Every finding on record at The Haven at Brandermill Woods

Based on observation, staff interview and facility document review, the facility staff failed to prepare, store and serve food in a sanitary manner from the main kitchen. The findings include:The outside freezer had frozen condensation on the fan unit. Expired yogurt was available for use in the produce walk-in refrigerator. The production refrigerator had a foul odor from thawed chicken juice spillage in the floor. The walk-in production refrigerator was in use with condensation dripping from the fan unit that had a black substance on the fan grates and along the bottom edge of the unit. The floor, piping and back wall of the production refrigerator was wet from condensation dripping from the fan. On 7/21/26 at 11:15 a.m., accompanied by the hospitality director, the facility's main kitchen was inspected. The walk-in freezer (outside) was observed with heavy frozen condensation covering the fan grates and ice hanging from the fan unit. Four containers of yogurt with an expiration date of 7/18/26 were stored in the walk-in produce refrigerator. Upon entrance to the walk-in production refrigerator, a strong, foul odor was noted. A thermometer in the unit registered 39 degrees (F) and multiple frozen meats were observed on the bottom shelf in containers. There was no visible source of the foul odor. A fan unit with two operating fans was observed near the ceiling on the back wall of this refrigerator. Water was observed continuously dripping from the fan unit. Water was dripping from the bottom edge of the unit and along the insulated piping with water noted on the refrigerator floor below the unit. There were two fans in the unit and the grates to both fans had a black substance on the surface and inside the grates. This black substance was also noted along the bottom of the fan unit. On 7/21/26 at 11:25 a.m., the hospitality manager and executive chef (other staff #1), present during the inspection of the production refrigerator, were interviewed about the dripping condensation, dirty fan and foul odor. The executive chef stated the foul odor was noted this morning and that there were no opened or spoiled food items in the refrigerator. The executive chef and hospitality director stated they did not know the source of the foul odor. The hospitality director stated he was not sure what was wrong with the fan unit. The executive chef stated the black substance on the fan grates was cleaned earlier, had reappeared on the unit and he was not sure of the source of the substance. During this kitchen inspection, accompanied by the hospitality director, pan storage was observed. Six prep pans on the drying rack beside the compartment sink were observed nested and wet. On the storage rack near the food prep area was a large stainless colander with water visible along the edge, dripping onto the pans stored below the colander. Three other prep pans were observed on this rack stored nested and wet, with water visible on the outside surfaces. The pans on this rack were identified by the hospitality director as ready-to-use. On 7/21/26 at 12:56 p.m., the dietary manager was interviewed about the above observations. The dietary manager stated he did not know the source of the foul odor and condensation in the walk-in production refrigerator but would investigate. On 7/21/26 at 1:28 p.m. the dietary manager stated the frozen condensation on the fan unit in the walk-in freezer had been an ongoing problem and he thought it might be related to where the freezer was located (outside). Regarding the foul odor in the walk-in production refrigerator, the dietary manager stated he found chicken blood in the floor in the back corner on the unit. The dietary manager stated the spillage was from thawing meat that had not been cleaned and that this was likely the source of the odor. On 7/22/26 at 2:04 p.m., the dietary manager was interviewed about the dirty fan unit with dripping condensation observed in the walk-in production refrigerator. The dietary manager stated there had been a reported problem with the unit over the past weekend and he was not sure what caused the dripping condensation or dirty fan grates. Regarding food storage, the dietary manager stated the yogurt with expired dates should have been discarded. The dietary manager stated food items were reviewed daily and any expired or out of date items were supposed to be discarded. The dietary manager stated washed/sanitized pans were supposed to be stored separated until dry and not nested wet. On 7/23/26 at 7:50 a.m., the dietary manager presented policies regarding food storage and cleaning. The dietary manager stated there was a weekly cleaning schedule for the walk-in refrigerators and freezers and that any spills were expected to be cleaned immediately. The dietary manager stated the cooks were responsible for cleaning racks and storage areas in the refrigerators and for cleaning any spills or contamination when they occurred. The facility's policy titled Cleaning, Sanitizing and Warewashing (undated) documented weekly cleaning requirements for all walk-in refrigerators and freezers that included cleaning of shelves, walls, floors and gaskets. The facility's Weekly Kitchen Deep Cleaning Schedule (undated) documented the walk-in refrigerators were scheduled for cleaning each Sunday and that walk-in freezers were scheduled for cleaning each Friday. The facility's policy titled Wet Nesting Prevention (undated) documented, .Wet nesting is a sanitation failure that occurs when freshly washed, still-wet items - plates, pots, pans . are stacked or nested together before they have air-dried. Trapped moisture between the surfaces blocks airflow and creates a dark, damp pocket where bacteria multiply rapidly. The equipment leaves the sink or dishmachine sanitized and returns to the line contaminated .Air-dry all washed items completely on a rack before stacking or storing .Confirm items are dry to the touch before they go on the clean shelf .DO NOT stack or nest washed pans, bowls, or trays while any surface is still wet .All washed and sanitized items are air-dried completely on drying racks before they are stacked or stored . (Sic) These findings were reviewed with the administrator and director of nursing during a meeting on 7/22/26 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interviews, clinical record reviews, and facility documentation reviews the facility staff failed to ensure that a complete and accurate clinical record was maintained for four residents, Resident #3 (R3), Resident #4 (R4), Resident #26 (R26), and Resident #19 (R19) out of a survey sample of 15 residents. The findings included: 1.The facility staff failed to maintain a complete and accurate clinical record for R3's contracted hospice services. On 7/23/2026 at 9:44 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that the hospice binder for the residents that was on hospice was not kept on the nursing unit. She stated the hospice binder was kept in the medical records office, so the hospice notes could be uploaded into the patient medical record. On 7/23/2026 at10:12 AM, the Director of Nursing (DON) was interviewed. She stated that the hospice notes was to be faxed to the facility within 48 to 72 hours and then uploaded into the residents medical record. On 7/23/2026 at 10:28 AM, the medical record staff, other staff #2 (OS2) was interviewed. During the interview OS2 stated she had only been working at the facility for one month and was trying to get all the resident documents downloaded into clinical records. She also stated that the expectation was to download the documents into the clinical record within 24 to 48 hours after receiving the documents. She was not aware of how the facility was getting the hospice notes to be able to download into the medical records. She said, I really don't know how it works and really don't know the system I am still learning. She was aware of the hospice notes not being available in the medical record for R3. OS2 stated she would find out what the procedure was for obtaining the hospice notes from outside contractures. She never provided the answer to the procedure for how she obtained the hospice notes to download into the resident's medical record prior to exit conference. On 7/23/26, a clinical record review was conducted. During the review, there was no documentation for visits by the hospice nurse, aide, social worker or chaplain in the clinical record. There was no hospice binder on the nursing unit for R3's hospice notes. On 7/23/26, a review of facility documentation was conducted. The facility document that was provided was a contract with R3's hospice provider. The contract read in part, Hospice shall provide the Hospice Patient and his/her primary care giver(s) (including Nursing Home, as applicable) with education and training to allow the appropriate performance of responsibilities identified in the Hospice Plan of Care. (d) As frequently as required by the Hospice Patient's condition, but no less frequently than every fifteen (15) days, the Hospice Interdisciplinary Committee (in collaboration with the patient's Attending Physician) shall review, revise and document the Hospice Plan of Care to include information from updated patient assessments, and progress toward outcomes and goals specified in the Hospice Plan of Care. All such updates shall be communicated to Nursing Home. The hospice must assure orientation of SNF/NF or ICF/MR staff furnishing care to hospice patients in the following: A. Hospice philosophy B. Hospice policies and procedures regarding methods of comfort, pain control, symptom management, and post mortem care C. Principles about death and dying and individual responses to death D. Patient rights E. Appropriate forms and record keeping requirement. On 7/23/26, an end of day meeting was conducted with the DON and the Administrator. They were made aware of the above concerns. No additional information was provided prior to the exit conference. 2. For Resident #4 (R4), the facility failed to discontinue an order to monitor for side effects of anticoagulants and continued to document monitoring of side effects of anticoagulants after R4's anticoagulants were discontinued. Diagnoses for R4 include vascular dementia, hypertension, congestive heart failure, atrial fibrillation, neuromuscular dysfunction of bladder, constipation, benign prostatic hypertrophy, polyneuropathy, spinal stenosis, psychosis, depression, anxiety, adjustment disorder, coronary artery disease, presence of cerebrospinal fluid drainage device, urethritis, cellulitis of corpus cavernosum and penis, urinary tract infection, abnormal weight loss, pneumonia, urinary retention, hypersecretion of calcitonin, coronary artery bypass graft, suicidal ideations, repeated falls, senile degeneration of brain, macular degeneration, chronic hepatitis, rheumatoid arthritis, OA, restlessness and agitation. On the most recent Minimum Data Set (MDS), a quarterly assessment with an assessment reference date (ARD) of 6/3/2026, R4 was unable to complete the Brief Interview for Mental Status (BIMS) and was noted to have severe impairment to cognitive daily decision making. Review of the clinical records for R4 demonstrated a physician's order for Anticoagulant therapy to observe and report to physician as needed signs and symptoms of complications every shift entered on 12/10/2025. There was no indication in the clinical record that R4 was receiving anticoagulants. R4's Medication Administration Records (MARs) for the months of March, April, May, June, and July of 2026 demonstrate that nursing staff is administering (or marking complete) the order to observe and report to physician signs and symptoms of anticoagulant therapy complications three times daily, or every shift. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 7/22/2026 at 2:40 PM. LPN #1 stated that the physician should be the one to discontinue the order to monitor for side effects of anticoagulants when a resident is no longer receiving anticoagulants. Nursing staff can also place a note into the doctor book if they need to communicate with the physician regarding any orders. An interview was conducted with the Director of Nursing (DON) on 7/23/2026 at 9:05 AM. The DON stated that nurses typically enter the orders to observe for side effects of a medication when the resident is taking that particular class of medication. She stated that the time they may observe a resident for signs and symptoms of anticoagulants varies depending on the anticoagulant and if the resident has a history of bleeding issues, such as a gastrointestinal (GI) bleed. The Medical Director was interviewed on 7/23/2026 at 9:35 AM. The Medical Director stated that anytime a resident is placed on an anticoagulant, the staff will also observe for signs and symptoms of complications from anticoagulants. She stated that some residents who are not on anticoagulants should be monitored for bleeding depending on their medical histories. She stated that ideally there would be a separate order to monitor for signs and symptoms of bleeding for residents not on anticoagulants that need monitoring. Because the documentation system doesn't have an order built to monitor for signs and symptoms of bleeding, she utilizes the order to observe for complications of anticoagulant therapy as it is similar. The Medical Director stated that she was aware that R4 was not on anticoagulants, however due to R4's history of hepatitis and hydrocephalus with a shunt, she felt that R4 should be monitored for signs and symptoms of bleeding. The above information was presented to facility leadership on 7/23/2026 at 11:00 AM. No further information was provided prior to exit. 3. For Resident #26, (R26), the facility failed to discontinue an order to monitor for side effects of anticoagulants and continued to document monitoring of side effects of anticoagulants after R26's anticoagulants were discontinued. Diagnoses for R26 include periprosthetic fracture of the left knee, atrial fibrillation, congestive heart failure, anemia, hypotension, hypertension, chronic kidney disease stage III, coronary artery disease, constipation, depression, adjustment disorder with anxiety, pain, onycholysis, fluid overload, gout, gastrointestinal (GI) bleed, urinary tract infection, insomnia, history of falling, deep tissue injury, cognitive communication deficit, muscle weakness, hyperlipidemia, edema, and morbid obesity. On the most recent Minimum Data Set (MDS), a quarterly assessment with and assessment reference date (ARD) of 5/8/2026, R26 scored a 14 out of 15 on the Brief Interview for Mental Status indicating that R14 is cognitively intact. Review of R26's clinical records revealed a physician's order for Apixaban (an anticoagulant) five milligrams (mg) two times daily entered on 8/7/2025. A corresponding order for Anticoagulant therapy observe an report to physician as needed signs and symptoms of complications was also entered on 8/7/2025. Additional orders for Apixaban were entered on 10/29/2025, 1/21/2026, and 1/22/2026. The last order entered for Apixaban was discontinued on 1/24/2026. There were no further orders for anticoagulants noted in the clinical record. Despite the discontinuation of anticoagulants on 1/24/2026, review of R26's Medication Administration Records (MARs) for the months of March, April, May, June, and July of 2026 demonstrate that nursing staff is administering (or marking complete) the order to observe and report to physician signs and symptoms of anticoagulant therapy complications three times daily, or every shift. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 7/22/2026 at 2:40 PM. LPN #1 stated that the physician should be the one to discontinue the order to monitor for side effects of anticoagulants when a resident is no longer receiving anticoagulants. Nursing staff can also place a note into the doctor book if they need to communicate with the physician regarding any orders LPN #1 stated that R26 has a history of a GI bleed and maybe that was why staff is continuing to observe for signs and symptoms of complications of anticoagulant therapy. An interview was conducted with the Director of Nursing (DON) on 7/23/2026 at 9:05 AM. The DON stated that nurses typically enter the orders to observe for side effects of a medication when the resident is taking that particular class of medication. She stated that the time they may observe a resident for signs and symptoms of anticoagulants varies depending on the anticoagulant and if the resident has a history of bleeding issues, such as a GI bleed. The Medical Director was interviewed on 7/23/2026 at 9:35 AM. The Medical Director stated that anytime a resident is placed on an anticoagulant, the staff will also observe for signs and symptoms of complications from anticoagulants. She stated that some residents who are not on anticoagulants should be monitored for bleeding depending on their medical histories. She stated that ideally there would be a separate order to monitor for signs and symptoms of bleeding for residents not on anticoagulants that need monitoring. Because the documentation system doesn't have an order built to monitor for signs and symptoms of bleeding, she utilizes the order to observe for complications of anticoagulant therapy as it is similar. The Medical Director stated that she was aware that R26 was no longer on anticoagulants, however due to R26's history of a GI bleed, she felt that R26 should be monitored for signs and symptoms of bleeding. The above information was presented to facility leadership on 7/23/2026 at 11:00 AM. No further information was provided prior to exit. 4. Resident's wound provider inaccurately documented a pressure injury as present on admission when the ulcer was acquired at the facility. Resident #19 (R19) was admitted to the facility with diagnoses that included hypertension, osteoporosis, brain degeneration, diabetes, dementia, psychotic disturbance, mood disorder, anxiety, urinary tract infection, deep tissue damage to sacrum and heel and vitamin deficiency. The minimum data set (MDS) dated [DATE] assessed R19 with severely impaired cognitive skills. R19's clinical record documented an admission assessment dated [DATE] listing the resident had no skin impairments. A skin assessment dated [DATE] documented R19 was assessed with a deep tissue injury on the right heel. A nursing note dated 6/30/26 documented the resident had a new deep tissue injury on the right heel and documented the injury as acquired in-house. R19's clinical record included wound physician progress notes dated 7/13/26 and 7/20/26 documenting assessment and treatment interventions for the right heel deep tissue injury. The progress notes dated 7/13/26 and 7/20/26 documented the heel deep tissue injury as, Noted to be present on admission per staff. On 7/22/26 at 3:46 p.m., the registered nurse responsible for MDS assessments (RN #2) was interviewed about the conflicting starting point for R19's right heel deep tissue injury. RN #2 reviewed the clinical record and stated the wound nurse identified the deep tissue injury as a new skin impairment on 6/30/26 that was acquired at the facility. RN #2 stated she was not sure why the provider documented the wound as present upon admission. On 7/23/26 at 8:19 a.m., RN #2 stated she contacted the wound physician and that the physician's note indicating the deep tissue injury as present on admission was inaccurate and written in error. This finding was reviewed with the administrator and director of nursing during a meeting on 7/22/26 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on observation and staff interview, the facility staff failed to maintain one of two walk-in refrigerators in proper working order. The findings include:The walk-in production refrigerator was operating with a dirty fan unit that had condensation dripping continuously from the unit with water running along the insulated piping on the back wall and onto the floor of the refrigerator. On 7/21/26 at 11:15 a.m., accompanied by the hospitality director and executive chef, the facility's walk-in production refrigerator was inspected. The unit had in-process food items stored on racks/shelves and thawing meat stored in containers on the bottom shelves. A fan unit with two operating fans was observed near the ceiling on the back wall of the refrigerator. Water was observed continuously dripping from the fan unit. Water was dripping from the bottom edge of the unit, along the insulated piping with water noted on the refrigerator floor below the unit. The grates for both fans had a black substance on the surface and inside the grates. This black substance was also noted along the bottom of the fan unit. On 7/21/26 at 11:25 a.m., the hospitality manager and executive chef (other staff #1), present during the inspection of the production refrigerator, were interviewed about the dripping condensation and dirty fan. The hospitality director stated he was not sure what was wrong with the fan unit. The executive chef stated the black substance on the fan grates was cleaned earlier, had reappeared on the unit and that he was not sure of the source of the substance or why the condensation was dripping from the unit. On 7/21/26 at 12:56 p.m., the dietary manager was interviewed about the above observations. The dietary manager stated he did not know why condensation was continuously dripping from the fan unit. On 7/22/26 at 2:04 p.m., the dietary manager stated there had been a reported problem with the unit over the past weekend and he was not sure what was causing the condensation or dirty fan grates. This finding was reviewed with the administrator and director of nursing during a meeting on 7/22/26 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on observation and staff interviews, the facility staff failed to ensure expired syringes with attached needles were removed from available stock for one out of two medication rooms. The findings included: The facility staff failed to ensure expired syringes with attached needles were removed from available stock.On [DATE] at 11:14 a.m., an observation was made of the medication room on hall 100 with a licensed practical nurse, (LPN1). During the observation of the medication room, expired luer lock disposable 23-gauge x 1-inch syringes with attached needles was identified. The expiration date on the packages was [DATE]. The expired syringes were given to LPN1.On [DATE] at 11:51 a.m., an interview was conducted with a registered nurse, (RN1). RN1 stated that if there was expired syringes in the medication room, that management would be made aware and that the expired syringes would be disposed of in the sharps container. On [DATE] at 3:18 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that nurses should check medication rooms because they are in the medication rooms daily and the nurses should dispose of expired syringes in the sharps container or biohazard if syringes are clean. On [DATE], a meeting was held with the Administrator and DON, and they were made aware of the above concerns. Policy was requested but was not provided.No additional information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a