Every finding on record at The Green House Cottages of Poplar Grove

Based on observations, interviews, record review, facility policy review, it was determined that the facility failed to ensure care planned fall interventions were implemented for one (Resident #1) of three residents reviewed for quality of care. It was also determined that the facility failed to notify Resident #1's guardian that the resident refused to take ordered medication more than two times in a row. The findings include: A review of a facility policy titled, Fall Guidelines, Section General Resident Care Plan Documentation Guidelines, List new intervention developed for each fall with date of implementation. The policy indicated the charge nurse duties included update the care plan with new interventions and the Director of Nurses (DON) or designee duties included In-service staff of interventions in place to prevent injury. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2025, indicated Resident #1 had diagnoses which included: unspecified dementia, depression, type 2 diabetes mellitus with hyperglycemia and diabetic neuropathy, hyperlipidemia and hypertension. A Brief Interview of Mental Status (BIMS) score of 13 was coded, indicating the resident was cognitively intact. Section GG [Functional Abilities], within the MDS, indicated, the resident was independent in eating, oral hygiene, upper and lower dressing, putting on/taking off footwear and personal hygiene. It was also revealed within Section GG, that the resident required supervision assistance with toileting hygiene and shower/bathe self. The MDS indicated the resident was independent to roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walk ten (10) feet, and walk 50 feet with two (2) turns. The resident required, supervision assistance to walk 150 feet. The number of falls since the prior assessment revealed two (2) falls with no injury. A review of Resident #1's Care Plan Report, indicated the resident was at risk for falls, related to other abnormalities of gait and mobility. The report revealed the resident had an actual fall with no injury on 01/29/2024, an intervention initiated on 01/29/2024 included fall mat to side of bed. The report indicated the resident had an actual fall on 02/04/2025, an intervention initiated on 02/04/2025 included Call Don't Fall signage placed in room for visual que. A review of Progress Note, dated 03/10/2025, indicated Resident #1 had suffered an unwitnessed fall. No interventions were initiated with this fall. During an observation on 05/07/2025 at 10:49 AM, this surveyor observed Resident #1 room. This surveyor did not note any fall mats on the floor, and there was not a Call Don't Fall sign posted in the resident ' s room. During an observation on 05/08/2025 at 07:40 AM, this surveyor observed Resident #1 room. This surveyor did not note any fall mats on the floor, and there was not a Call Don't Fall sign posted in the resident ' s room. During an interview on 05/08/2025 at 08:29 AM, LPN #1 verified there was not a fall mat in Resident #1's room and there was not a Call Don't Fall sign posted in Resident #1's room. During an interview, on 05/08/2025 at 08:34 AM, the Director Of Nursing (DON) indicated there was not a fall mat in Resident #1's room and there was not a Call Don't Fall sign posted in Resident #1's room. A review of a facility policy titled Resident Rights and Responsibilities indicated, If a Resident/Elder is adjudged incapacitated under the laws of the State, the right of the Resident/Elder will be exercised by the individual appointed under State law to act on the Resident/Elder's behalf. The policy stated, Appropriate nursing facility staff will provide the Resident/Elder or the Resident'/Elder's Health Insurance Portability and Accountability Act (HIPPA) authorized representative with information about his or her health status. The policy further stated, The reasons the Resident/Elder refuses treatment will be assessed, and alternate treatment will be offered. The nursing facility will attempt to clarify and educate the Resident/Elder as to the consequences of refusal. A review of In the Matter of [Resident #1], an Incapacitated Person; Order for the appointment of guardian of the person and estate dated 10/09/2023, granted (Resident #1's Guardian) as Appointment of Guardianship of Resident #1. A review of Progress Note dated 03/27/2025 at 6:23 AM, indicated that Resident #1's Guardian was notified that the resident had been refusing insulin for the past two (2) weeks. The note indicated the APRN was notified and spoke with the Guardian. The note indicated the Guardian requested to be notified when the resident refused two (2) times in a row. During an interview on 05/07/2025 at 5:10 PM, with Resident #1's Guardian, via telephone call, it was revealed the guardian was called earlier this date [05/07/2025] by a nurse from the facility and reported that Resident #1 had refused medication for nerve pain, and a multivitamin. The Guardian reported being called one (1) time before today, and stated the facility reported the resident's sugar was high. The Guardian reported during the call a request was made for the facility to place notice in the resident's file to contact the guardian if the resident refused to take [pronoun] ordered medication. A review of a facility policy titled, Specific Medication Administration Procedures indicated if a resident refuses medication, research refusals for possibility of dry mouth, resident reluctance, development of swallowing difficulty. No research implementation as to possibility of dry mouth, resident reluctance, development of swallowing difficulty found in Resident #1 ' s review of records. A review of Medication Administration Record (MAR) March 2025, for Resident #1, revealed the following: a. Order dated 04/25/2023 [Name Brand Non-Steroidal Anti-Inflammatory Medication] oral tablet delayed release 81 mg one (1) tablet by mouth one (1) time a day, for heart health. The resident refused 21 out of 31 doses. b. Order dated 04/24/2023 [Generic HMG-CoA Reductase Inhibitor] (a medication used to treat high cholesterol levels) 40 mg give one (1) tablet by mouth at bedtime for hyperlipidemia (high levels of fat in the blood). The resident refused 15 out of 31 doses. c. Order dated 04/25/2023 [Generic Anti-depressant] (medication to treat depression) oral tablet 10 mg give one (1) tablet by mouth one (1) time a day for depression. The resident refused 21 out of 31 doses. d. Order dated 12/11/2023 [Generic Diuretic] (a medication used to help reduce the amount of water buildup in the body) oral tablet 25 mg give one (1) tablet by mouth one (1) time a day for hypertension (high blood pressure). The resident refused 21 out of 31 doses. e. Order dated 10/25/2024 [Generic Vasodilator] (a medication used to relax blood vessels) oral tablet 100 mg give one (1) tablet by mouth every twelve (12) hours for hypertension (high blood pressure). The resident refused 21 out of 31 morning doses. The resident refused 16 out of 31 evening doses. f. Order dated 02/09/2024 [Generic Combination Hormone] subcutaneous suspension (70-30) (a medication used to help control blood sugar levels) 100 unit/ml Inject 35 unit subcutaneously one (1) time a day for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 15 out of 31 doses. g. Order dated 04/24/2023 [Generic Fast-acting Hormone] injection solution (a medication used to lower blood sugar levels) 100 unit/ml inject as per sliding scale. NOTIFY MD IF BLOOD SUGAR IS BELOW 60 OR GREATER THAN 400, subcutaneously before meals for diabetes mellitus (a disease that results in too much sugar in the blood). 6:30 AM: The resident refused 13 out of 27 doses. 11:30 AM: The resident refused 19 out of 29 doses. 4:30 PM: The resident refused 20 out of 28 doses. Fingerstick Blood Sugar on 03/10/2025 at 11:30 AM, 506 mg dl. h. Order dated 02/07/2024 [Generic Anti-ulcer Medication] (a medication used to treat and prevent stomach ulcers) oral tablet one (1) gram give one (1) tablet by mouth four (4) times a day for Gastroesophageal Reflux Disease [GERD] (a disease that allows stomach acid to irritate and damage the food pipe lining). 8:00 AM: The resident refused 21 out of 31 doses. 12:00 PM: The resident refused 23 out of 31 doses. 4:00 PM: The resident refused 10 out of 31 doses. 8:00 PM: The resident refused 16 out of 31 doses i. Order dated 02/08/2024 [Generic Combination Hormone] subcutaneous suspension (70-30) (a medication used to lower blood sugar levels) 100 unit/ml Inject 20 unit subcutaneously in the evening for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 23 out of 31 doses. j. Order dated 04/24/2023 [Generic Fast-acting Hormone] injection solution (a medication used to lower blood sugar levels) 100 unit/ml Inject as per sliding scale subcutaneously at bedtime for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 13 out of 28 doses. k. Order dated 12/11/2023 [Name Brand Anticonvulsant] (a medication that blocks pain from nerve damage in the body) oral capsule 300 mg give one (1) capsule by mouth every twelve (12) hours for nerve pain. The resident refused 20 out of 31 morning doses. The resident refused 13 out of 31 evening doses. A review of the Medication Administration Record (MAR) April 2025, for Resident #1, revealed the following: a. Order dated 04/25/2023 [Name Brand Non-Steroidal Anti-inflammatory Drug] oral tablet delayed release 81 mg give one (1) tablet by mouth one (1) time a day for heart health. The resident refused 12 out of 30 doses. b. Order dated 04/24/2023 [Generic HMG-CoA Reductase Inhibitor] (a medication used to treat high cholesterol levels) tablet 40 mg give one (1) tablet by mouth at bedtime for hyperlipidemia (high levels of fat in the blood). The resident refused 18 out of 30 doses. c. Order dated 04/25/2023 [Generic Antidepressant] (medication to treat depression) oral tablet 10 mg give one (1) tablet by mouth one (1) time a day for depression. The resident refused 19 out of 30 doses. d. Order dated 12/11/2023 [Generic Diuretic] (a medication used to help reduce the amount of water buildup in the body) oral tablet 25 mg give one (1) tablet by mouth one (1) time a day for hypertension (high blood pressure). The resident refused 16 out of 30 doses. e. Order dated 10/25/2024 [Generic Vasodilator] (a medication used to relax blood vessels) oral tablet 100 mg by mouth every 12 hours for hypertension (high blood pressure). The resident refused 14 out of 30 morning doses. The resident refused 18 out of 30 evening doses. f. Order dated 02/09/2024 [Generic Combination Hormone] subcutaneous suspension (70-30) (a medication used to help control blood sugar levels) 100 unit/ml Inject 35 unit subcutaneously one (1) time a day for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 12 out of 30 doses. g. Order dated 04/24/2023 [Generic Fast-acting Hormone] injection solution (a medication used to lower blood sugar levels) 100 unit/ml inject as per sliding scale. NOTIFY MD IF BLOOD SUGAR IS BELOW 60 OR GREATER THAN 400, subcutaneously before meals for diabetes mellitus (a disease that results in too much sugar in the blood). 6:30 AM: The resident refused 13 out of 27 doses. 11:30 AM: The resident refused 21 out of 30 doses. 