or manufacturer suggested guidelines. On 2/17/15 at 8:35 AM Nurse #1 was preparing to perform a blood glucose check on Resident #3 and it was observed that 2 glucometers were stored together uncovered in the medication cart drawer. Each glucometer was labeled with a resident name. Nurse #1 removed the glucometer for Resident #3, donned gloves and performed the blood glucose check without disinfecting the glucometer prior to use. Upon completion of the blood glucose check, Nurse #1 cleaned the glucometer with a disposable germicidal wipe, wrapped the glucometer in the wipe and returned it to the medication cart drawer. Nurse #1 stepped away from the medication cart and washed her hands. On 2/17/16 at 8:45 AM Nurse #1 was preparing to perform a blood glucose check on Resident #5. Nurse #1 removed the glucometer for Resident #5 from the medication cart drawer, donned gloves and performed the blood glucose check without disinfecting the glucometer prior to use. Upon completion of the blood glucose check, Nurse #1 cleaned the glucometer with a disposable germicidal wipe, wrapped the glucometer in the wipe and returned it to the medication cart drawer. An interview with Nurse #1 on 2/17/16 at 8:50 AM revealed that she normally disinfects the glucometers only after use, if that is wrong she will change the way she is doing it. During an interview with the Director of Nurses on 2/17/16 at 9:30 AM indicated that her expectations were that the glucometers were to be cleaned before and after use and according to the policy.

Based on review of facility policy, observation and staff interview, the facility failed to label and date opened food items in the cooler and in the freezer. The findings included: A facility policy titled "Food Storage" effective 10/01/13 stated, in part, "all food products shall be marked with the date the item was received by nutritional services. Ready-to-eat-commercially prepared foods shall be marked with a discard date at the time of opening or preparation. The discard date shall be seven (7) days after the food has been opened if the food has been refrigerated at 40 degrees F (Fahrenheit) or less." 1. An observation of the cooler was conducted on 2/11/14 at 8:05 AM. There were four rolls of raw hamburger (five pounds each) thawed and undated, two (2) bags of raw chicken pieces (raw) thawed and undated, five (5) cooked potatoes in a bowl undated and one plastic container of cooked beets undated. On 2/11/14 at 8:25 AM, the Dietary Manager stated the items in the cooler should have been dated immediately upon storage. 2. An observation of the freezer was conducted on 2/11/14 at 8:15 AM. There was one half (1/2) bag of opened brussel sprouts undated and one half (1/2) bag of corn nuggets undated. On 2/11/14 at 8:25 AM, the Dietary Manager stated the items in the freezer should have been dated after being opened and before restoring the items in the freezer.

Based on record review, observation and staff interview, the facility failed to complete the staffing information accurately. The findings include: On 1/15/12 at 4:30 PM and 1/16/13 at 9:00 AM, the daily staffing sheets were observed. The staffing sheets were not completed accurately. The census and the staffing for the assisted living were included in the daily staffing sheets. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She indicated that she did not know that the daily staffing sheet was only for the certified beds.