current plan of care and documentation of care/services from contracted hospice agencies for two of fifteen residents in the survey sample (Residents #2 and #19). The findings include: 1. Resident #19 had no current plan of care or documentation of care/services provided by the contracted hospice agency. Resident #19 (R19) was admitted to the facility with diagnoses that included hypertension, osteoporosis, brain degeneration, diabetes, dementia, psychotic disturbance, mood disorder, anxiety, urinary tract infection, deep tissue damage to sacrum and heel and vitamin deficiency. The minimum data set (MDS) dated [DATE] assessed R19 with severely impaired cognitive skills. R19's clinical record documented the resident was enrolled in hospice starting on 10/25/25. The most recent hospice plan of care was signed by the hospice physician on 4/26/26 and listed the certification period for the care plan as 4/21/26 through 6/19/26. R19's clinical record documented no updated care plan from the hospice agency since the one initiated on 4/21/26. R19's clinical record included no documentation of nursing assessments, nursing visits or aide visits from the hospice agency. The hospice plan of care (dated 6/19/26) documented nursing visits would be conducted once each week, and aide visits were required twice per week. There was no initial assessment by the hospice staff included in the clinical record. On 7/22/26 at 2:43 p.m., the licensed practical nurse (LPN #2) caring for R19 was interviewed about hospice services. LPN #2 stated that hospice nurses for R19 came weekly along with aide visits. LPN #2 stated she thought the notes from assessments and visits were uploaded into the clinical record. On 7/22/26 at 2:45 p.m., the medical records clerk was interviewed about any records from R19's hospice that had not been included in the electronic health record. The medical records clerk stated she was not sure and would investigate. On 7/23/26 at 8:46 a.m., the Director of Nursing (DON) presented printed copies of nursing assessments, visits, aide visits and social worker visits from R19's hospice agency. The DON stated that the hospice agency had not forwarded the documents to the facility for uploading to the clinical record. The DON stated these documents were provided by the hospice agency yesterday (7/22/26) upon request. The DON reviewed the provided notes and located an updated hospice plan of care signed by hospice on 6/24/26 with the certification period listed as 6/20/26 through 8/18/26. The DON stated this updated hospice care plan had not been provided to the facility until documents were requested yesterday (7/22/26). The hospice agreement with R19's hospice agency signed on 7/20/22 documented, .Services provided to each resident under Hospice will be determined by an interdisciplinary team (IDT), which will include members of the Facility staff and Hospice staff. Both staffs will work cooperatively with the resident/family to assess needs and to develop a comprehensive care plan in accordance will all applicable State and Federal regulations governing nursing facilities and hospices. All services shall be delivered in accordance with the patient's plan of care .The Hospice nurse will furnish the Facility with a copy of the completed Hospice plan of care to be incorporated into the Facility medical record at the time of the resident's admission to Hospice .The plan of care will be updated by Hospice staff in coordination with Facility staff and reviewed by the resident's attending physician as often as necessary but not less than every 60 days. A copy of the updated plan of care will be maintained at both the Facility and Hospice . (Sic) This finding was reviewed with the Administrator and DON during a meeting on 7/22/26 at 4:30 p.m. with no further information presented prior to the end of the survey. 2. Resident #2 (R2) had no current plan of care or documentation of care/services provided by the contracted hospice agency. On 7/23/2026 at 10:12 AM, the Director of Nursing (DON) was interviewed. She stated that the hospice notes were to be faxed to the facility within 48 to 72 hours and uploaded into the residents medical record. On 7/23/2026 at 10:28 AM, the medical record staff, other staff #2 (OS2) were interviewed. During the interview OS2 stated she had only been working at the facility for one month and was trying to get all the resident documents downloaded into clinical records. She also stated that the expectation was to download the documents into the clinical record within 24 to 48 hours after receiving the documents. She was not aware of how the facility was getting the hospice notes to be able to download into the medical records. She said, I really don't know how it works and really don't know the system I am still learning. OS2 stated she would find out what the procedure was for obtaining the hospice notes from outside contractures. She never provided the answer to the procedure for how she obtained the hospice notes to download into the resident's medical record prior to exit conference. On 7/23/26, a clinical record review was conducted. R2's clinical record documented the resident was enrolled in hospice starting on 1/4/24. The most recent hospice plan of care was signed by the hospice physician on 4/23/26 and listed the certification period for the care plan as 4/23/26 through 6/21/26. R2's clinical record documented no updated care plan from the hospice agency since the one initiated on 4/23/26. R2's clinical record included no documentation of nursing assessments, nursing visits or aide visits from the hospice agency. The hospice plan of care (dated 6/21/26) documented nursing visits would be conducted once each week, and aide visits were required twice per week. There was no initial assessment by the hospice staff included in the clinical record. On 7/23/26 at 10:15 AM, the DON provided printed copies of nursing assessments, visits, aide visits and social worker visits from R2's hospice agency. The DON stated that the hospice agency had not forwarded the documents to the facility for uploading to the clinical record. The documents were provided by the hospice agency today upon request. On 7/23/26, the hospice agreement with R2's hospice agency signed on 1/4/24 documented, read in part, .Services provided to each resident under Hospice will be determined by an interdisciplinary team (IDT), which will include members of the Facility staff and Hospice staff. Both staff will work cooperatively with the resident/family to assess needs and to develop a comprehensive care plan in accordance will all applicable State and Federal regulations governing nursing facilities and hospices. All services shall be delivered in accordance with the patient's plan of care .The Hospice nurse will furnish the Facility with a copy of the completed Hospice plan of care to be incorporated into the Facility medical record at the time of the resident's admission to Hospice .The plan of care will be updated by Hospice staff in coordination with Facility staff and reviewed by the resident's attending physician as often as necessary but not less than every 60 days. A copy of the updated plan of care will be maintained at both the Facility and Hospice. On 7/23/26, an end of day meeting was conducted with the DON and the Administrator. They were made aware of the above concerns. No additional information was provided prior to the exit conference.

Based on observations, staff interviews and review of the U.S. Food Code, the facility failed to ensure food was stored in accordance with professional standards for food safety. These failures had the potential to increase the prevalence and spread of foodborne illnesses and infection for all 44 facility residents. Findings include: During the initial kitchen tour on 03/28/23 at 11:30 AM with the Director of Dining Services (DDS), inspection of one walk-in freezer revealed four packages with no label to indicate what the food item was or how long it had been in the freezer. The DDS was unable to identify two of the four items. There were seven food items in the freezer that were dated 2021 and appeared freezer burned. These items included pot roast, beef puree, corn, meatballs, beet puree, baked bean puree, sloppy [NAME] sauce, and brisket. There were three food items that were dated 2022 and appeared freezer burned. These items included baked beans, beef, and corned beef. The DSS stated that the kitchen normally did not keep frozen food items longer than six months and confirmed that these 14 items should have been discarded. Further inspection of the dry storage area revealed a container of cheese sauce that had been opened and not dated. Inspection of the walk-in meat and eggs refrigerator revealed an opened container of thousand island dressing, a container of salsa, and a package of provolone cheese that were not dated. The DDS confirmed all these items should have been labeled and dated. Further inspection of the three door freezer revealed opened packages of frozen omelets, French toast, hashbrowns, pork riblets, and eggplant patties that were not labeled or dated. None of these food items were securely closed, exposing them to freezer burn. The DSS confirmed all these items should be properly stored and dated. During an interview on 03/30/23 at 8:03 AM, the Dietary Manager revealed that the DDS went through the freezers and discarded the items that had been there longer than six months. Review of the U.S. Food and Drug Administration's 2022 Food Code revealed, . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD. Further review revealed, Date marking of ready-to-eat TCS [Time and temperature controlled] food held for more than 24 hours to control the growth [illness causing bacteria] . 'First-In-First-Out' (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on interview, clinical record review and facility documentation, the facility staff failed to provide nursing services that meet with professional standards of care for 1 Resident (#197) in a survey sample of 22 Residents. The findings included: For Resident #197 the facility staff failed to clarify an ambiguous order for an Opioid (oxycodone) and an Opioid Antagonist (Depade). On 3/28/23 a review of the clinical record revealed the following excerpts from the physician orders: 3/24/23 5:42 PM - Oxycodone [an opioid pain medication] 5 mg [milligrams] Give 1 tablet by oral route as needed for pain. 3/24/23 5:42 PM - Depade 50 mg. [An opioid antagonist. Opioid antagonists block the effects of opioids] Give 1 tablet by oral route once daily. On further review of the clinical record, it was found that Resident #197 had been admitted to the facility from the hospital on 3/24/23. Excerpts from the hospital discharge summary are as follows: Page 1 of 5 Hold Naltrexone [Depade] for now to ensure adequate pain control. Page 2 of 5 Start taking these medicines: Oxycodone 5 mg every 4 hours as needed for pain. Naltrexone (Depade) 50 mg by mouth once daily On 3/28/23 at 11:40 AM, an interview was conducted with the Director of Nursing (DON) who stated she was aware that the Resident was receiving Depade and Oxycodone. When asked what the purpose was for giving opioid and an opioid antagonist, she stated that the Resident was an alcoholic and needed to be on Depade. When asked if she found the orders conflicting, she stated they were. When asked if the orders should have been clarified, the DON stated that the admitting nurse goes over the medications with the physician and gets approval for the discharge medications from the hospital. From the