4:30 PM: The resident refused 20 out of 30 doses. Finger Stick Blood Sugar on 04/16/2025 at 11:30 AM, 470 mg dl. h. Order dated 02/08/2024 [Generic Combination Hormone] subcutaneous suspension (70-30) (a medication used to lower blood sugar levels) 100 unit/ml Inject 20 unit subcutaneously in the evening for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 20 out of 30 doses. i. Order dated 04/24/2023 [Generic Fast-acting Hormone] injection solution (a medication used to lower blood sugar levels) 100 unit/ml Inject as per sliding scale subcutaneously at bedtime for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 11 out of 29 doses. j. Order dated 02/07/2024 [Generic Anti-ulcer medication] (a medication used to treat and prevent stomach ulcers) oral tablet 1 (1) gram give one (1) tablet by mouth four (4) times a day for Gastroesophageal Reflux Disease [GERD] (a disease that allows stomach acid to irritate and damage the food pipe lining). 8:00 AM: The resident refused 13 out of 30 doses. 12:00 PM: The resident refused 22 out of 30 doses. 4:00 PM: The resident refused 10 out of 29 doses. 8:00 PM; The resident refused 17 out of 30 doses. k. Order dated 12/11/2023 [Generic Anticonvulsant] (a medication that blocks pain from nerve damage in the body) oral capsule 300 mg give one (1) capsule by mouth every 12 hours for nerve pain. The resident refused 12 out of 30 morning doses. The resident refused 18 out of 30 evening doses. A review of the Medication Administration Record (MAR) May 2025, for Resident #1, revealed the following: a. Order dated 04/25/2023 [Name Brand Non-Steroidal Anti-inflammatory Drug] oral tablet delayed release 81 mg give one (1) tablet by mouth one (1) time a day for heart health. The resident refused 4 out of 7 doses. b. Order dated 04/24/2023 [Generic HMG-CoA Reductase Inhibitor] (a medication used to treat high cholesterol levels) tablet 40 mg give one (1) tablet by mouth at bedtime for hyperlipidemia (high levels of fat in the blood). The resident refused 4 out of 7 doses. c. Order dated 04/25/2023 [Generic Antidepressant] (medication to treat depression) oral tablet 10 mg give one (1) tablet by mouth one (1) time a day for depression. The resident refused 5 out of 7 doses. d. Order dated 12/11/2023 [Generic Diuretic] (a medication used to help reduce the amount of water in the body) oral tablet 25 mg give one (1) tablet by mouth one (1) time a day for hypertension (high blood pressure). The resident refused 4 out of 7 doses. e. Order dated 10/25/2024 [Generic Vasodilator] (a medication used to relax blood vessels) oral tablet 100 mg by mouth every 12 hours for hypertension (high blood pressure). The resident refused 4 out of 7 morning doses. The resident refused 5 out of 7 evening doses. f. Order dated 02/09/2024 [Generic Combination Hormone] subcutaneous suspension (70-30) (a medication used to help control blood sugar levels) 100 unit/ml Inject 35 unit subcutaneously one (1) time a day for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 1 out of 8 doses. g. Order dated 04/24/2023 [Generic Fast-acting Hormone] injection solution (a medication used to lower blood sugar levels) 100 unit/ml inject as per sliding scale, subcutaneously before meals for diabetes mellitus (a disease that results in too much sugar in the blood). 6:30 AM: The resident refused 1 out of 8 doses. 11:30 AM: The resident refused 4 out of 6 doses. 4:30 PM: The resident refused 4 out of 7 doses. h. Order dated 02/07/2024 [Generic Antiulcer Medication] (a medication used to treat and prevent stomach ulcers) oral tablet one (1) gram give one (1) tablet by mouth four (4) times a day for Gastroesophageal Reflux Disease [GERD] (a disease that allows stomach acid to irritate and damage the food pipe lining). 8:00 AM: The resident refused 5 out of 7 doses. 12:00 PM: The resident refused 3 out of 7 doses. 4:00 PM: The resident refused 4 out of 7 doses. 8:00 PM: The resident refused 4 out of 7 doses. i. Order dated 02/08/2024 [Generic Combination Hormone] subcutaneous suspension (70-30) (a medication used to lower blood sugar levels) 100 unit/ml Inject 20 unit subcutaneously in the evening for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 4 out of 7 doses. j. Order dated 04/24/2023 [Generic Fast-acting Hormone] (a medication used to lower blood sugar levels) solution 100 unit/ml Inject as per sliding scale subcutaneously at bedtime for diabetes mellitus (a disease that results in too much sugar in the blood). The resident refused 3 out of 7 doses. k. Order dated 12/11/2023 [Name Brand Anticonvulsant] (a medication that blocks pain from nerve damage in the body) oral capsule 300 mg give one (1) capsule by mouth every twelve (12) hours for nerve pain. The resident refused 4 out of 7 morning doses. The resident refused 4 out of 7 evening doses. During an observation on 05/08/2025 at 8:00 AM, this surveyor observed LPN #1 during Resident #1's medication administration. The LPN explained all medications and uses of medications clearly to the resident and allowed the resident time to ask questions. The resident had placed their Guardian on speaker phone, during the administration visit. The resident refused their multivitamin and [Generic Anti-ulcer medication]. The resident did accept [Name Brand Anticonvulsant] (a medication that blocks pain from nerve damage in the body), [Generic Antidepressant] (medication to treat depression), [Generic Vasodilator] (a medication used to relax blood vessels), and [Generic Diuretic] (a medication used to help reduce the amount of water in the body) During an interview on 05/08/2025 at 12:50 PM, with the Advanced Practice Registered Nurse (APRN), she indicated she was aware Resident #1 did refuse medications at times. The APRN indicated if the Guardian had requested to receive notification when the resident refused medications, then the Guardian should have been notified every time the resident refused a medication. She indicated it was important for a resident to receive the ordered medications, due to the hazards possible to the resident's well-being if they did not take the medications. During an interview on 05/08/2025 at 1:30 PM, with the Director of Nursing (DON), she reported if a resident refused medication, she expected the nurses to educate the resident on the importance of medication compliance, then come back at a later time to try again. She then indicated she expected the nurses to report the occurrence to the APRN or the on call APRN. She indicated a guardian should be notified of medication refusals every time a resident refused a medication. The DON reported she did think the staff were contacting the guardian every time the resident refused a medication but was unable to find the documentation supporting that they had contacted the guardian. During an interview on 05/08/2025 at 2:44 PM, with the Administrator, he revealed that he was aware Resident #1 did refuse to take medications at times. He reported that it was important a resident received the ordered medications, without interruption, to keep the resident healthy and doing well. The Administrator indicated, if a guardian asked to be notified when the resident refused to take medication, the guardian should be notified every time the resident refused.

Based on observation, record review, interview, and facility policy review, it was determined that the facility failed to ensure the rear casters of the mechanical lift were not locked with lifting and lowering resident to prevent accidents and injuries affecting 1 sampled (Resident #270) of 4 sampled residents reviewed for accidents. The facility failed to ensure the residents environment was free of accidents and hazards for 1 sampled (Resident #48) of 4 sampled residents reviewed for accidents and hazards. The Findings include: Review of Resident #270's Care Plan revealed diagnoses of subdural hemorrhage, respiratory failure, and type II diabetes. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/2024 indicated a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact). Resident#270 required total assistance for toileting, bathing, and dressing the lower body. Review of Resident #270's Care Plan, dated 09/19/2024, revealed resident was dependent on helpers, was unable to provide any effort for toileting and required the assistance of 2 helpers. Review of an in-service titled Mechanical Lift Usage Instructions and Training for All Staff, dated 07/12/24, revealed the mechanical lift was for safe movement of residents. The in-service did not address use of the rear casters/wheels while raising or lowering a resident. On 10/01/24 at 9:25 AM, Shahbaz #4 was observed rolling a mechanical lift under Resident #270's bed with the legs in the open position, rear casters were locked, and Resident #270 was raised up from the bed. A wheelchair was rolled between the open legs, rear casters/wheels were locked, and Resident #270 was lowered into a wheelchair. During an interview with Shahbaz #4 on 10/01/24 at 09:39 AM, Shahbaz #4 stated they locked the rear wheels when lifting and lowering Resident #270 with the mechanical lift so the lift did not roll away, because it could injure the resident. Shabaz #5 said the wheels are locked so it does not move while lifting and lowering residents to prevent tipping. On 10/02/24 at 08:53 AM, Director of Nursing (DON) was asked the process for lifting and lowering a resident with a lift. DON stated, the legs of the mechanical lift should be open, and the rear wheels should be locked so that it cannot move and cause an injury to the resident. The Surveyor requested a copy of mechanical lift in-services, and the mechanical lift user guide. On 10/02/24 at 09:41 AM, The Administrator provided the portable lift owner's manual and page 31 revealed, when lifting and moving a resident, the rear casters/wheels of the mechanical lift should not be locked to avoid the resident and lift from tipping and endangering the resident. On 10/01/24 at 8:53 AM, surveyor observed an unsecured oxygen tank sitting inside a black bag in the bathroom propped up on the vanity. On 10/01/24 at 1:41 PM, surveyor observed an unsecured oxygen tank sitting inside a black bag in the bathroom propped up on the vanity. On 10/02/24 at 8:58 AM, surveyor observed an unsecured oxygen tank sitting inside a black bag in bathroom propped up on the vanity. On 10/02/24 at 8:59 AM, Resident #48 stated they does not use oxygen and had asked staff to take the oxygen tank out of their bathroom several times, but the staff had not taken it out and it needed to go in the room for oxygen tanks. On 10/02/24 at 9:01 AM, Licensed Practical Nurse (LPN) #1, informed the surveyor the tank should not be in the bathroom, and it should be in the oxygen room. LPN #1 said her concern was if the tank fell over it could blow up. On 10/02/24 at 9:08 AM, a review of Resident #48's Physician Orders reflected Resident #48 did not have an order for oxygen. Resident #48 was not care planned for oxygen and Resident #48's MDS does not indicate they used oxygen. On 10/04/24 at 8:33 AM, the Director of Nursing (DON) provided the policy Handling of Oxygen and Flammable Gas which states oxygen cylinders will be stored in a designated ventilated area, stored in a safe manner to prevent cylinder from fall over. On 10/04/24 at 8:28 AM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated the oxygen cylinders should be stored in the supply closet in the canister holder, and they cannot be on the floor due to safety. The oxygen cylinders could fall over and cause a combustion. On 10/04/24 at 8:34 AM, the DON stated oxygen cylinders should be stored in the supply closet in cylinder holders because they could fall over and cause a flammable hazard, and they should not be stored in a bathroom.