Based on record review and staff interview, the facility failed to develop policies and procedures for administration of influenza and pneumococcal vaccines, and failed to document education prior to administering influenza vaccines for 2 (Residents #7 and #13) of 3 sampled residents. The findings included: 1. Upon request for its influenza and pneumococcal immunization policies and procedures, the facility provided the following: (1) Centers for Disease Control (CDC) " Vaccine Information Statement " for the influenza vaccine dated 2012-2013, (2) the CDC " Pneumococcal [MEDICATION NAME] Vaccine " information statement dated 10/6/09, (3) an undated " Annual Influenza Vaccine Administration Consent Form " , (4) an undated " Pneumococcal Polysaccaride Vaccine Administration Consent Form " , and (5) an " Influenza/Pneumonia Vaccine Record " form dated 10/15/02. During an interview on 1/16/13 at 5:15 PM, Administrative Staff #1 stated that the facility did not have formal policies and procedures for influenza and pneumococcal immunizations. 2. Resident #7 was admitted to the facility on [DATE]. Record review revealed an " Annual Influenza Vaccine Administration Consent Form " signed 10/12/11 by the responsible party (RP). Her " Influenza/Pneumonia Vaccine Record " revealed that she had the influenza vaccine on 10/3/12. There was no documentation that the RP had received education about the vaccine or had an opportunity to decline the vaccine prior to its administration. During an interview on 1/16/13 at 5:15 PM, Administrative Staff #1 stated that the facility did not require signed authorizations for vaccines annually, nor proof that education was provided. 3. Resident #13 was readmitted to the facility on [DATE]. Record review revealed an " Annual Influenza Vaccine Administration Consent Form " signed 5/14/12 by the responsible party (RP). Her " Influenza/Pneumonia Vaccine Record " revealed that she had the influenza vaccine on 10/4/12. There was no documentation that the RP had received education about the vaccine or had an opportunity to decline the vaccine prior to its administration. During an interview on 1/16/13 at 5:15 PM, Administrative Staff #1 stated that the facility did not require signed authorizations for vaccines annually, nor proof that education was provided.

Based on record review, observation and staff interview, the facility failed to review and revise the care plans after residents developed pressure ulcers for 2 (Residents #4 and #8) of 2 sampled residents with pressure ulcers. The findings include: 1. Resident #8 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. Review of the care plan dated 12/6/12 revealed that Resident #8 was at risk for pressure ulcers due to limited mobility, muscle weakness and pain. Review of pressure ulcer records revealed that on 12/28/12, Resident #8 had a stage 2 pressure ulcer on her buttocks and a stage 1 on her elbow. The care plan was not revised to reflect actual pressure ulcers. During an interview on 1/16/13 at 11:11 AM, Nurse #1 stated that care plans should be updated by the nurses when changes occur, and Resident #8's care plan should have been updated when the pressure ulcers were first observed. 2. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#4's cognitive status was intact and she had no pressure ulcer. Review of the admission records dated 10/18/12 revealed that Resident #4 was admitted to the facility with " dark pink areas on the right buttocks " . The weekly pressure ulcer records were reviewed. The records indicated that on 12/18/12, Resident #4 had developed a stage II pressure ulcer to the left buttock. This was treated with [MEDICATION NAME] and was healed up on 12/30/12. On 1/9/13, Resident #4 had developed a stage II pressure ulcer to the left buttock. The treatment ordered for the left buttock pressure ulcer (stage II) was [MEDICATION NAME] and to be changed every 3 days. On 1/16/13 at 3:20 PM, Resident #4 was observed. The treatment for [REDACTED]. The left buttock pressure ulcer was covered with [MEDICATION NAME] when observed. The care plan was reviewed. The care plan was not revised to address the care/treatment for [REDACTED]. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She agreed that the care plan should have been revised when the resident had developed a stage II pressure ulcer.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 3 (Residents #3, #4 and #9) of 9 sampled residents. The findings include: 1. Resident #9 was admitted to the facility on [DATE]. On 10/3/12 a urine specimen indicated the resident had a urinary tract infection [MEDICAL CONDITION] and she was started on antibiotic therapy. The care plan revealed no problem of UTI and no interventions specific to UTI. During an interview on 1/16/13 at 6:30 PM, Nurse #1 indicated the care plan should have included UTI. 2 a. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#4's cognitive status was intact and she had an indwelling catheter. The care plan for Resident #4 was reviewed. There was no care plan to address the care/treatment for [REDACTED]. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She agreed that the use of the indwelling catheter should have been care planned but it was not. 2 b. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#4's cognitive status was intact and she had limitation in range of motion on both upper and lower extremities. The care plan for Resident #4 was reviewed. There was no care plan to address the care/treatment of [REDACTED]. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She agreed that the contracture should have been addressed in the care plan. 2 c. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#4's cognitive status was intact and she had UTI (urinary tract infection) listed under infections.. The care plan for Resident #4 was reviewed. There was no care plan to address the care/treatment for [REDACTED]. Review of the records revealed that Resident #4 was treated with antibiotics for UTI on 10/26/12, 11/10/12, 12/2/12 and 12/20/12. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She agreed that the UTI should have been addressed in the care plan. 3. Resident # 3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#3 ' s cognitive status was intact and she was receiving [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]). The care plan was reviewed. There was no care plan to address the use of the [MEDICAL CONDITION] medications. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She agreed that the use of the [MEDICAL CONDITION] medications should have been addressed in the care plan.