Lippincott Website https://journals.lww.com/nursing/fulltext/2003/01001/advice_on_avoiding_lawsuits.11.aspx Don't carry out an order from a health care provider if you have any doubt about its accuracy or appropriateness. Follow your facility's policy for clarifying an ambiguous order. Document your efforts to clarify the order and note whether it was carried out. On 3/30/23 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure the pharmacist recognized irregularities during a Drug Regimen Review for 1 Resident (#197) in a survey sample of 22 Residents. The findings included: For Resident #197 the pharmacy failed to recognize the contraindications of giving Depade and Oxycodone. On 3/28/23 a review of the clinical record revealed the following excerpts from the physician orders: 3/24/23 5:42 PM - Oxycodone (an opioid pain medication) 5 mg (milligrams) Give 1 tablet by oral route as needed for pain. 3/24/23 5:42 PM - Depade 50 mg. (an opioid antagonist) Give 1 tablet by oral route once daily. On further review of the clinical record, it was found that Resident #197 had been admitted to the facility from the hospital on 3/24/23. Excerpts from the hospital discharge summary are as follows: Page 1 of 5 Hold Naltrexone [Depade] for now to ensure adequate pain control. Page 2 of 5 Start taking these medicines: Oxycodone 5 mg every 4 hours as needed for pain. Naltrexone (Depade) 50 mg by mouth once daily On 3/28/23 at 11:40 AM an interview was conducted with the DON who stated she was aware that the Resident was receiving Depade and Oxycodone. When asked what the purpose was for giving opioid and an opioid antagonist, she stated that the Resident was an alcoholic and needed to be on Depade. On 3/30/23 at approximately 2:00 PM an interview was conducted with the NP who wanted to address the survey team about the medications. The NP stated that the Resident was on Depade for alcohol dependency and had been taking the medication prior to the admission to the facility. She stated that the hospital did hold the medication while she was in hospital. She stated that the rational for re-starting the medication at the facility was that the Resident could have gone into withdrawals. When asked if this medication order seemed conflicting, she stated that it was not because one medication was for pain the other was for alcohol dependency. Surveyors explained the role of the Depade was to block the effects of Narcotics thus working against the effects of the Oxycodone not to prevent withdrawals. According to the SAMHSA.gov (Substance Abuse and Mental Health Services Administration) website: https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/naltrexone Naltrexone for Alcohol Use Disorder [[NAME]] When starting naltrexone for [NAME], patients must not be physically dependent on alcohol or other substances. To avoid strong side effects such as nausea and vomiting, practitioners typically wait until after the alcohol detox process before administering naltrexone. Patients should not take naltrexone if they: Currently use or have a physical dependence on opioid-containing medicines or opioid drugs, such as heroin, or currently experiencing opioid withdrawal symptoms. On 3/30/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of unnecessary psychotropic medications for 1 Resident (#16) in a survey sample of 22 Residents The findings included: For Resident #16 the facility staff failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days. On 3/28/23 during clinical record review it was discovered that Resident #16 had an order for PRN Lorazepam (an anti-anxiety medication). The clinical record revealed the Resident had PRN Lorazepam orders as follows: 1/14/23 8:11 PM - Lorazepam Intensol 2 mg/ml oral concentrate Give 0.5 ml (1mg) by oral route every 4 hours PRN. 'Schedule Every 4 hours PRN for 14 days 1/31/23 3:46 PM - Lorazepam Intensol 2 mg/ml oral concentrate Give 0.5 ml (1mg) by oral route every 4 hours PRN. Schedule - PRN. 2/24/23 8:42 AM - Lorazepam Intensol 2 mg/ml oral concentrate Give 0.5 ml (1mg) by oral route every 4 hours PRN. Schedule PRN Original order date: 1/31/23 Resident #16's order was originally written for 14 days however the subsequent orders were written as just PRN with no end dates. The order written on 1/14/23 was not re-ordered until 1/30/23 (3 days overdue) and the order on 1/31 /23 was not re-ordered until 2/24/23 (10 days overdue) and the current order as of 3/30/23 is (20 days overdue.) The Pharmacy Recommendation stated that per federal guidelines 483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in S483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The physician signed the pharmacy recommendation dated 1/26/23 and wrote the word Hospice. On 3/28/23 at 11:40 AM, an interview was conducted with the Director of Nursing (DON) who stated she was aware that the Resident was receiving Lorazepam PRN for anxiety. When asked about the prescribing time of PRN anti-anxiety medications she stated she was aware that PRN psychotropic's were limited to 14 days. She stated this was a hospice patient. The DON was informed that hospice does not exclude the physician from proper documentation of diagnosis and rationale for prescribing and expected duration of the treatment. On 3/30/23 at approximately 2:00 PM, an interview was conducted with the Nurse Practitioner (NP) who stated that the reason the medication is prescribed as PRN is because the patient is end of life and on hospice. The patient will be anxious when he or she feels air hunger in the last stages of dying and it needs to be there when the Resident needs it, and we don't know when that will be. The NP was told that the Regulation is not saying they cannot have the medication longer than 14 days it is saying that the appropriate documentation must be in the clinical record to support the orders. On 3/20/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, interviews, and review of facility policies, the facility failed to ensure proper food handling and hand hygiene was performed in the dining room for 15 residents (R) (R4, R23, R30, R11, R16, R3, R18, R14, R35, R37, R192, R13, R17, R28, and R12). This failure has the potential to cause contamination of foods served to residents in the facility. Findings include: Review of the facility's policy titled, Dietary Employee Personal Hygiene, revised date 10/2020, stated the purpose of the policy was to, utilize the following guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. In the section titled, Hands and Fingernails, the policy stated, Employees should never use bare hand contact with any foods, ready-to-eat or otherwise. In addition, the policy stated, Gloves are to be worn as indicated and changed appropriately to reduce the spread of infection. A review of the facility's Hand Hygiene policy, revised on 04/07/20, stated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The facility further stated, This applies to all staff working in all locations within the facility. 1. Observations conducted on 03/29/21 at 11:32 AM revealed Nursing Home Waitstaff (NHW)11 was observed preparing drinks for 15 residents (R4, R23, R30, R11, R16, R3, R18, R14, R35, R37, R192, R13, R17, R28, and R12) who were eating in the dining room area of the 200 unit of the facility. NHW11 was observed to wipe her hands on a towel but did not wash her hands, use hand sanitizer, or wear gloves while pouring and serving the drinks to the residents in the dining room. In addition, NHW11 was observed placing her left thumb inside the ice bucket while putting ice in resident cups. NHW11 was further observed removing plastic wrap from pitchers of water and lemonade while serving drinks without performing any hand hygiene or wearing gloves. In addition, NHW11 was observed opening cartons of thickened cranberry juice and thickened lemonade for two residents from paper cartons without performing hand hygiene or wearing gloves. Observations conducted on 03/29/21 at 11:43 AM revealed Dietary Aide (DA)17 was observed in the Unit 200 kitchen dipping beef and barley soup into five soup bowls without wearing gloves or washing hands prior to service after touching the countertops with hands. NHW11 was observed serving the 5 cups of soup to residents in the dining room without performing any hand hygiene or wearing gloves. In addition, the Certified Dietary Manager (CDM) was observed checking the temperatures of food on the tray line without wearing gloves. The CDM was observed wiping the food thermometer with a paper towel and placing the thermometer into a pan of potatoes without wearing gloves. Observations conducted on 03/29/21 at 11:51 AM revealed the Food Service Director (FSD) assisting with food service in the 200-unit kitchen. The FSD was observed dipping tomato soup into a soup bowl without wearing gloves. On 03/31/21 at 10:00 AM, an interview was conducted with the CDM. The CDM stated servers and waitstaff were not required to wear gloves while serving foods in the dining rooms of the facility. However, the CDM confirmed all dietary staff are required to wear gloves in the kitchen areas where food is plated prior to being served. In addition, the CDM stated he expected waitstaff to perform hand hygiene between food service to each resident. On 03/31/21 at 10:30 AM, an interview was conducted with the FSD. The FSD stated waitstaff are not required to wear gloves while serving food or drinks to residents in the dining room. The FSD further stated waitstaff should handle dishware, cups, and any other container with food without placing their hands on top or inside the area where foods or drinks would be placed. An additional interview was conducted with the CDM on 04/01/21 at 9:01 AM. The CDM stated dietary staff are required to wear gloves when staff are plating foods. The CDM stated the FSD and DA17 should have been wearing gloves when plating foods from the tray line in the 200-unit kitchen on 03/29/21. In addition, the CDM stated proper hand hygiene to be performed by dietary staff during food service. The CDM further stated he was wearing gloves when checking the temperature of the food on the tray line. The CDM stated waitstaff should always handle plates, cups, and service ware from the outside and bottom of the dishes and should use tongs to get ice out of ice buckets during drink service. The CDM stated waitstaff should never have hands on top of plates or inside containers of foods or drinks. 2. On 03/30/21 at 11:48 AM in the dining room, Certified Nurse Aide (CNA) 1 assisted R12 to remove her face mask and place it in a paper bag. CNA1 did not wash or sanitize her hands, then moved to R37, picked up her facemask from the table, and placed it in a paper bag. On 03/31/21 at 11:43 AM, CNA1 stated she had received training on the facility's established hand hygiene policy and procedures. She stated she should have washed or sanitized her hands after touching a resident's mask and before touching the next one. On 04/01/21 at 9:32 AM, the Assistant Director of Nursing, who also served as the facility's Infection Preventionist, stated she would expect staff to sanitize their hands after touching a resident's mask to avoid the potential spread of infection. Review of the facility's Hand Hygiene policy, revised 04/07/20, documented, Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand hygiene is indicated and will be performed . before and after handling clean or soiled dressings, linens, etc. [and] after handling items potentially contaminated with blood, body fluids, secretions, or excretions. The policy did not specifically address handling of residents' masks.