Based on observation, interview, and facility policy review, the facility failed to ensure that pills were properly stored in the acceptable package or bottle to prevent mediation errors in Building 1 and failed to ensure a thermometer and temperatures were being monitored in the narcotic refrigerator in Building 4 to ensure medications were stored at an appropriate temperature. Findings include: On 10/02/24 at 8:46 AM, While checking the medication cart in building #1, two loose, round, tan pills and residue of pills were found inside the top drawer of the cabinet, in the far-right corner. Licensed Practical Nurse, (LPN) #6 stated they looked like a supplement, and she would waste the pills. Surveyor asked if someone had to be notified prior to wasting, or if they had a process, and LPN #6 replied, Yes, I would tell the Director of Nursing (DON). LPN #6 stated that it was not appropriate to store loose pills, and she would expect to find pills in an identifiable bottle to protect residents. On 10/02/24 at 8:50 AM, DON arrived and placed the two intact pills in a plastic bag for further inspection, and disposed of the two-round, tan-colored pills. On 10/02/24 at 8:52 AM, DON stated pills should be stored in the proper container and slot because staff could mistakenly administer medication that was not meant for a patient. She reported that nursing was educated every day on medication storage, and the policy was to store medications in their package or bottle. DON confirmed nursing and med techs are responsible for the medication carts, but ultimately nursing was responsible. On 10/03/24 at 8:10 AM, LPN #1 accompanied the surveyor to the medication storage area in Building #4. When asked the temperature of the refrigerator LPN #1 stated that there was no thermometer. She stated the available Ozempic 2 mg (milligram)/3 ml (milliliter) pen and Lorazepam 29.75 ml bottle should be stored at 36-46 degrees Fahrenheit Surveyor asked if she could confirm the temperature of the refrigerator right now and LPN #1 said, Honestly, no I cannot tell you the temperature because there is not a thermometer in the refrigerator. LPN #1 confirmed it was important to make sure the medications were stored at the right temperature, so it would not break down. On 10/03/24 at 8:20 AM, DON was asked who was responsible for checking the narcotic refrigerator temperatures, and where is that documented. DON stated that nurses are responsible to check the temperature every night, and a temperature log was not kept. DON revealed maintenance defrosted the refrigerator on Saturday and may have forgotten to place the thermometer back in the refrigerator. DON confirmed that medications must be at a certain temperature if required. On 10/03/24 at 8:39 AM, Nurse Consultant #7 provided a policy titled Pharmaceutical Services, which revealed medication storage areas are checked monthly for proper storage, expired medications, and cleanliness. Drugs and biologicals are expected to be labeled and stored in accordance to accepted professional principles, in compartments under proper temperature controls. On 10/03/24 at 9:10 AM, DON provided an in-service titled Nursing, dated 05/06/2024, which revealed nursing was responsible for making sure medications were stored properly and were not to be taken from its original package or bottle. Medications were not to be stored in carts or cabinets without proper labeling.

Based on observation, record review, and interview, it was determined that the facility failed to ensure that a comprehensive care plan addressed pain for 1 of 1 sampled resident (Resident #58) reviewed for pain management to ensure appropriate interventions were in place. The Findings include: Review of Resident #58's Care Plan revealed diagnoses of cancer, inability to use legs, and type II diabetes. Review of an Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2024 suggest a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) Section J0100 a. suggested resident was on scheduled pain medication, section J0200 showed pain assessment interview should be conducted, J0300 indicated pain was present, J0410 indicated Resident #58 had occasional pain, and section J0510 on the MDS suggested pain occasionally affects Resident #58's sleep. A review of Physician Orders, dated 09/05/2024, revealed that pain should be evaluated every shift, and a scheduled pain medication should be given every 8 hours. A review of Physician Orders, dated 09/17/2024, revealed an opioid pain medication was scheduled 1 tablet every 6 hours as needed for pain. A review of Physician Orders, dated 09/25/2024, revealed an opioid pain patch should be applied every three days at bedtime for pain. During an interview with Shahbaz #8 on 10/03/24 at 11:46 PM, Shahbaz #8 revealed Resident #58 had spinal cancer and frequently complained of back pain. During an interview on 10/03/24 at 3:25 PM, MDS Nurse #2 confirmed the MDS dated [DATE] showed Resident #58 received scheduled pain medication and confirmed the Shahbaz would look in the care plan to find interventions. MDS Nurse #2 looked in the computer records and stated she was not seeing pain on Resident #58's care plan but pain should be, and MDS Nurse #2 or the other MDS Nurse #3 were responsible for addressing pain on the care plan because the MDS looks at the resident as a whole and it is important that things make it from the MDS to the care plan to ensure residents get the care they need. MDS Nurse #2 confirmed that the Resident Assessment Instrument (RAI) manual is used as a guide for the MDS. The Surveyor asked MDS Nurse #2 to provide documentation from the RAI manual showing where the process was missed with care planning. On 10/03/24 at 3:45 PM, MDS Nurse #2 reported, she could not find anything in the RAI manual, but by documenting yes on Care Area Assessment (CAA) Worksheet it should carry over to the care plan

Based on observation, record review, and interview the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 1 (Resident #2) of 2 sampled residents that were reviewed for respiratory therapy. The findings are: Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/27/24 indicated Resident #2 had diagnoses of chronic obstructive pulmonary disease, stroke, dementia and functional quadriplegia (loss of movement in all four limbs), scored 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and received oxygen therapy. A Review of a Physician's order, dated 06/14/2022 indicated, May have Oxygen 2-3 LPM [liters per minute] Via N/C [Nasal Cannula] as needed every shift for Shortness of breath and/or pulse ox [oximetry] [oxygen level] < [less than] 90%. Review of a Care Plan with a revision date of 01/18/2024 indicated Resident #2 received oxygen therapy at 2 liters per nasal cannula as needed with the goal being the resident would have no signs or symptoms of poor oxygen absorption. A task/intervention included staff to observe the oxygen flow rate matched the ordered amount when oxygen was in use. On 9/30/2024 at 12:31 PM, Resident #2 was observed lying in bed, with O2 at 1.5 liters/minute via NC. On 10/01/2024 at 11:00 AM, Resident #2 was observed lying in bed with O2 at 1.5 liters/minute via NC. On 10/01/2024 at 5:45 PM, Resident #2 was observed lying in bed with O2 at 1.5 liters/minute per NC. On 10/02/2024 at 2:24 PM, the surveyor asked Licensed Practical Nurse (LPN) #1 to accompany the surveyor to Resident #2's room to observe oxygen therapy administration. Upon interview LPN #1 stated that the oxygen flow rate was 1.5 liter/minute and should be at 2L for resident #2. LPN #1 adjusted the flowmeter to 2 Liters per minute at that time. LPN #1 stated the process for ensuring flow rates of oxygen are correct is up to the LPN to check the provider orders. LPN #1 stated that the flow rate should had been checked earlier that day. LPN #1 stated Resident #2 was able to pull the nasal cannula off at times but was not able to get out of bed and adjust the oxygen rate. On 10/2/24 at 5:50 PM, an interview of LPN #1 was conducted. LPN #1 stated that provider orders are checked every shift by the LPN. LPN#1 stated the rate could have been accidentally turned down to 1.5 liters/minute when the tubing was being changed on 9/29/2024 but should be at 2 liters/minute. LPN #1 stated the dating of the tubing change was verified this morning and the rate was verified to be at 2 liters/minute, but it must have been looked at incorrectly. LPN #1 stated they could not speak for any incorrect flow rates on 9/30/24 or 10/1/24 because they did not work that day, nor could they speak for any night shift. In addition, LPN #1 stated verification of rates for medications and therapies is important because the order is written to maximize health/life. On 10/3/2024 at 2:30 PM, the Director of Nurses (DON) was interviewed. The DON stated the process for ensuring orders are accurate depends on the order written: for instance, if it is a daily order, it should be checked every day, if it is a monthly order, it is to be checked once per month. The person responsible for checking orders is the licensed nurse. Continuous oxygen would be checked every shift (day shift and night shift). The DON stated it is important for physician orders to be followed as written because it is a physicians' order. On 10/3/2024 at 3:10 PM, the DON was asked for a policy regarding verifying physician orders on oxygen therapy. On 10/4/2024 at 8:33 AM, the policy titled Handling of Oxygen and Flammable Gas OLTC Reg.321 (undated) provided by the Director of Nurses did not address the verification of Oxygen therapy orders.

47916 Based on observation and facility policy review, the facility failed to ensure expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria, and to ensure food stored in the freezer were appropriately dated. The findings are: On [DATE] at 9:56 AM, a clear, unsealed, package of hot dogs dated [DATE] was stored in the door of the refrigerator, located in the pantry of Cottage 6. The Dietary Manager (DM) immediately removed the hot dogs and said these are not good and should have been used or removed 7 days after being opened because they can cause someone to get sick. On [DATE] at 10:52 AM, While checking the freezer in Building 1 (Dogwood), 2 frozen apple pies were observed without received dates. DM stated, frozen pies should have a received date so staff can tell when they arrived or need to be thrown out. On [DATE] at 12:31 PM DM provided a policy titled Storage of Food and Beverages Brought by Visitors; it does not cover opened prepackaged meat items. On [DATE] at 2:06 PM, DM provided a policy titled Food and Nutrition Services; it does not cover opened prepackaged meat items.