Based on staff interview and record review, the facility failed to accurately code 1 (Resident #7) of 5 Minimum Data Sets (MDS's), and failed to ensure Registered Nurse's signature on 4 (Residents #3, #4, #7 and #8) of 5 MDS assessments. The findings include: 1. Resident #7 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #7 had limitations of all four extremities that interfered with daily functions or placed resident at risk of injury. On 1/16/13 at 8:20 AM, Resident #7 was observed walking with a walker through the living area into the dining room. She was able to feed herself breakfast. During an interview on 1/16/13 at 3:50 PM, Nurse #1 indicated Resident #7 had no impairment in arm movement, but had some difficulty with her legs due to arthritis. During an interview on 1/16/13 at 6:40 PM, Nurse #2 acknowledged that she had done the quarterly assessment for range of motion for Resident #7. She stated that the resident had impairment in one leg only, and that she had coded the MDS incorrectly. 2. Resident #8 had an admission MDS dated [DATE]. There was no signature to indicate who had completed the nursing sections of the MDS, and no Registered Nurse (RN) signature verifying assessment completion. During an interview on 1/16/13 at 5:30 PM, Administrative Staff #2 indicated that she assigned MDSs to be divided among 4 RNs. The RNs gave her the completed assessments which were written on paper; she entered them into the computer, printed them out and placed them in the MDS charts. There was no formal process to alert the nurse that the printed assessments were ready for signatures. During an interview on 1/16/13 at 6:30 PM, Nurse #1 stated she had done the assessment but had not signed it. Nurse #1 indicated that MDS completion was divided between 4 nurses, and the social worker actually printed the MDSs and placed them on the charts. 3. Resident #7 had a quarterly MDS dated [DATE]. There was no signature to indicate who had completed the nursing sections of the MDS, and no Registered Nurse (RN) signature verifying assessment completion. During an interview on 1/16/13 at 5:30 PM, Administrative Staff #2 indicated that she assigned MDSs to be divided among 4 RNs. The RNs gave her the completed assessments which were written on paper; she entered them into the computer, printed them out and placed them in the MDS charts. There was no formal process to alert the nurse that the printed assessments were ready for signatures. 4. Resident #4 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment was completed with the reference date of 10/25/12. The CAAS (Care Area Assessments) summary form dated 10/25/12 was reviewed. The form had no signature and date from the RN (registered nurse) for CAA process and there was no signature and date of the person completing the care plan decision. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She was aware that nobody had been signing the CAAS and the care planning decision but it will get fixed. 5. Resident #3 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment was completed with the reference date of 12/26/12. The CAAS summary form dated 12/26/12 was reviewed. The form had no signature and date from the RN (registered nurse) for CAA process and there was no signature and date of the person completing the care plan decision. On 1/16/13 at 9:10 AM, Nurse #1 was interviewed. She was aware that nobody had been signing the CAAS and the care planning decision but it will get fixed.