Based on observation, staff interview, and record review, the facility failed to ensure one (Resident (R) 35) of 15 residents observed eating in the dining room received food in a pureed form to meet her individual needs. This failure had the potential to cause swallowing difficulties, choking, or aspiration (accidental inhalation of food particles into the lungs). Findings include: Review of R35's physician Orders tab in the electronic health record (EHR) revealed an order, which originated on 06/18/20, for Puree Diet with Nectar liquids - no straws! R35's 03/16/21 Change of Condition Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/16/21, documented she received a mechanically-altered diet. R35's most recent Quarterly Nutritional Assessment, dated 10/09/20, documented, Slow decline in overall status is noted . Current diet, restricted diet and consistency, is provided for comfort and support. Supplemental nutrition is provided. Fair intake noted. Staff assist and encourage intake. Will continue diet as tolerated The assessment documented R35 was to receive a diet of pureed consistency. Review of R35's 04/16/20 Care Plan, located in the EHR Care Plans tab, documented R35 was at risk for malnutrition/dehydration. The Care Plan went on to document, 02/08/21: [R35] requested ham salad sandwich approved by nurse [NAME] and [NAME]. The approaches included: provide a puree diet with nectar liquids - no straws! . record food intake each meal . [and] encourage resident to eat 100% of diet for adequate nutrition and hydration. On 03/30/21 at 12:00 PM in the dining room, R35 was served a pureed sandwich (made of slurried bread and pureed meat, by Nursing Home Waitstaff (NHW) 2. NHW2 told her it was a chicken salad sandwich, and R35 stated, No, I ordered ham salad. Ham. The pureed sandwich was left in front of the R35, and she began to eat small bites. Her tray card was left at the table, and documented she was to receive a pureed diet. At 12:07 PM, NHW2 served R35 a sandwich made of regular consistency deli-sliced ham and regular white bread; it was not pureed. When served, R35 asked NHW2 what kind of bread she had received, stating it did not look like the usual bread and it seemed undercooked to her. NHW2 responded it was white bread and walked away. On 03/30/21 12:10 PM, the NHW2 stated he was unsure why R35 received a regular sandwich as opposed to pureed, but he was told by his manager that if a resident asked specifically for a different consistency, it was their right to receive it. NHW2 stated R35 did not request a different consistency than puree and again stated he was unsure why she was given a regular consistency ham sandwich. On 03/30/21 at 12:11 PM, a staff member alerted NHW2 that the R35 requested a ham salad sandwich and would not eat the regular deli ham sandwich. At 12:14 PM, the resident was served a ham salad sandwich on regular white bread; it was not pureed. In an interview on 03/31/21 at 9:30 AM, the Director of Nursing (DON) stated that if the family or the resident asked for a different consistency than what was ordered by the physician, the facility tried to honor their rights if they thought it was something the resident could manage. She stated R35 had been seen by speech therapy, and it was determined a pureed diet was appropriate, but if she requested a different food consistency, the facility would try to honor it with education on the risks. She stated the pureed food should always be tried first, and different consistencies only provided upon resident or family request. The DON added that any time a different consistency was requested, the facility would educate the resident on the risks of consuming a less restrictive consistency. The DON stated in the case of R35, the resident's responsible party was notified and had approved the provision of regular ham salad sandwiches back in February 2021. On 03/31/21 at 9:50 AM, Speech and Language Pathologist (SLP) 1 stated a pureed consistency was the preferred and safest consistency for R35. She stated R35 should be offered pureed foods at every meal unless she were to request something different. SLP1 stated she would expect the staff to offer her foods in a pureed form first, and only provide a less restrictive consistency if requested. SLP1 stated the ham salad would be more of a ground or pureed texture, where the deli sliced ham was definitely not; it was a regular consistency. The SLP stated she was not involved in the development of the care plan regarding serving regular ham salad sandwiches to R35, as she was not seeing R35 in February 2021. On 04/01/21 at 9:03 AM, the Dietary Manager (DM) stated he was involved in the development of the Care Plan regarding serving a regular ham salad sandwich, which was discussed with the resident and her responsible party. He stated if R35 requested a ham salad sandwich, it should be served in pureed form first with slurried bread and pureed meat. If R35 refused to eat the pureed sandwich, the nursing staff or speech therapist should be notified, the resident should be educated on the risks, and the requested food provided if approved by both the resident and nursing staff or speech therapist. The DM stated all dietary staff were educated on the need to get approval from nursing or speech therapy before serving any food that was not in the appropriate consistency as ordered by the physician. The DM stated R35 should always be served pureed foods first, and only offered a different consistency if she refused to eat the pureed food. The DM stated the sliced deli ham was not at all appropriate for a pureed diet, and the ham salad would be more of a chopped consistency. The DM stated NHW2 should have provided a pureed ham salad sandwich to R35 when she requested a ham salad sandwich. The DM did not know why a regular deli ham sandwich, and then a regular ham salad sandwich, were served to R35 on 03/30/21. The facility's 03/16/20 Therapeutic Diet Orders policy documented, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences per resident rights . Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow infection control practices to control and prevent infections, COVID-19, for 2 Residents (Resident #6 & #7) in a survey sample of 7 Residents. The findings included: On 2/4/21, upon entry the facility, the DON (Director of Nursing) stated they had 2 new admissions yesterday (2/3/21). Employee C identified the new admissions during the facility tour as Resident #6 and Resident #7. On 2/4/21, during a facility tour, Surveyor A was accompanied by Employee C, the facility Infection Preventionist. Employee C stated that the facility is not permitting any communal dining due to the high rate of COVID-19 positivity in the local and surrounding communities. They are serving all Residents in their rooms and on disposable products. Employee C went on to state they are not permitting visitors or group activities due to the rate of positivity being so high at this time. During a tour of the entire facility, and all Resident care areas, it was observed that no Resident rooms had any signage on the doors to indicate any transmission based precautions are in use. There were no stations of PPE observed in any of the hallways. Surveyor A asked to see the new admissions. Surveyor A and Employee C stopped outside of Resident #7's room, Surveyor A questioned how staff would know this person was on precautions and Employee C stated, everyone knows who is on quarantine, we have daily meetings, discuss their status and therapy knows when they are on quarantine and when their day 14 is so they know they have to stay in their room. Employee C was asked what PPE is used to care for new admissions on quarantine and she stated, everyone wears a mask and they wear gloves. Employee C was asked if staff are wearing isolation gowns and she stated no. Surveyor A asked for clarification if the person is on any type of precautions and Employee C confirmed they were not. Employee C defined the quarantine periods as the resident is not able to come out of their room during the 14 day quarantine period. On 2/4/21 during facility tour interviews were held with various staff to include Employee E, a housekeeper, CNA A, and LPN A. Upon interview, all 3 of these staff (Employee E, CNA A and LPN A) stated they do not wear full PPE with any Residents. They stated while they were trained on how to use PPE, how to don and doff they have not had to use it due to COVID-19. Review of the clinical record for Resident #7 revealed no physician orders for any type of quarantine, transmission based precautions or monitoring for COVID-19. Hospital records revealed a COVID-19 test on 2/2 that indicated not detected