Based on observation, record review, interview, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed appropriately with peri care to prevent cross contamination, and the spread of infection. This failed practice affected 1 sampled (Resident #270) resident requiring assistance for incontinence care, with the potential to affect 2 sampled (Resident #58, Resident #270) residents reviewed for bowel and bladder. Findings include: Review of Medical Diagnoses Report revealed Resident #270 had a diagnoses of subdural hemorrhage, respiratory failure, and type II diabetes. Review of an Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/2024 indicated a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact). Resident #270 required moderate assistance with meals and personal hygiene, and total assistance for toileting, bathing, and dressing the lower body. On 10/01/24 at 09:25 AM, Shahbaz #5 was observed removing Resident #270's wet brief after rolling down the front with the right hand, and then removed wipes without performing hand hygiene. Resident #270 urinated during care on 3 clean wipes held over the perineal area, and then wipes were used to wipe the perineal area in a circular motion multiple times before Shahbaz #5 changed gloves. Shahbaz #4 wiped Resident #270's perineal area including wiping the buttocks then pulling up Resident #270's clean pants and placing a lift pad under Resident #270 without performing hand hygiene. On 10/01/24 at 09:45 AM, Shahbaz #4 confirmed that she assisted in wiping Resident #270's buttocks and stated she did not change gloves or perform hand hygiene during incontinence care, or when dressing resident and placing a lift pad under Resident #270. Shahbaz #5 confirmed that after resident urinated the same wipe was used to wipe off the perineal area, before changing gloves. Shahbaz #4 stated there was a concern for cross contamination by not providing proper hand hygiene. On 10/02/24 at 08:56 AM, During an interview with Director of Nursing (DON), DON stated she expects staff to wipe residents one time in one direction, then use a clean wipe in another area, Hand hygiene should be done prior to going from dirty to clean in the resident's environment to prevent cross contamination and the spread of germs. Surveyor requested in-services, and procedures and policies on peri care. Review of an in-service titled Peri Care, dated 07/10/2024, revealed staff were expected to wear gloves, roll down and remove residents brief, and to change gloves when soiled. All staff were to change their gloves when changing from the front to the back. When state was in the building always use 2 people, one for clean and one for dirty. Staff were expected to swipe with 1 wipe front to back.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an orderly, uncluttered environment for 1 (Resident #3) of 3 sampled residents. The findings include: Resident #3 had diagnoses of hepatic failure, cirrhosis of liver, and heart failure. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/2024 documented a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact). On 04/30/2023 at 09:15 AM, the following observations were made in Resident #3 ' s bathroom: 1. Two wheelchairs and one shower chair in the shower stall. Clothing and blankets were stacked on top of the chairs. 2. The toilet had a raised seat extender. On top of the raised seat extender was the bath basin used for bed baths, draining water from the basin into the toilet. 3. The bathroom sink had several wet wash clothes drying on the sink. On 04/30/2024 at 9:30 AM, Resident #3 was asked, Are they providing good care for you? Resident #3 responded, I have had colon cancer with treatments of chemotherapy, causing my gallbladder and liver to fail. My mind is very sharp, and I can make my needs known. I would like to get up out of bed, shower, and wear my own clothes. Resident #3 was asked, Do they get you up and provide showers? Resident #3 stated, I usually get a bed bath, the bathroom is too cluttered. The Surveyor asked, Have you asked the facility to unclutter the bathroom? Resident #3 stated, I have asked them to move some of the equipment out of the bathroom, one of those wheelchairs is not mine. On 04/30/2024 at 10:23 AM, Certified Nursing Assistant (CNA) #1 was asked, Can Resident #3 let [his/her] needs be known? CNA #1 stated, [Resident #3] calls on the call light, cannot get up, and we help [him/her] when [he/she] calls us. The Surveyor asked, Does the facility get [him/her] up and offer showers? CNA #1 responded, [Resident #3] only wants bed baths, and we cannot get in the shower because the room has too much equipment. On 04/30/2024 at 5:15 PM, the Administrator was asked, Are you aware that Resident #3 cannot access their shower or toilet due to clutter and storage in the bathroom? The Administrator stated, The Resident has refused to get out of bed, according to the staff. However, the bathroom should have been cleaned out without all this clutter. We can move equipment out and she has a niece that can remove some items out of the bathroom. A facility policy titled, Housekeeping and Maintenance read in part, .Rooms will be cleaned and put in order daily. If the resident chooses to keep his own room, the room will be regularly observed to ensure a clean, orderly room.

Based on observation, interview and record review, the facility failed to ensure staff washed their hands when serving meals, follow the menu and ensure the menu was posted. The findings are: On 12/27/23 at 12:27 PM, Certified Nurse Aid (CNA) #1 was observed running her hands down her braids without washing her hands. She passed lunch trays without washing her hands between residents. A Fall/Winter menu for 12/28/23 documented that the residents should have gravy, and a choice of cereal for breakfast. On 12/28/23 at 8:38 AM, the residents were not served gravy for breakfast, and the menu was not posted. The Surveyor asked CNA #3 in Cottage 3 Can you tell me why the residents were served gravy with their breakfast? She stated, I don't know. On 12/28/23 at 8:43 AM, the residents were not served gravy, or cereal for breakfast, and the menu was not posted in Cottage #3. CNA #5 was asked, Can you tell me why the residents are not served gravy, or cereal, and why the menu is not posted? She stated, They didn't send any gravy, and we're out of milk. The Surveyor asked, Can you tell me why the menu is not posted? She stated, I don't know. On 12/28/23 at 8:51 AM, the menu was not posted in Cottage #9. The Surveyor asked CNA #9 Can you tell me why the menu is not posted? She stated, I'm not sure. On 12/28 23 at 8:46 AM CNA #9 was serving the residents breakfast in Cottage #10. The residents were not served gravy and there was no menu posted. CNA #9 was asked, Can you tell me why the residents are not served gravy for breakfast, and why the menu is not posted? She stated, They didn't send the gravy. She was asked, Can you tell me why the menu is not posted? She stated, I don't know. On 12/28/23 at 12:30 PM, the Surveyor asked CNA #3, Can you tell me why the menu is not posted where the residents can see it? She stated, I have no clue. I've asked them to do it. They are supposed to put it on the board, but we don't have a board. The Surveyor asked, Should you touch your hair without washing your hands when passing out meal trays? She stated, no. On 12/28/23 at 1:50 PM, the Surveyor asked the dietary manager, Can you tell me why the residents didn't receive gravy with their breakfast this morning? She stated, The cooks are supposed to make the gravy. She was asked, Can you tell me why some of the cottages didn't have milk this morning? She stated, I'm not sure because we have milk. She was asked, Who's responsible for posting the menu so the residents are able to see it? She stated, The cooks and aids are responsible for putting up the menu. On 12/28/23 at 2:21 PM the Surveyor asked CNA #2, Should you touch your hair without washing your hands when passing out meal trays? She stated, No ma'am, you should always wash your hands. She was asked, Can you tell me why the menu is not posted where the residents can see it? She stated, Most of them have them in their room. On 12/28/23 at 2:37 PM the surveyor asked CNA #4, Can you tell me why the menu is not posted where the residents can see it? She stated, I don't know. She was asked, Should you touch your hair without washing your hands when passing out meal trays? She stated, No. On 12/28/23 at 2:44 PM the Surveyor asked CNA #4, Should you touch your hair without washing your hands when passing out meal trays? She stated, no. On 12/28/23 at 3:10 PM, the Surveyor asked the Director of Nurse (DON), who is responsible for posting the menu? She stated, Dietary manager. She was asked, Can you tell me why the menu is not posted where the residents can see it? She stated, I didn't know it wasn't.