Based on observation and staff interviews, the facility failed to maintain sanitary conditions in the kitchen when kitchen staff failed to remove gloves, wash hands and reapply clean gloves between kitchen tasks. The findings included: On 12/21/2011 at 11:06 AM., kitchen staff #1 was observed to remove two pieces of bread from the bread wrapper with her gloved hands, put melted butter on each piece of bread and placed it on the grill. Without removing her gloves, she placed cheese on the bread and grilled the cheese sandwich. While the sandwich was being cooked, kitchen staff #1 used the same gloved hands to move pots, pans and touched utensils to stir other food items. After she removed the sandwich from the grill with a flat utensil, she placed the sandwich on a cutting board and cut the sandwich in half, picked up the sandwich with her gloved hand and put it on a plate. During interview at 11:10 AM., kitchen staff #1 stated she always wore gloves when she prepared food and, normally, did not change her gloves during the meal preparation. She stated she removed her gloves and changed them if she changed tasks such as answering the telephone. On 12/21/2011 at 11:12 AM., Administrative staff #3 stated kitchen staff #1 should have removed her gloves, washed her hands and put on new gloves when she went from preparing the sandwich to touching the utensils and pans of food. He further stated that these were two different kitchen tasks and kitchen staff had been instructed to change gloves and wash their hands between kitchen tasks.

Based on observation and staff interviews, the facility failed to display the Survey Results information without residents/ visitors having to ask where the Survey Results information was located. The findings included: On 12/21/2011 at 5:20 PM., survey results were noted to be posted on a small bulletin board located in a corner near the living room area on the skilled nursing unit. The Bulletin Board was approximately 4 1/2 feet from the floor. There was not a sign identifying that the survey results were posted there. On 12/21/2011 at 5:26 PM., Administrative staff #1 stated the Survey Results should be labeled so anyone would know where it was and could read it without having to ask nursing staff for the results. On 12/22/2011 at 7:40 AM., Administrative staff # 4 stated the Survey Results should be posted in the nursing area in an area that the residents can easily access including wheelchair residents. Residents and visitors should not have to ask where the results are posted.

Based on observation and staff interviews, the facility failed to post state agency information. The findings included: On 12/21/2011 at 5:26 PM., an observation revealed there was not a sign posted with information on the name, address and contact information for the Division of Health Service Regulation (DHSR) and the complaint intake unit information. On 12/21/2011 at 5:26 PM., Administrative staff #1 stated she did not know that the information for the DHSR and Complaint intake unit was not posted. An observation of the skilled nursing area revealed that there was no posting of state agency information. On 12/22/11 at 8:43 AM., Administrative staff #2 stated the information for the state complaint unit was only on the facility contract, signed at admisiod. She further indicated that she reviewed the agency numbers with the resident and/or responsible party each time the resident was admitted to the skilled nursing unit.

Based on observation, record review and staff interviews, the facility failed to secure a urinary catheter to prevent excessive tension on the catheter for one of one residents (Resident #2). Findings included: Resident #2 was admitted to the facility 11/29/2010. Cumulative [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) 12/24/2010 indicated Resident #2 had short and long term memory problems and was moderately impaired in daily decision-making. He required limited assistance with transfers, ambulation and personal hygiene and extensive assistance with bathing and dressing. Resident #2 had an indwelling urinary catheter. A physician's progress note dated 12/14/2010 stated Resident #2 required an indwelling urinary catheter due to the inability to void and the indwelling catheter would need to be permanently in place. During the observation of urinary catheter care on 1/5/2011 at 3:05 PM., the urinary catheter tubing was not secured to Resident #2's leg. Nurse #1 stated Resident #2 was usually up in his chair during the day and wore a leg bag when he was out of bed. She stated he usually had a secure catheter holder and said she would expect the nursing assistants to notify her if the tubing was not secured. She stated she did not know if there was a policy regarding securing the catheter tubing but stated it was definitely better to have it secured. Nurse #1 taped the catheter tubing to Resident #2's upper thigh. On 1/5/2011, NA #1 stated Resident #2 normally got up in a chair during the day. Day staff would change the urinary drainage bag to a leg bag which was secured to the leg with straps. She stated she had never seen the urinary catheter tubing secured to Resident #2's leg. On 1/5/2011 at 4:10 PM., the Director of Nursing stated she expected the urinary catheter tubing to be secured. She stated she would have used tape to secure the tubing and said the facility did not have a secure catheter holder in stock. She provided the Catheter Care facility policy and indicated it did not include instructions to secure the urinary catheter.