and the lab report read, The specimen is Negative for [DIAGNOSES REDACTED]-CoV-2, the novel Coronavirus associated with COVID-19. A negative result does not rule out COVID-19. A COVID-19 Rapid Test dated 2/3 read NOTD (not detected) and the lab report stated, negative results do not preclude [DIAGNOSES REDACTED]-CoV-2 infection and should not be used as the sole basis for patient management decisions. Review of the clinical record for Resident #6 revealed no physician orders for any type of quarantine, transmission based precautions or monitoring for COVID-19. Hospital records revealed a COVID-19 test on 2/1 and another on 2/2 that indicated not detected and the lab report read, negative results do not preclude [DIAGNOSES REDACTED]-CoV-2 infection and should not be used as the sole basis for patient management decisions. On 2/04/21 at approximately 1:45 PM, Surveyor B conducted a telephone interview with the Director of Nursing (DON) and the Infection Preventionist (IP) about the facility's COVID infection control policies. The DON and IP confirmed that current CDC (Center for Disease Control and Prevention) recommendations for COVID-19 Infection Prevention and Control are practiced at the facility. The DON was asked about the facility's process for receiving new admissions from the hospital and she stated, We require 2 COVID negative test results from the hospital prior to receiving the admission and when they arrive, we put them in a quarantine in their room for 14 days, we (staff) wear standard PPE (personal protective equipment), just an N95 facemask and gloves, but we do not initiate any special isolation precautions, the resident is just not allowed out of their room for 14 days until we can be sure that no symptoms develop. The DON was asked if it was possible for a new admission to be exposed to the [MEDICAL CONDITION] during transportation from the hospital to the facility and she stated, the Medical Transport people know what to do, for the most part they also wear a mask, but anything is possible that is why they (the new resident) are not allowed to leave their room for 14 days once they get here. The DON was asked if it was possible for a person to receive 2 COVID negative test results and actually be in the very early stages of a COVID infection to the point that their [MEDICAL CONDITION] load may be too low to be detectable and she stated, Yes, again, that is why they have to stay in their room for 14 days and monitor for any symptoms of COVID. Review of the facility policy titled SNF Admissions/COVID-19 Response with an effective date of 6/3/2020, read: upon admission, residents will be quarantined to their room for 14 days. After 14 days, residents will be allowed to do therapy in the hallways. CDC guidance to nursing facilities stated: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html The findings were reviewed with the facility Administrator, DON and Infection Preventionist on 2/5/21. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to conduct COVID-19 testing in accordance with established requirements for 1 Resident (Resident #3) in a survey sample of 7 Residents. The findings included: Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) (an assessment tool) with an ARD ( assessment reference date) of 12/10/20, was coded as an annual assessment. Resident #3 had a BIMS (brief interview for mental status) score of 9 out of a possible 15. This indicated moderately impaired cognition. This assessment also coded Resident #3 as having required extensive assistance of staff for assistance with ADL's (activity of daily living) to include: bed mobility, transfers, dressing, toileting and personal hygiene. Review of the clinical record for Resident #3 revealed a Physician order that read Resident may have COVID-19 testing as indicated. There was a nursing note entry dated 1/1/2021, that read, Resident has become increasingly weak when assisted into wheelchair to bathroom with almost zero percent weight bearing ability. On 1/11/21 at 12:31 PM, an entry into the nursing notes for Resident #3 read, Resident lethargic this am, declined breakfast, responded to verbal stimuli .Awake at lunch time, returned to sleep, declined lunch. An entry at 1:40 PM, read new order received and noted for STAT (urgent) CXR (chest x-ray) due to lethargy and slight cough. RR (name redacted) notified and in agreement. At 2:19 PM, an entry was made into the record that read, Resident assisted to bathroom (requiring max assist) urinated and returned to bed, declined food at this time, fluids given. On 1/11/21 at 2:27 PM, an entry was made by the NP (nurse practitioner) that read, Seeing patient today for increased lethargy and malaise. She is currently resting in bed. Staff reports no po (by mouth) intake today and difficulty arousing patient to get oob (out of bed). Orders: CXR now- done, UA/CNS (urinalysis with culture and sensitivity), CBC (complete blood count lab), CMP (complete metabolic panel) on 1/12. On 1/13/21 at 3:52 PM, an entry was made into the record of Resident #3 by the MD (medical doctor) that stated CTSP (contacted to see patient) for AMS (altered mental status). This am she took all of her meds and ate all of her breakfast. She has several loose stools this am but none this afternoon. Has had more behaviors but also missed dosing of her psych meds yesterday. No CP(chest pain), SOB (shortness of breath), or [MEDICAL CONDITION] NNO (no new orders). Review of the clinical record revealed COVID-19 testing had taken place on 1/25/21 and again on 1/28/21. On 2/4/21 at approximately 11:00 AM, the DON (Director of Nursing) was made aware of the concern that Resident #3 had exhibited signs and symptoms of COVID-19 on 1/11/21 and had not been tested for COVID-19 until 1/25/21. The DON stated she would look into this. On 2/4/21 at approximately 12:05 PM, the DON returned with a document printed from the NHSN (National Healthcare Safety Network) which indicated Resident #3 had been tested for COVID-10 on 1/18/21. On 2/4/21 at 12:06 PM, an interview was held with Employee C, the facility Infection Preventionist. Employee C was shown the documentation in the clinical record for Resident #3 of being symptomatic for COVID-19. Employee C confirmed that lethargy and lack of appetite are symptoms of COVID-19. When asked about testing for COVID-19, Employee C stated they conduct testing if someone is symptomatic, perform twice weekly testing if in an outbreak and then routine testing of staff if not in an outbreak. Employee C stated, we have a standing order to test if symptomatic and have a prn (as needed) order. We have plenty of test in the med room and staff can perform testing. When advised that on 1/11/21 Resident #3 had symptoms of COVID-19 and wasn't tested , Employee C stated, the nurse practitioner saw her and didn't order a COVID test. Surveyor A asked Employee C if they already had a standing order for COVID testing and it is protocol to test Residents when symptomatic what else they needed from the practitioner, Employee C stated nothing, I see your issue. On 2/4/21 during a group interview with Surveyor B the DON and Employee C, both confirmed they do follow CDC guidance. A review of the facility policy titled Coronavirus Testing with a revision date of 9/2/2020, read: Policy Explanation and Compliance Guidelines: 3. Priority testing should be as follows: a. Staff or Residents with signs and symptoms. Procedure: 4. Residents who have signs or symptoms will be tested and will be placed on transmission-based precautions pending test results. The CDC reports symptoms of COVID-19 as: People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html The CDC guidance regarding testing stated: Testing of symptomatic Residents: Testing residents with signs or symptoms of COVID-19: At least daily, take the temperature of all residents and ask them if they have any COVID-19 symptoms. Perform [MEDICAL CONDITION] testing of any resident who has signs or symptoms of COVID-19. Clinicians should use their judgment to determine if a resident has signs or symptoms consistent with COVID-19 and whether the resident should be tested . Individuals with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Some may present with only mild symptoms or other less common symptoms. Clinicians are encouraged to consider testing for other causes of respiratory illness, such as influenza, in addition to testing for [DIAGNOSES REDACTED]-CoV-2. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html On 2/5/21, during a pre-exit meeting Surveyor A reviewed the concerns of Resident #3 being symptomatic and the facility staff's failure to perform COVID-19 testing. No further information was provided.