Based on observation, record review and interview, the facility failed to ensure fingernails were regularly trimmed to maintain good hygiene and grooming for 1 Resident #4 sampled residents who required staff assistance with nail care. The findings are: 1. Resident #4 had diagnoses of Primary Generalized Arthritis and Need for Assistance with Personal Care. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23 documented the Resident scored 08 (08-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS) and required substantial / maximal assistance with personal hygiene / Activity of Daily Living (ADL)s except eating. b. A Care Plan, last completed on 12/06/23, documented the Resident had an Activities of Daily Living (ADL) self-care performance deficit related to weakness and Arthritis and her nails were to be checked for length and trimmed as necessary. c. On 12/27/23 at 12:09 PM, Resident #4 was sitting up in her chair, visiting with family. At 12:16 PM, Certified Nursing Assistant (CNA) #6 brought in the Resident's lunch meal and as she was setting it up, the Resident said, my fingernails are too long, look at them (and she raised both hands with the palms facing her so surveyor could see her nails). I've almost clawed myself several times. Resident's fingernails were approximately greater than a quarter inch in length and the edges were jagged. d. On 12/27/23 at 3:02 PM, the Resident's Progress Notes were reviewed for 11/01/23 to 12/27/23 and there was no documentation that the Resident refused nail care. e. On 12/28/23 at 8:52 AM, the Surveyor asked the Resident if her nails could be looked at and she held out her hands and her nails were approximately greater than a quarter inch in length and the edges were jagged. The Resident stated no one has taken care of her nails. f. On 12/28/23 at 10:08 AM, the DON provided a copy of the Resident's ADLs for 12/01/23 to 12/28/23. There was no documentation for the 7AM to 3PM (7/3) shift of 3 PM to 11 PM (3/11) shift that the Resident refused personal hygiene care as denoted by RR= (Resident Refused). g. On 12/28/23 at 2:24 PM, CNA #6 confirmed the CNAs were responsible for providing nail care to Resident's and if a Resident refused, she reported and charted it. The Surveyor asked CNA #6 to describe Resident #4 ' s nails. She described the Resident's nails as clean but needed to be filed and shaped. She stated she wouldn't try to trim them because of how the resident's skin is, and she was concerned about snipping her skin. She also pointed to the edges of the Resident's nails and said she would try filing them instead of cutting them. h. On 12/28/23 at 3:10 PM, CNA #7 was interviewed, and said she didn't know what to do if a Resident refused nail care because she hadn't had any to say no when offered. CNA #7 was asked if Resident #7 ever requested to have her nails trimmed and she stated, Yes we just tried to do that, and she threw the nail file at us. i. On 12/29/23 at 10:45 AM, DON was asked for a policy on ADL care. At 11:03 AM, the DON informed the Team Coordinator there is no policy for ADL care.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination; 5 of 10 ice machines and 7 of 10 ice scoop holders were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 10 of 10 kitchens; Hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from the kitchen in Cottages #3, #5, #6, #8 and #10, and hand hygiene was maintained during food service to minimize the risk of food borne illness in Cottages #3 and #8. These failed practices had the potential to affect 4 residents in Cottage #1, 11 residents in Cottage #2, 13 residents in Cottage #3, 14 residents in Cottage #4, 12 residents in Cottage #5, 13 residents in Cottage #6, 14 residents in Cottage #7, 12 residents on Cottage #8, 7 residents in Cottage #9, and 11 residents in Cottage #10 who received meal trays from the cottage kitchens, (Total census: 107), as documented on a list provided by the Dietary Supervisor. The findings are: 1. Cottage 1: On [DATE] at 11:24 AM, the ice scoop holder on top of the ice machine had light gray matter in it. The ice scoop was resting directly in contact with a black residue. The Surveyor asked the Dietary Supervisor to wipe the wet black residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. She stated, It was lightly brown. The Surveyor asked the Dietary Supervisor how often the ice scoop holder was cleaned and who used the ice from the machine. She stated, The CNAs [Certified Nursing Assistants] use it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. 2. Cottage 2: On [DATE] at 11:28 AM, the following spices in the cabinet above the food preparation counter did not have an opened date on them: a. An opened box of iodized salt was not covered, and no date of when it was opened. b. Greek seasoning. c. Ground cumin. d. Ground cinnamon. e. Basil leaves. f. Lemon pepper seasoning salt. g. Ground glove. h. Ground nutmeg. i. Ground poultry seasoning. j. Ground thyme. k. Garlic powder. l. 2 Mediterranean style oregano leaves. m. 2 ground all spices. n. Poultry seasoning. o. Ground black pepper. p. Light Chili powder. q. Ground white pepper. r. Grated parmesan cheese. On [DATE] at 11:36 AM, the scoop holder on top of the ice machine had an accumulation of wet black/grayish residue around the area where the ice scoop was resting. The ice scoop was resting directly in contact with the black/grayish residue. The Surveyor asked the Dietary Supervisor to wipe the wet black/grayish residue. She did, and the wet black/grayish residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. She stated, It was wet black/grayish matter. The Surveyor asked how often the ice scoop holder was cleaned and who used the ice from the machine. She stated, The CNAs use it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. We clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 11:40 AM, an opened bag of pancake mix was on a shelf in the dry storage room. The bag was not dated. On [DATE] at 3:59 PM, a CNA placed one corndog into a blender, ground and poured it into a bowl. She covered the bowl with foil and placed it in the oven. On [DATE] at 4:03 PM, CNA #4 put her apron on, contaminating her hands. Without washing her hands, she placed gloves on her hands contaminating the gloves. At 4:05 PM, she picked up a banana, peeled off the skin, and diced it with a knife. She then used her contaminated gloved hands to pick up the diced banana. As she was ready to transfer it into a bowl, the Surveyor immediately asked her what she should of done after touching dirty objects and before handling food items or clean equipment. She stated, I should have washed my hands. 3. Cottage #3: On [DATE] at 11:46 AM, the following spices in the cabinet above the food preparation counter did not have an opened date on them: a. An opened box of iodized salt was not covered. b. Ground white pepper. c. Ground cinnamon. d. Ground nutmeg. e. Italian seasoning. f. Ground thyme. g. Mediterranean style oregano leaves. h. Poultry seasoning. i. 2 French Mustard. On [DATE] at 11:48 AM, the following observations were made on a shelf in the refrigerator in the kitchen. a. An opened bottle of ginger ale with no opened date. b. An opened bottle of grape jelly with no opened date. On [DATE] at 11:51 AM, the left inside of ice machine in the dry storage room had accumulation of black, gray, and rust residue on it. The Surveyor asked the Dietary Supervisor to wipe the wet black residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor to describe what was on the left corner of the ice machine, how often the ice machine was cleaned and who used the ice from the machine. She stated, They were black/gray and rust. The CNAs use it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. They are supposed to clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 11:56 AM, a bag of instant nonfat milk was on a shelf in the storage room with an expiration date of [DATE]. On [DATE] 12:26 PM, observed CNA #17's hair was hanging out 12 inches and not contained while serving lunch. On [DATE] 12:29 PM, observed CNA #17 without a hairnet on dishing plates of food while CNA #18 passed the trays to residents. On [DATE] 12:35 PM, observed CNA #17's hair was hanging out 12 inches and not contained while dishing plates of food for the residents. On [DATE] at 10:36 AM, the Surveyor asked the Infection Control Preventionist (ICP) why staff's hair should be contained while preparing and serving the residents food. The ICP stated, For infection control and to prevent contamination. A facility policy titled, Infection Control Program, provided by the Director of Nursing (DON) on [DATE] at 9:27 AM documented, . IV. Personal Hygiene A. Proper attire for food handlers should include a hair covering all hair (hair nets) . 4. Cottage #4: On [DATE] at 11:58 AM, the following spices in the cabinet above the food preparation counter did not have an opened date on them: a. Ground black pepper. b. Paprika. c. Basil leaves. d. Mediterranean style oregano leaves. e. Ground white pepper. f. Ground cayenne pepper. g. Onion powder. h. Garlic powder. i. Lemon pepper. j. Ground nutmeg. k. Celery seed. l. Rosemary. m. Yellow mustard. n. Bottle of hot sauce. o. Poultry seasoning. p. Ground cinnamon. On [DATE] at 11:59 AM, the following observations were made on a shelf in the kitchen refrigerator: a. An opened bottle of ginger ale with no date when it was opened. b. An opened bottle of grape jelly with no date when it was opened. On [DATE] at 1:21 PM, the following observations were made in the freezer: a. Two containers of vanilla ice cream had ice cycles on them. The Surveyor asked the Dietary Supervisor to describe the appearance of the ice cream. She stated, They have frostbite. b. An opened ziplock bag of bacon was on a shelf. The bag was not sealed. On [DATE] at 1:23 PM, an opened bag of pancake mix was on a shelf in the storage room with no open date. 5. Cottage #5 On [DATE] at 10:11 AM, the ice machine in the storage room had a wet black residue on the inside of the left side corner of the panel. The Surveyor asked the Dietary Supervisor to wipe the residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who used the ice from the machine. She stated, The CNAs used it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. They are supposed to clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 10:12 AM, the scoop holder on top of the ice machine in the storage room had a wet black residue around the area where ice scoop was resting. The ice scoop was resting directly in contact with the black residue. The Surveyor asked the Dietary Supervisor to wipe the wet black residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked how often the ice scoop holder was cleaned and who used the ice from the machine. She stated, The CNAs use it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. We clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 10:16 AM, the following observations were made on a shelf in the refrigerator: a. An opened ziplock bag of sausage patties. The bag was not sealed. b. An opened ziplock bag of slices of cheese. The bag was not sealed. On [DATE] at 10:20 AM, observed an opened bag of chicken tenders on a shelf in the freezer. The bag was not sealed. On [DATE] at 10:21 AM, the following observations were made on a rack in the storage room: a. An opened bag of cornflakes. The bag was not sealed and did not have an opened date. b. An opened box of cream of wheat. The box was not covered and did not have an opened date. On [DATE] at 10:23 AM, the following spices in the cabinet above the food preparation counter did not have an opened date: a. A container of sugar free syrup b. A container of grated parmesans cheese c. 2 Lemon pepper seasoning salt d. Italian seasoning e. Ground black pepper f. Mediterranean style oregano leaves g. Ground paprika h. Ground gloves i. Ground thyme j. [NAME] leaves k. Basil leaves l. Baking powder with an expiration date of [DATE]. On [DATE] at 8:27 AM, CNA #7 placed 4 servings of sausage links into a blender, ground and poured into a pan on the steam table. The temperature of the ground sausage links when checked on the steam table by the Dietary Supervisor was 100 degrees Fahrenheit. The meat was not reheated before being served to the residents. 6. Cottage #6: 1. On [DATE] at 10:31 AM, the following spices inside a cabinet above the food preparation counter did not have an opened date: a. Ground black pepper b. Ground cayenne pepper c. Ground celery seed d. Ground celery salt e. Ground rosemary f. Ground nutmeg g. ground Mediterranean style seasoning h. Rubbed sage i. Chili powder j. ground dill seed k. Ground poultry seasoning l. Lemon pepper seasoning salt m. Ground thyme n. Ground cinnamon o. Ground allspice p. Ground cumin q. Ground gloves r. Onion powder s. Bottle of white vinegar On [DATE] at 10:37 An opened zip lock bag that contained crescent was on a shelf in the refrigerator. The bag was not sealed. There was no date of when it was opened. On [DATE] at 10:38 AM, an opened box of tortillas was in the freezer. The box was not covered and the bag inside the box was not sealed. On [DATE] at 10:39 AM, the ice machine in the storage room had wet black residue inside the left and right-side corners of the panel. The Surveyor asked the Dietary Supervisor to wipe the residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who used the ice from the machine. She stated, The CNAs used it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. They are supposed to clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 10:42 AM, an opened zip lock bag of breaded chicken patties was on a shelf in the freezer. The bag was not sealed. On [DATE] at 12:33 PM, the temperatures of the food items on the steam table when checked by the Dietary supervisor were: a. Beef Enchilada casserole - 115 degrees Fahrenheit. b. Chuckwagon Corn - 115 degrees Fahrenheit. On [DATE] at 8:10 AM, CNA #5 turned on the faucet and washed her hands. She turned off the faucet with her bare hands contaminating her hands. She removed gloves from a drawer and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands she picked up a clean blade and attached it to the base of the blender to be used in grounding foods to be served to the residents who required mechanical soft diets for breakfast. On [DATE] at 8:13 AM, the temperatures of the food items when checked on the plates by the Dietary Supervisor were: a. Ground sausage - 110 degrees Fahrenheit. b. Scrambled eggs - 120 degrees Fahrenheit. 