Based on observation, staff interview and facility documentation review the facility staff failed to serve food in accordance with professional standards for food service safety. A. Dietary staff were observed to use improper handwashing technique. B. Coffee temperatures were not monitored. The findings included: On 7/31/18 at 11:50 a.m., observation of the lunch meal service began in the HCC kitchen. The tray line was set up beneath a large window that opened into the dining room. Once prepared, the meal trays were passed through the window from the diet staff in the kitchen to the dietary staff serving the trays. Hand sanitizer was affixed to the wall next to the window on the dining room side. The hand sanitizer was used by Diet Staff A after delivering a tray and before entering the kitchen. She did not wash her hands once in the kitchen. She prepared a cup of tea and left the kitchen. At 11:54 a.m., Diet Staff B left the serving line and washed her hands. She washed her hands for approximately 3 seconds and used her bare hands to turn off the faucet. On 7/31/18 at 12:01 p.m., observation of the lunch meal service began in the rehab kitchen. Diet Staff C was serving from the tray line. She washed her hands for approximately 10 seconds and donned a pair of gloves. Diet Staff D entered the kitchen from the back room. She donned a pair of gloves without washing her hands first. While wearing the gloves, Diet Staff D took out a pan, pressed the pump for the oil container to add oil to the pan, touched a door handle, removed two slices of cheese from a pan and removed two slices of bread from the bag. Gloves were not changed prior to touching the ready to eat foods. After the sandwich was made, Diet Staff D washed her hands with good technique. At the same time, Diet Staff C continued to wear the same pair of gloves from the first observation. With her gloved hands, she removed a sandwich bun from the container, opened the bun and put it on a plate. She carried the plate and a spatula to the warming oven, touched the handle to the oven, removed a turkey burger with the spatula, opened the cheese container, removed a piece of cheese for the sandwich and placed the bun on top. She prepared two sandwiches using this process. At 12:05 p.m., Diet Staff E entered the kitchen to wash his hands. He turned the faucet off with his bare hands. At 12:08 p.m., Diet Staff F was observed to use the hand sanitizer affixed to the dining room wall immediately outside the door to the rehab kitchen. She was not observed to wash her hands. Handwashing instructions were hung above the sink in the rehab kitchen. The instructions read: 1. wet hands 2. Soap (20 seconds) 3. Scrub backs of hands, wrists, between fingers, under fingernails 4. Rinse 5. Towel dry 6. Turn off taps with towel. The policy titled Handwashing dated 1/17/12 was provided. The policy read, Dining staff must wash their hands before starting work and after the following activities: clearing tables or bussing dirty dishes, touching clothing or aprons, touching anything else that may contaminate hands, such as dirty equipment, work surfaces or used towels. The procedure read, 3. Vigorously scrub hands and arms for twenty seconds. The policy also read, 5. Rinse thoroughly under running water. Turn off faucet using a single-use paper towel. On 8/1/18 at 4:45 p.m., the Administrator and Director of Nursing (DON) were notified of the issue. They stated that they understood and would address the issue. B. On 7/31/18, the Dietary Manager was asked to provide the food temperature logs. She stated that the foods were taken with a digital thermometer and the temperatures were stored electronically. She was asked to print the last week of food temperatures. On 8/1/18, the temperature log was provided as requested. The temperature log did not include temperature readings for coffee. On 8/1/18 at 8:20 a.m., the Dietary Manager and Diet Staff G were asked to take the temperature of the coffee in both kitchens. The digital thermometer had food items per-programmed into the device. It was explained by Diet Staff G that all she had to do is select the food item for which she was taking a temperature and save the temperature reading. When asked to take the temperature of the coffee, Diet Staff G stated that coffee was not a food choice available in the digital thermometer. Coffee temperatures were take by Diet Staff G as follows: HCC kitchen: 183.6 degrees Fahrenheit Rehab kitchen: 158.5 degrees Fahrenheit On 8/1/18 at 8:40 p.m., an interview was held with the Dietary Manager and the Administrator. The Dietary Manager was asked if she monitored the coffee temperatures. She stated that she did take them every morning, but she did not record the temperatures. When asked who took the temperatures on the days she did not work, the Diet Manager stated that she thought one of the other staff took them. It was verified with the Administrator that there had not been any burn accidents at the facility since the past survey. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to prepare and serve food in a sanitary manner. 1. The ice machine drain pipe was in contact with the floor and it had black mold along its length. Findings included: 1. The ice machine drain pipe was in contact with the floor and it had black mold along its length. During the tour of the kitchen on 6/27/2017 at 1:20 PM the ice machine was examined to assure that the drain pipe was situated properly, avoiding contamination of the ice. The drain pipe, which was a white plastic pipe approximately ¾ in diameter, was seen exiting the machine on the underside in the front. It went down to the floor and turned in a 90 degree angle toward the back of the underside of the machine. It was now lying on the floor for a distance of approximately 2'. The floor drain was located to the rear of the machine. In front of the drain was a short piece of 2 x 4 lumber. The pipe crossed on top of this wood which brought it off the floor, and the end of the pipe was now situated above the floor drain to facilitate draining. The white plastic pipe was seen to have black mold along the full length to the end of the pipe, and the floor had dust, dirt and debris along the entire length of the ice machine. It was possible for the mold bacteria to enter the end of the pipe and travel to the ice storage area. An interview was immediately conducted with Employee C, Dietary Manager, who was unaware of the situation. At 2:00 PM on 6/27/2017 Employee D, Maintenance Supervisor, was seen cleaning the underside of the ice machine and repositioning the drain pipe. He stated that mold could creep up the pipe into the ice machine. On 6/28/2017 at 4:00 PM Employee A, Facility Administrator was informed of the unsanitary condition of the ice maker. She stated that she was unaware of this situation. On 6/29/2017 at 10:00 AM, Employee E, Corporate Nutrition Director, stated that he was unaware of this situation and that it was repaired immediately. A review of the facility policies and procedures Sanitation Inspection was conducted and it stated It is the policy of (facility) to maintain a food service area that is clean and sanitary. Administration was informed of the findings on 6/29/2017 at 11:30 AM.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to follow the professional standards of practice for one Resident (Resident #10) in a survey sample of 15 residents. For Resident #10, the facility staff failed to ensure 2 medications were administered as ordered by a physician. The findings included; Resident #10, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #10's most recent MDS (Admission minimum data set) was not completed, as he was a new Resident, however, the Resident was observed, and interviewed, and found to be confused and required extensive assistance with activities of daily living, and was a hospice Resident. Review of Resident #10's physician's orders [REDACTED]. There were no notes documented by staff in the clinical record for the omissions other than not observed in the eMAR notes; 6-24-17 [MEDICATION NAME] (high cholesterol medication) 3.125 milligrams to be given three times daily. The medication was omitted, and the reason given for the omission was documented in the eMAR notes, as, not observed. No nursing notes document this omission. 6-25-17 [MEDICATION NAME] (antianxiety medication) 1.0 mg (milligrams) tablet at 9:00 p.m. every day. The medication was omitted and the reason given for the omission was documented in the eMAR notes, as, not observed. No nursing notes document this omission. The physician progress notes [REDACTED]. There was no indication that the responsible party, nor the physician was ever made aware that these medication omissions occurred. Resident #3's care plan was reviewed, and stated administer medications as ordered. On 6-28-17 at 4:30 p.m., the Director of Nursing (DON) and Administrator were interviewed, and stated they would look into the discrepancy. The DON delivered a copy of the E-MAR, physician progress notes [REDACTED]. On 6-29-17 at 9:30 a.m. the DON was interviewed and stated, I don't know why it was omitted, it is what it is. The Director of Nursing (DON) and Administrator provided the facility policy which stated to verify the medication is being administered at the proper time, prescribed dose, and by the correct route. Resolve any concerns about the medication with the provider, prescriber, and/or staff involved with the patient's care. The DON stated Mosby's as their standard. Guidance for professional standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's/ Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. The administrator and DON (director of nursing) were informed of the failure of the staff to ensure medications were administered on 2 occasions for Resident #10 at the end of day debriefings on 6-28-17, and 6-29-17. No further information was provided by the facility.

Based on observation, staff interview and facility documentation review the facility staff failed to use effective hair restraints. Staff were observed in the kitchen with hair partially covered with a hair net. Contracted repairmen were observed in the kitchen without wearing effective hair restraints. The diet aide was at the prep table. The diet manager was carrying food out to the auxillary dining room. There was preparation of the food when the maintenance men walked thru the kitchen. The findings included: An initial tour of the main kitchen was conducted in the presence of the Dietary Manager on 5/17/16 at 6:25 p.m The Dietary Manager wore a hair restraint, but it did not effectively cover her short hair. Hair between the hair line and middle top of the head was exposed. The Dietary Manager was observed in the small long term care kitchen on 5/18/16 at 11:40 a.m. during lunch service. Again, her hair was not effectively restrained. On 5/18/15 at 11:45 a.m., a dietary aide was observed in the main kitchen. She wore a hair net, but her bangs were not covered. At this time, a younger man in street clothes walked into and through the kitchen. He wore a base ball cap. He had curly hair that hung out the back of the cap about 2 inches. Another man walked through the kitchen without a hair restraint. Kitchen staff identified the man as a contractor who was working on the walkin freezer. The hair restraint issue was reviewed with the dietary manager on 5/19/16 at 8:10 a.m. She stated that a hair restraint should be worn by anyone entering the kitchen. She stated that she did not know the repair man was in the kitchen the previous day. The facility policy Personal Hygiene was reviewed. The policy read 2. A clean and neat personal appearance is required. Practice good hygiene and hair control. All workers are to wear hair restraints when in kitchen areas. All food handling employees must use effective hair restraints to prevent the contamination of food or food contact surfaces. The Administrator was notified of the issue at the end of day meeting on 5/19/16.