7. Cottage #7: On [DATE] at 10:47 AM, the following spices in the cabinet above the food preparation counter did not have an opened date: a. Garlic powder. b. Mediterranean style oregano leaves. c. Fancy Spanish paprika. d. Light chili powder. e. Ground black pepper. f. Grated parmesans cheese. g. 2 Lemon pepper seasoning salt. h. Italian seasoning. i. Ground black pepper. j. Ground poultry seasoning. k. Ground nutmeg. l. Ground mustard. m. Ground Cumin. n. Ground cinnamon. o. Ground white pepper. p. Basil leaves. q. Baking powder with an expiration date of [DATE]. r. A box of iodized salt. s. A bottle of pure lemon extract. On [DATE] at 10:51 AM, the inside of the ice machine had wet black residue on both corners of the panel. The Surveyor asked the Dietary Supervisor to wipe the wet black residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who used the ice from the machine. She stated, The CNAs used it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. They are supposed to clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 10:52 AM, the scoop holder on top of the ice machine had a wet black residue around the area where the ice scoop was resting. The ice scoop was resting directly in contact with the black residue. The Surveyor asked the Dietary Supervisor to wipe the wet black residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked how often the ice scoop holder was cleaned. She stated, We clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 12:35 AM, the temperature of the food when checked on the steam table by the Dietary Supervisor was: a. Beef Enchilada casserole - 120 degrees Fahrenheit. 8. Cottage #8: On [DATE] at 10:55 AM, the following spices in the cabinet above the food preparation counter did not have an opened date: a. Basil leaves. b. Lemon pepper seasoning salt c. Ground thyme. d. Garlic powder. e. 2 Mediterranean style oregano leaves. f. Two ground all spices. g. Poultry seasoning. h. Fancy Spanish paprika. i. Light Chili powder. j. Ground black pepper. k. Grated parmesans cheese. l. 2 Lemon pepper seasoning salt. m. Italian seasoning. n. Ground black pepper. o. Ground poultry seasoning. p. Ground nutmeg. q. Onion powder. r. Ground mustard. s. Ground cumin. t. Chili powder. u. [NAME] leaves. v. Grated parmesan cheese. w. Ground cinnamon. x. Rubbed sage. y. Ground white pepper. z. Celery salt. On [DATE] at 11:08 AM, the scoop holder on top of the ice machine had a wet black residue around the area where ice scoop was resting. The ice scoop was resting directly in contact with the black residue. The Surveyor asked the Dietary Supervisor to wipe the wet black residue. She did, and the wet black residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. She stated, It was wet black dirt. The Surveyor asked how often the ice scoop holder was cleaned and who used the ice from the machine. She stated, The CNAs used it to fill the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. We clean it once a week. The Surveyor asked if it looked like it had been cleaned once a week. She stated, No. On [DATE] at 11:59 AM, observed CNA #8 periodically remove his phone from his pocket to check the screen while passing out the lunch plates. CNA #8 did not sanitize his hands at any time during the process. On [DATE] at 12:14 PM, observed CNA #8 move between residents, alternately feeding one or the other, and at the same time monitoring his phone on the table in front of him. At no time were hands washed or sanitized. On [DATE] at 12:19 PM, observed CNA's #7 and #8 passing out plated desserts. moving from one resident to the next, placing their hands on wheelchair handles, a resident's shoulder, and the table. At no time were hands sanitized. On multiple occasions CNA #8 used his hands to move his waist long braids over his shoulder and to his back without sanitizing his hands after. On [DATE] at 8:34 AM, CNA #8 was in the kitchen with 24 inch long braids hanging down with no hair restraint. The Surveyor asked the reason he was not wearing a hair net. He stated, I couldn't find the hair net. On [DATE] at 8:39 AM, CNA #9 placed 5 servings of sausage links into a blender and ground. At 8:40 AM, she poured the ground sausage links into a pan on the steam table. At 8:42 AM, the temperatures of the foods when checked on the steam table by the Dietary Supervisor were: a. Ground sausage - 98 degrees Fahrenheit. b. Sausage links - 100 degrees Fahrenheit. The above food items were not reheated before being served. On [DATE] at 12:11 PM, observed CNA #8 in the kitchen with braids hanging to the waist not contained in a hairnet filling plates and serving the plates. CNA #8 did not sanitize or wash his hands during the meal service. 9. Cottage #9: On [DATE] at 12:21 PM, the temperatures of the food items when checked on the heating element by the Dietary Supervisor was: a. Beef enchilada - 124 degrees Fahrenheit. On [DATE] at 3:35 PM, an opened bottle of mayonnaise was on a shelf in the refrigerator. The bottle was not dated. On [DATE] at 3:38 PM, an opened box of crisp rice was on a shelf in the storage room. The box was not dated. On [DATE] at 3:40 PM, the following spices in the cabinet above the food preparation counter did not have an opened date: a. 3 containers of lemon and pepper seasoning salt. b. Ground thyme. c. Ground celery salt. d. Ground nutmeg. e. Chili powder. f. Yellow mustard. g. Poultry seasoning. h. Ground Italian seasoning. i. Fancy Spanish paprika. j. Basil leaves. k. Ground white pepper. l. Garlic powder. m. Vanilla flavoring. n. Grated parmesan cheese. o. An opened jar of grape jelly with an opened date of [DATE]. The manufacturer specification on the bottle documented, Refrigerate after opening. On [DATE] at 11:58 AM, CNA #10 after touching a gallon of milk, picked up a piece of cornbread with her hand and placed it into the blender to be pureed and served it to the residents who required pureed diets. 10. Cottage 10: On [DATE] at 11:15 AM, the following spices in the cabinet above the food preparation counter did not have an opened date: a. Basil leaves. b. An opened box of iodized salt was not covered and did not have an opened date. c. An opened bag of brown sugar was not sealed and did not have an opened date. On [DATE] at 10:18 AM, the following observations were made on a shelf in the dry storage room: a. An opened box that contained a bag of crisp rice was on a shelf. The box was not covered, and the bag was not sealed. There was no opened date. b. A bag of instant dry milk with an expiration date of [DATE]. On [DATE] at 7:56 AM, CNA #3 turned off the sink faucet, contaminating her hands. Without washing her hands, she attached the blade to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. The Surveyor immediately asked CNA #3 what she should you have done after touching dirty objects before touching clean equipment. She stated, Washed my hands. On [DATE] at 8:13 AM, the temperatures of the pureed food items when checked by the Dietary Supervisor in divided plates were: a. Pureed eggs - 119 degrees Fahrenheit. b. Pureed sausage with bread and water - 116 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 39316 44852

Based on observation, interview and record review, the facility failed to ensure physician orders were followed; glucometers were cleaned before and after each use; hand hygiene was performed between residents; medication cart was not left unlocked and with medications on top, and the computer screen was closed when out of the line of sight of the nurse. during medication pass. The findings are: 1. Resident #106: A Physician's Order with a start date of 10/09/23 noted Resident #106 was to receive Lispro Insulin per sliding scale with meals. On 10/18/23 at 12:36 PM, during observation of the noon medication pass, observed Licensed Practical Nurse (LPN) #6 preparing to perform a finger stick glucose test on Resident #106. LPN #6 performed the finger stick. The glucometer was not cleaned prior to or after being used. LPN #6 then administered Glargine Insulin (a long-acting insulin) instead of Lispro Insulin (a rapid acting insulin) as documented on the physician orders for a sliding scale blood sugar of 278. LPN #6 then documented on Resident #106's Medication Administration Record (MAR) 8 units of Lispro insulin Lispro was administered. 2. Resident #311: A Physician's Order with a start date of 10/06/23 noted Resident #311 was to receive Diclofenac Sodium External Gel 1 % topically every 6 hours for pain to affected area by using the supplied ruler to measure the appropriate dose. On 10/18/23 at 12:51 PM, observed LPN #6 don gloves, squeeze an unmeasured amount of gel from Diclofenac Sodium Topical Gel 1% tube into her gloved hands, rubbing them together. She then rubbed Resident #311's left shoulder, left hand, left knee, right shoulder, and right hand. No ruler or other measurement of gel was used. 3. On 10/18/23 at 12:10 PM, observed LPN #6 perform a finger stick glucose test on Resident #312. The glucometer was returned to the top of the medication cart without being cleaned prior to or after use. 4. On 10/18/23 at 11:28 AM, LPN #6 walked away from the medication cart. On top of the medication cart was one uncovered, clear plastic medication cup containing a thick yellow liquid and 3 blister pack cards of Eliquis and Levothyroxine. The medication cart was out of the line of site of LPN #6. 5. On 10/18/23 at 12:10 PM, LPN #6 walked away from the medication cart and entered a resident's room. The medication cart was unlocked with 3 boxes of artificial tears sitting on top of the cart. 6. On 10/18/23 at 12:36 PM, LPN #6 entered a resident's room to administer medications leaving the medication cart in the hall unlocked and out of her line of site. 7. On 10/18/23 at 11:52 AM, observed LPN #6 perform a finger stick glucose test on Resident #80. LPN #6 LPN #6 placed the glucometer and supplies on the table in the sitting area. No hand hygiene was performed before donning gloves. LPN #6 picked the glucometer up from the table and placed it on the pants leg of Resident #80, performed the finger stick then removed her gloves. LPN #6 returned the glucometer to the medication cart without it being cleaned. LPN #6 did not perform hand hygiene after removing her gloves or prior to preparing and administering Resident #80 ' s medication. 8. On 10/18/23 at 11:41 AM, observed LPN #6 leave the medication cart unattended. The screen on the laptop on the cart was left open and Resident #67's date of birth and medications could be viewed easily. 9. On 10/18/23 at 12:54 PM, during an interview LPN #6 confirmed glucometers should be cleaned after each use with an alcohol pad; she did not clean the glucometer after each use today; hands should be cleaned after every resident and after removing gloves; the medication cart should be locked with no medications or keys on left on top and the computer screen should be closed when the medication cart is left unattended. 10. On 10/20/23 at 11:13 AM, during an interview the Infection Control Preventionist (ICP) confirmed glucometers should be cleaned with a [named] anti-germicidal after every blood sugar stick by the nurse to prevent cross contamination and because it's blood. The ICP also confirmed hand hygiene should be performed between each patient and before and after giving medications to protect the patient from infection and prevent cross contamination. 11. On 10/20/23 at 11:26 AM, during an interview the Director of Nursing (DON) confirmed the nurse should clean the glucometers with [Named] anti-germicidal in between every use and after you are done with medication pass. The DON also confirmed hand hygiene should be performed in between every patient and between medication passes to prevent cross contamination. 12. A facility policy titled, Preparation and General Guidelines, revised 01/2018, provided by the DON on 10/19/23 at 3:26 PM showed, Policy Medications are administered as prescribed in accordance with good nursing principles and practices . Procedure 4. Five rights - right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration (l) when the medication is selected. (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away . 13. A facility policy titled, Hand Hygiene, provided by the DON on 10/19/23 at 3:36 PM documented, Guidance: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Guidelines: .l. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom . Hand Hygiene Table Condition .Between resident contact . After handling contaminated objects . Before preparing or handling medications . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . 14. On 10/20/23 at 10:35 AM, a review of the facility instructions for cleaning glucometers provided by the DON on 10/19/23 at 3:26 PM documented, .Use two disposable wipes for each cleaning and disinfecting procedure . Gently wipe the surface area of the test strip port making sure that no fluid enters the port .

Based on observation, interview and record review, the facility failed to provide necessary services to maintain grooming, personal hygiene, and nail care for 1 (Residents #310) of 1 sampled residents who required assistance for nail care. The findings are: Resident #310: Resident #310's October 2023 Physician Orders did not address diabetic fingernail care. The Care Plan with an initiated date of 09/17/23 did not address diabetic fingernail care or interventions. On 10/16/23 at 11:22 AM, observed Resident #310 sitting at the dining table. Resident #310's fingernails were 1/2 inches in length beyond the end of the fingertip. The Surveyor asked if he liked his fingernails long. Resident #310 stated, No, I've asked them to cut them and they say they don't have fingernail clippers, that's what upsets me, they don't stock fingernail clippers or toothpicks. On 10/19/23 at 10:19 AM, the Surveyor asked Certified Nursing Assistant (CNA) #16 who clips Resident #310's fingernails? CNA #16 stated, [Resident #310] is a diabetic, so that would be the nurse. On 10/19/23 at 1:24 PM, the Director of Nursing (DON) confirmed a resident who is diabetic should have an order for diabetic nail care and that there was no documentation of fingernail care for Resident #310. On 10/19/23 at 1:25 PM, the Minimum Data Set (MDS) Coordinator confirmed she is the one who updates the care plans, and that fingernail care should be on the care plan. 44852

Based on observation, interview and record review, the facility failed to ensure a resident centered activities program was provided daily in each cottage. The findings are: On 10/16/23 at 10:40 AM, observed Certified Nursing Assistant (CNA) #8 interacting with the residents in Cottage 8. The Surveyor asked about the morning activity. He stated, We don't usually have activities. There is a schedule, but the Activity Director doesn't come over here to lead or instruct the staff. On 10/19/23 at 10:15 AM, entered Cottage 3 and was greeted by Shahbaz #11. The Surveyor asked about the morning activities. She stated, We didn't have one this morning. The Activity Calendar on the wall noted Exercise was at 10:00, Coffee/Chat at 10:30. On 10/19/23 at 10:23 AM, entered Cottage 2 and was greeted by Shahbaz, #12. The Surveyor asked what activity had taken place this morning. She stated, I don't think we had one this morning. On 10/19/23 at 10:30 AM, entered Cottage 1. The Surveyor asked if an activity was conducted this morning. She stated no, most everybody is in therapy. On 10/19/23 at 10:45 AM, entered Cottage 9 and encountered Shahbaz #13. The Surveyor asked if an activity had taken place this morning. She stated, None this morning. On 10/19/23 at 11:00 AM, the Surveyor asked the Activity Director to describe how activities were to be provided in the cottages. She stated, The goal is for me to make the calendar and provide the supplies. The cottage staff are supposed to actually do the activities. The Surveyor asked who monitors whether the activities actually take place. The Activity Director stated, That would be the CNA's and me. The Surveyor informed the Activity Director that no activities were held in Cottage 1, Cottage 2, Cottage 3, or Cottage 9 this morning. She stated, Then I need to go talk to them right now. The Surveyor informed the Activity Director that no activities took place on Monday in Cottages 8 and 9. She stated, Now I know I did some activities on Monday. We painted pumpkins in Cottage 9. No wait, I was off on Monday, that was Tuesday. On 10/19/23 at 12:04 PM, entered Cottage 4, the Surveyor asked CNA #14 if there were morning activities this morning. CNA #14 stated, We didn't have any this morning. On 10/19/23 at 12:24 PM, The Activity Director said each cottage has a Department Head assigned to it. The Surveyor asked if the Department Head reviews the activity calendar and ensures that a plan for completion is in place. The Activity Director stated she could not answer that and said that the activities in Cottage 5 are self-directed, that a game of dominoes is always going on. Resident #42 spoke up and stated, This is our home, we are always doing something. On 10/19/23 at 12:33 PM, entered Cottage 6. CNA #5 reported that no activities were held this morning. On 10/19/23 at 12:38 PM, entered Cottage 7. CNA #15 denied that activities were held this morning. On 10/19/23 at 12:45 PM, entered Cottage 8. Licensed Practical Nurse (LPN) #1 was uncertain as to whether activities were held this morning. She stated, I think they usually just put on a movie or play some music. A review of the facility policy titled, Activity Programs, documented, Activities. The nursing facility provides an ongoing program of Resident/Elder activities/meaningful engagements Activities will be varied in nature and should be designed to meet the individual needs, interests, and limitations of Residents/Elders in accordance with the Resident/Elder's comprehensive assessment and in conjunction with the Resident/Elder's requests. This includes all Residents/Elders that are bedfast, ambulatory and disabled. These activities should provide meaningful engagement, mental, social and spiritual stimulation . On 10/20/23 at 10:30 AM, the Surveyor asked the Administrator to describe his concept of the facilities activity program. He stated, The general plan is that the activities go along with the culture of each cottage. Some cottages are more active than others. The Surveyor asked if it is his expectation that an activity of some type is to be held in each cottage each morning. The Administrator stated, Yes, but these will vary depending on the residents in each cottage, what they might want to do.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than 5% during the medication pass. The findings are: During the medication pass observation there were 28 opportunities with 2 errors for a 7.14% error rate. 1. Resident #106: On 10/18/23 at 12:36 PM, during observation of the noon medication pass, Licensed Practical Nurse (LPN) #6 administered Glargine Insulin (a long-acting insulin) instead of Lispro Insulin (a rapid acting insulin) as documented on the physician orders for a blood sugar of 278. LPN #6 documented on Resident#106's Medication Administration Record (MAR) 8 units of Lispro insulin was administered. A review of Resident #106's Physicians Orders dated 10/09/23 noted Resident #206 was to receive Lispro Insulin per sliding scale subcutaneously. 2. Resident #311: A Physician's Order with a start date of 10/06/23 noted Resident #311 was to receive Diclofenac Sodium External Gel 1 % topically every 6 hours for pain to affected area by using the supplied ruler to measure the appropriate dose. On 10/18/23 at 12:51 PM, observed LPN #6 don gloves, squeeze an unmeasured amount of gel from Diclofenac Sodium Topical Gel 1% tube into her gloved hands, rubbing them together. She then rubbed Resident #311's left shoulder, left hand, left knee, right shoulder, and right hand. No ruler or other measurement of gel was used. On 10/20/23 at 11:13 AM, the Infection Control Preventionist (ICP) confirmed physician orders should be followed. On 10/20/23 at 11:26 AM, the Director of Nursing (DON) stated the facility has to follow physician orders. A facility policy titled, Preparation and General Guidelines, revised 01/2018, provided by the DON on 10/19/23 at 3:26 PM documented, .Medication Administration-General Guidelines Policy Medications are administered as prescribed . 4) Five rights - right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration (l) when the medication is selected. (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed to prevent significant medication errors for 2 (Residents #80 and #106) of 2 sampled residents observed during medication pass. The findings are: 1. Resident #106: On 10/18/23 at 12:36 PM, during observation of the noon medication pass, Licensed Practical Nurse (LPN) #6 administered Glargine Insulin (a long acting insulin) instead of Lispro Insulin (a rapid acting insulin) as documented on the physician orders for a blood sugar of 278. LPN #6 documented on Resident#106's Medication Administration Record (MAR) 8 units of Lispro insulin was administered. A review of Resident #106's Physicians Orders dated 10/09/23 noted Resident #206 was to receive Lispro Insulin per sliding scale subcutaneously. On 10/20/23 at 11:13 AM, the Infection Control Preventionist (ICP) confirmed physician orders should be followed. On 10/20/23 at 11:26 AM, the Director of Nursing (DON) stated the facility has to follow physician orders. 39316 2. Resident #80: On 10/17/23 at 3:28 PM, review of Resident #80's October 2023 MAR showed on 10/1/23 at 12:00 PM, a blood glucose reading of 186. A 4 with initials was documented in the 12:00 administration box. A 4 means vitals outside of parameters for administration per the MAR. A Physicians Order dated 08/04/23 noted Resident #80 was to receive Humalog insulin per sliding scale. Per the sliding scale Resident #80 was to receive 2 units of insulin for a blood sugar in the range of 150 - 200. On 10/18/23 at 11:13 AM, the Surveyor asked LPN #5 what Chart Code 4 means on the MAR. LPN #5 stated, It means vitals outside of perimeter. The Surveyor asked why insulin wasn ' t administered as ordered per the sliding scale on 10/01/23 for Resident #80. LPN #5 stated, I don't know why I didn't. On 10/20/23 at 11:26 AM, the Surveyor asked the DON what Chart Code 4 means on Resident #80's October MAR on 10/01/23 at 12:00 PM. The DON stated, Vitals outside parameter for administration. The Surveyor asked what Resident #80's blood glucose reading was for 10/01/23 at 12:00 PM. The DON stated, One eighty six. The Surveyor asked how many units of insulin the nurse should administer with a blood sugar of 186. The DON stated, According to the order, [Resident #80] should have gotten two units. 3. A facility policy titled, Preparation and General Guidelines, revised 01/2018, provided by the DON on 10/19/23 at 3:26 PM documented, .Medication Administration-General Guidelines Policy Medications are administered as prescribed . 4) Five rights - right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration (l) when the medication is selected. (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away .