Based on observation and staff interview, the facility staff failed to provide a safe environment on one of two units (the long term care unit). The hydrocollator, a device used to provide moist hot pack therapy, was stored in an unlocked room. The findings included: During general observations tour of the facility, the therapy gym was observed 5/18/16 at 1:22 p.m. Other A, the therapy manager stated the therapy department was in the process of being renovated. When asked, Other A stated the facility had a hydrocollator and it was being stored in the old therapy area. Other A showed the hydrocollator to the surveyor. The old therapy gym was entered easily with the door swinging inward and unlocked. Another door, close to the entry door was entered and the hydrocollator was sitting next to the wall. The door to that room was labeled as being a toilet. The hydrocollator was on and the log on the top indicated the water was 169 degrees Fahrenheit on 5/18/16. The log further indicated the temperature was maintained between 167 degrees to 169 degrees Fahrenheit. Other A stated the hydrocollator had been kept in the room since the renovations were in progress. No workman or work appeared to have been done in either the old therapy gym or the toilet room where the hydrocollator was stored. The hydrocollator was also observed 5/19/16 at 1:38 p.m. Both doors were unlocked and no staff were in the old therapy gym. Residents were observed independently mobile, both in wheelchairs and ambulating, near the door to the old therapy gym during both observations. Guidance for the safe storage of a hydrocollator was found at www.physical-therapy.advanceweb.com: Electrotherapy equipment must be inspected and calibrated. A temperature and cleaning log for the hydrocollator should be present. And there should be a safeguard in place so the hydrocollator can't be accessed by a resident without a therapist present. When interviewed the administrator stated the door should remain locked at all times, 5/19/16 at 11:10 a.m. The administrator and DON (director of nursing) were informed of the failure of the staff to ensure the hydrocollator was stored in a secure area that could not be accessed by Residents, 5/19/16 at 11:10 a.m.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed for 4 residents (Resident #1, #3, #2, & #7) of 17 residents in the survey sample, to complete a quarterly Minimum Data Set (MDS) assessment timely. 1. For Resident #1, the facility staff failed to complete a quarterly MDS (Minimum Data Set) within 92 days after a significant change assessment with an ARD (Assessment Reference Date) of 1/11/16. The quarterly MDS had an ARD of 4/12/16 but was not completed until 5/18/16. 2. For Resident #3, the facility staff failed to complete and submit a Quarterly Minimum Data Assessment which was due on 4/27/16. 3. For Resident #2, the facility staff failed to complete a Quarterly Minimum Data Assessment in a timely manner. Section G was not completed. 4. For Resident #7, the facility staff failed to complete a quarterly MDS (minimum data set) RAI (Resident Assessment Instrument) after an annual assessment with an ARD (assessment reference date) of 12/30/15 and the end of the survey 5/19/16. The findings included: Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD of 4/12/16 coded Resident #1 with severe cognitive impairment; required limited assistance from staff for bed mobility and dressing; and extensive assistance from staff for transfers, toilet use and personal hygiene. On 5/18/16 Resident #1's clinical record was reviewed. The review revealed a completed significant change MDS with an ARD of 1/11/16. The quarterly MDS, with an ARD of 4/12/16, was not completed until 5/18/16 which was greater than the required 92 days since the significant change MDS. On 5/18/16 at approximately 3:35 p.m. an interview was conducted with the MDS Coordinator, Licensed Practical Nurse-A (LPN-A). LPN-A was informed of the late quarterly MDS. When asked why it wasn't completed timely, LPN-A stated I'm behind on my schedule. When asked the importance of completing an MDS timely, LPN-A stated To track the status of the guest (resident), for payment, and for compliance purposes. Facility policy titled MDS 3.0 Completion included: .d) Quarterly Assessment-completed using an ARD no > (greater than) 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD) . On 5/19/16 at 11:10 a.m. the Administrator and Director of Nursing were informed of the quarterly MDS not done timely. No further information was provided by the facility staff. 2. For Resident #3, the facility staff failed to complete and submit a Quarterly Minimum Data Set Assessment which was due on 4/27/16. Resident #3 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #3's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment, with an Assessment Reference Date of 1/20/16 was reviewed. Resident #3 was coded as having intact cognition. Resident #3's next Quarterly Assessment was due on 4/27/16. As of the 5/19/2016, the last day of the survey, the assessment had not been completed. On 5/17/16 an interview was conducted with the MDS Coordinator (Licensed Practical Nurse A). When asked why the Quarterly Assessment wasn't done in a timely manner, the MDS Coordinator stated, I'm behind in my schedule. When asked what was the importance of submitting the assessment timely, she stated that it was used for payment to the facility, and compliance purposes. On 5/17/16 at 12 Noon, the facility Administrator (Employee B) was informed of the findings. No further information was received. 3. For Resident #2, the facility staff failed to complete a quarterly Minimum Data Set (MDS)assessment for Section G was not completed. Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. One MDS assessment had been competed for Resident #2. This was a 5 day admission assessment with an assessment reference date (ARD) of 1/22/16. Resident #2 was coded with no cognitive impairment and requiring assistance with activities of daily living. Resident #2 was due to have a quarterly MDS assessment completed in April 2016. This assessment had an ARD of 4/22/16. The assessment was not complete. Section G (Functional Status) was blank. On 5/18/16 at 9:45 a.m., the MDS coordinator was asked about the assessment. She stated that the assessment was not complete and was supposed to be done in 7 days (of ARD). The assessment was 20 days over due. The Administrator and Director of Nursing were notified of the MDS issue at the end of day meeting on 5/18/16. 4. For Resident #7, the facility staff failed to complete a quarterly MDS (minimum data set) RAI (Resident Assessment Instrument) after an annual assessment with an ARD (assessment reference date) of 12/30/15 and including the end of the survey on 5/19/16. Resident #7, a female, was initially admitted to the facility 2/8/15 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/30/15 was coded as an annual assessment. She was coded as having memory deficits and required moderate assistance with making daily life decisions. She was also coded as needing supervision to limited assistance of one staff member to perform her activities of daily living. Review of the clinical record revealed no completed assessment within 92 days of the annual assessment noted above. Documentation was evident a quarterly assessment was in the process of being completed, however as of 5/19/16 (141 days after the ARD of the annual assessment) the assessment had not been completed. LPN (licensed practical nurse) A, the MDS coordinator, stated 5/18/16 at 11:02 a.m., I am behind in completing my MDS. LPN A stated she had been at the facility a couple of months. Guidance was provided in Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual V 1.13 October, 2015 p. 2-31 The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident ' s status between comprehensive assessments to ensure critical indicators of gradual change in a resident ' s status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. The administrator and DON (director of nursing) were informed in the failure of the staff to complete a quarterly assessment within 92 days of the previous assessment, 5/31/16 at 11:10 a.m.

Based on staff interview, facility documentation review and observation, the facility staff failed to notify the State Agency (SA) of a fire at the facility. A dryer fire occurred, sometime in October, 2015 and the facility did not notify the SA. The findings included: During interviews to assess facility staff knowledge of emergency procedures, the evening nursing supervisor was interviewed, 5/18/16 at 3:45 p.m. The nursing supervisor stated there had been a fire in the facility's laundry, caused by lint, and she had put the fire out with the fire extinguisher. She further stated the fire had occurred about six months ago. During general observations, the laundry was observed. Other C, the laundry worker stated 5/19/16 at 8:50 a.m., she had been working at the time of the dryer fire. Other C stated she thought it was maybe at the end of October (2015). Other C stated she and one of the nurses smelled smoke and upon checking in the laundry, realized there was a fire in the dryer. Other C stated the bottom of the dryer was opened and flames were noticed on the bottom of the dryer, with part of the lint filter melted through. Other C stated after she and the nurse put the fire out with the fire extinguisher, facility security had arrived and disconnected the gas line and electric lines of the dryer. Maintenance checked the dryer the next day and called a contractor to come and check on the dryer. Other B, the maintenance director was interviewed 5/19/16 at 9:40 a.m. Other B stated the contractor determined lint had gotten up near the burner and caused a flash. Other B stated he did not consider the dryer fire to be a true fire, however he had not been at the facility at the time of the fire. Other B stated the dryer was relatively new and he had been unaware that the top of the dryer could be moved so the areas around the burner could be cleaned. Other B stated he could not remember when the dryer fire occurred and he stated he would try and find out when the fire occurred. As of the end of the survey, 5/19/16 at 12:45 p.m., no further information was provided, including when the fire actually occurred. The dryer was observed 5/19/16 at 8:50 a.m. Black scorched marks could be observed on the bottom of the dryer. The lint screen was clean and Other C stated the lint area was checked and cleaned three times a day. When asked for verification that the SA had been informed of the fire in the dryer, the administrator stated no verification had occurred, 5/19/16 at 11:10 a.m. The administrator stated she had been led to believe that no true fire had occurred. The administrator was unaware that the results from the fire were still visible in the dryer. Review of the facility's policy entitled Abuse Investigation and Reporting: 13. Unusual occurrences include: a. Any event involving a resident that is likely to result in legal action b. Medication errors that result in the resident being hospitalized or dying c. Suicides-attempted or successful d. Death or serious injury associated with the use of restraints e. Ingestion of toxic substances requiring medical intervention. f. Accidents or injuries of known origin that are unusual, such as a resident exiting the nursing home and sustaining an injury on facility property, or a resident being burned. g. Resident procuring and ingesting enough medication to result in an overdose. h. Any unusual event involving a resident or residents that my result in media coverage. PROCEDURE 1. Any reasonable suspicion of a crime against a resident or alleged violations involving theft, fraud, mistreatment, neglect or abuse, including injuries of an unknown origin and unusual occurrences, misappropriation of resident property or funds must be reported to the Health Care Facility administrator or his/her designee. 3. c. The Health Care Facility Administrator or his/her designee will prepare the Facility Reported Incident form and fax to the OLC (Office of Licensure and Certification-SA). Facility reports to the OLC should contain sufficient detail to demonstrate that a thorough investigation was conducted including, but not limited to: 1. Date of incident; 2. Names of resident, staff, or individuals involved; 3. Location of and description of the injury to the resident; 4. Location and description of the injury to the resident; 5. Immediate corrective action taken to protect the resident from further injury; 6. Mechanisms in place to prevent recurrence of the incident, including date of review of facility policies and procedures; and 7. Documentation of report to Adult Protective Services, law enforcement, or the Department of Health Professions, as appropriate. The administrator and DON (director of nursing) were informed of the failure of the facility to report an unusual occurrence, a dryer fire, to the SA 5/19/16 at 11:10 a.m.