Based on observation, interview and record review, the facility failed to ensure expired medications were removed from the medication storage rooms and medication carts. The findings are: On 10/19/23 at 8:53 AM, observed in the medication storage closet in Cottage 2 medication cards with medication on the floor. The storage bins contained medications and medical supplies mixed together in the same bins. Observed the following in the Medication Cart located in the common area in Cottage 1: a. Pharmacy bottle with a resident's name written in black marker with red capsules inside. Licensed Practical Nurse (LPN) #7 said, The resident's family brought them from home, we found them in the resident's room, and we cannot read what it says on the label. An expiration date of 10/17/23 was written on the bottle. On 10/19/23 at 9:44 AM, observed the following in Cottage #2's Medication Storage Room. a. Seven containers of diabetic tube feedings with an expiration date 7/24/2023. b. Twelve Heparin vials with an expiration date of 2002. c. Two containers of stool softener with an expiration date of 1/24/2023. On 10/19/23 at 9:44 AM, observed the following in Medication Cart #2: a. One Vitamin D3 soft gels with an expiration date of 7/2023. b. One Vitamin E 180 milligrams soft gels expiration date 9/2023. c. One Famotidine 10 milligram tablet with an expiration date of 9/2023. On 10/19/23 at 1:59 PM, observed the following in Cottage #5's Medication Storage Closet: a. 5% Dextrose 1000 milliliters IV fluid expiration date 9/2023. b. One 0.9% Sodium Chloride 250 milliliters expiration date 8/2023. c. Two Povidone-Iodine pads expiration date 11/25/22 and 8/6/22023. On 10/19/23 at 1:59 PM, observed the following in Cottage #5 Laundry Room Refrigerator: a. Xiidra (an eye drop) 0.2 milliliters with an expiration date of 7/2021. On 10/19/23 at 12:23 PM, the Surveyor asked how expired medications are disposed of. LPN #2 said, The nurses tear the tops off to be shredded and the medications go into the shorts. On 10/20/23 at 10:26 AM, the Director of Nursing (DON) stated over the counter medications and supplies are stored inside the medication closets. The nurses check the expiration dates and labels. Only the nurses and licensed staff have keys to the medications and narcotics. 48388

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu and facility quantified recipe for super calorie was followed to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who received meals in Cottage #3, 2 residents who received pureed diets and 2 residents who received super calorie foods in Cottage #10. The findings are: On 10/16/23, the menu for the noon meal documented for the residents on pureed diets were to receive 6 ounces (3/4 cup) of beef enchilada casserole and 1/2 cup of chuckwagon corn. A facility quantified recipe for super calorie diet for 2 servings documented, 1 cup of nonfat dry milk, 1/2 cup plus 3 tablespoons of whole milk. Mix dry milk and milk. Bring together to a low boil. Add 3/4 cup of oatmeal to milk mixture. Cook until thickened, stirring frequently. Add 3 tablespoons of brown sugar and 3 tablespoons of butter and stir to distribute evenly. Cottage #3: On 10/16/23 at 12:29 PM, the following observations were made during the noon meal service: a. Certified Nursing Assistant (CNA #1) #1 used a #8 scoop (1/2 cup) to serve a single portion of beef enchilada casserole to the residents, instead of 6 ounces (3/4 cup). b. CNA #1 used a #12 scoop (1/3 cup) to serve a single portion of chuckwagon corn to the residents, instead of a #8 scoop (1/2 cup). On 10/16/23 at 12:47 PM, the Surveyor asked CNA #1 what scoop sizes she used to serve the lunch meal to the residents. She stated, I used the scoops inside the food pans. The Surveyor asked how many servings she gave to each resident. She stated, I gave one serving each. On 10/17/23, the menu for the breakfast meal documented the residents on pureed diets were to receive a #8 scoop (1/2 cup) of pureed hot cereal and a cup of milk. The residents on super calorie were to receive one cup of super cereal. On 10/17/23 at 8:14 AM, the following observations were made during the breakfast meal service: a. The residents on pureed diets were served pureed eggs and pureed sausage with bread and water. There was no cereal and milk served to them. b. The residents on super caloric were served regular oatmeal. c. On 10/17/23 at 8:39 AM, the Surveyor asked CNA #3 the reason the residents on pureed diets did not receive cereal. She stated, They don't like oatmeal and we give them more of what they like. d. On 10/17/23 at 8:42 AM, the Surveyor asked CNA #3 how she prepared the oatmeal. She stated, I just used water and regular sugar.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance and nutritive value of pureed foods that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 2 residents who receive meal trays in the Cottage #10, as documented on a list provided by Dietary Supervisor on 10/17/23 at 10:58 AM. The findings are: Cottage #10: On 10/17/23, the facility quantified recipe for sausage link or patties for 2 servings documented, 2 per 1 serving. Add 1/2 cup of water or stock and 11/2 teaspoon of food thickener. Prepare according to regular recipe. Prepare slurry. Process until smooth adding 1 ounce slurry per portion. On 10/17/23 at 7:50 AM, Certified Nursing Assistant (CNA) #3 poured a cup of tap water on top of the sausage and bread inside of the blender and pureed. At 7:51 AM, CNA #3 poured the pureed sausage with bread and water into 2 divided plates. The water was separated from the meat mixture. On 10/17/23, the facility quantified recipe for scrambled eggs for 2 servings documented, Use 21/4 cup of scrambled eggs, add 2 teaspoon of food thickener. Prepare according to regular recipe. Add 1 teaspoon of food thickener per egg and blend until smooth consistency. Mixture should be thick enough to hold its shape. The pureed eggs served to the residents on pureed diets were not formed and the water was separated from the pureed eggs served to the residents on pureed diets. On 10/17/23 at 8:26 AM, the Surveyor asked the Dietary Supervisor to describe the appearance of the pureed food items served to the residents on pureed diets. She stated, Water was separated from both pureed sausage and pureed eggs. On 10/17/23 at 8:42 AM, the Surveyor asked CNA #3 how much water she used to puree the sausage with bread and scrambled eggs. She stated, I used a cup of water to puree the sausage with bread and some amount of water to puree scrambled eggs. The Surveyor asked how the foods would taste pureed with water. She stated, They will not taste good.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets as provided by the Dietary Supervisor on 10/16/23 at 10:58 AM. The findings are: Cottage #10: On 10/16/23 at 12:05 PM, Certified Nursing Assistant (CNA) #1 used a 2 ounce spoon to place 4 servings of chuckwagon corn with lots of juice into a blender, added 6 tablespoons of thickener and pureed. At 12:07 PM, CNA #1 poured the pureed chuckwagon corn into 2 divided plates. The consistency of the pureed chuckwagon corn was thick, with pieces of corn skin visible and was not smooth. On 10/16/23 at 12:11 PM, CNA #1 used a 6 ounce spoon to place 3 servings of beef enchilada casserole into a blender, added water and pureed. At 12:13 PM, CNA #1 poured the pureed beef enchilada casserole into 2 divided plates. The consistency of the beef enchilada casserole was lumpy and not smooth. There were pieces of meat visible in the mixture. On 10/16/23 at 12:53 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed beef enchilada is between mechanical soft and pureed. Pureed should be like pudding. You can see corn kernels in the pureed corn. It's too thick and has too much thickener. On 10/16/23 at 12:54 PM, the Surveyor asked CNA #2 who was assisting a resident with her lunch meal to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed beef enchilada should have been a little smoother, it should have been fine like pudding. Pureed corn has corn kernels in it and is thick. On 10/17/23 at 7:50 AM, CNA #3 poured a cup of tap water on the sausage and bread inside the blender and pureed. At 7:51 AM, CNA #3 poured the sausage with bread and water into 2 divided plates. The consistency of the pureed sausage with bread and water was lumpy and not smooth. There were pieces of meat visible in the mixture. The water was separated from the meat mixture. On 10/17/23 at 8:14 AM, the pureed eggs served to the residents on pureed diets were not formed. On 10/17/23 at 8:26 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed sausage was not smooth at all, it looks like mechanical soft, both the pureed sausage and pureed eggs. On 10/17/23 at 9:12 AM, the Surveyor asked CNA #3 to describe the consistency of the pureed food items served to the residents. She stated, They were watery and not smooth. The pureed sausage with bread looks like mechanical soft. Cottage # 9: On 10/18/23 at 11:53 AM, CNA #10 placed 4 servings of corn bread into a blender, added milk and pureed. At 11:57 AM, CNA #10 poured the pureed cornbread into 3 bowls. The consistency of the pureed cornbread was lumpy and was not smooth. There were pieces of cornbread crumbs in the mixture. On 10/18/23 at 12:09 PM CNA #10 placed 6 servings of ham and beans into a blender and pureed. At 12:13 PM, CNA #10 poured the pureed ham and beans into 4 bowls. The consistency of the pureed ham and bean was lumpy. There were pieces of beans skins visible in the mixture. On 10/18/23 at 12:15 PM CNA #10 used a 4 ounce spoon to place 4 servings of turnip greens into a blender and pureed. At 12:16 PM, CNA #10 poured the pureed greens into 4 bowls. The consistency of the pureed green was runny and was not smooth. Pieces of greens were still visible in the mixture. On 10/18/23 at 12:18 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents. She stated, The cornbread has crumbs. Pureed beans and pureed greens and cornbread needed to be pureed some more.