Every finding on record at The Home Place At Midway

Based on observation, interview, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The deficient practices had the potential to affect all residents with a census of 26.Observation and interviews on 02/26/2026 revealed hot water was stored at temperatures below the level needed to prevent growth of Legionella.Observation of the Hope and Faith House laundry rooms on 02/26/2026 revealed the aprons provided were made of cloth and would not protect staff clothing from splashes from contaminated linens.Observation of the Hope House clean linen storage on 02/26/2026 revealed clean blankets piled up on the floor beside the linen cart.The findings include:Review of the facility's policy titled, Water Management Plan, not dated, revealed the facility was to establish a Water Management Team including the Administrator, Director of Nursing, and Maintenance Director. Further review revealed the facility identified water heaters as a potential source of Legionella growth. Continued review revealed the facility was to monitor water temperatures daily in each building. However, the policy did not provide a temperature range required for water heaters and circulating hot water.Review of the Centers for Disease Control and Prevention (CDC) document Monitoring Building Water, dated 03/15/2024, revealed healthcare facilities should store hot water at above 140 degrees Fahrenheit (F) to prevent Legionella growth.In an interview on 02/26/2026 at 4:57 PM, the Maintenance Director stated he kept the water heaters set at 120 degrees F. He stated that temperature was what he was told by a contractor to set it at for Legionella management. In an additional interview at 6:05 PM, the Maintenance Director stated he did further research and found the recommended temperature for Legionella prevention was 130 degrees F, so he adjusted the water temperatures for each water heater accordingly.1. Observation on 02/26/2026 at 6:05 PM revealed the temperature gauge for the water heater for the Hope House read 121 degrees F. In interview on 02/26/2026 at 3:48 PM, the Infection Preventionist/Director of Nursing (IP/DON) stated she had not participated in the development of the water management plan. She further stated the facility did not have empty rooms or areas where water would be stagnant, so she believed the risk of Legionella growth was low.In an interview on 02/26/2026 at 4:23 PM, the Administrator stated the facility relied on a contacting company to assess their water management program, and they followed their recommendations for Legionella prevention, which included testing annually. She further stated the contracting company did not provide them with recommendations on water temperatures.Review of the facility's policy titled, Infection Prevention and Control, dated 10/2025, revealed the facility was to follow national standards and guidelines to prevent and control the spread of infection and communicable diseases. Further review revealed the facility was to handle, store, process, and transport linens in a manner to prevent the spread of infection.2.a. Observation on 02/26/2026 at 11:32 AM in the Hope House laundry room revealed the apron available for staff to use while cleaning heavily soiled linens made of cloth instead of an impermeable material.Observation on 02/26/2026 at 11:46 AM in the Faith House laundry room revealed the apron available for staff to use while cleaning heavily soiled linens made of cloth instead of an impermeable material.In an interview on 02/26/2026 at 3:48 PM, the IP/DON stated the aprons in the laundry rooms were for staff to wear while they rinsed heavily soiled linens to prevent splashing of potentially infectious material onto staff clothing. She stated the cloth aprons in the laundry rooms were permeable and would not protect staff members' clothing.In an interview on 02/26/2026 at 4:23 PM, the Administrator stated it was important for the staff to have the appropriate personal protective equipment (PPE) to wear while handling soiled linens. She further stated the cloth aprons were not adequate because cloth would allow potentially contaminated material to soak through to staff members' clothing.b. Observation on 02/26/2026 at 11:35 AM revealed the clean linen cart outside the laundry room in Hope House was overflowing. Further observation revealed a pile of clean blankets stacked beside the linen cart on the floor.In an interview on 02/26/2026 at 3:48 PM, the IP/DON stated linens should be stored off the floor. She further stated if the cart was overflowing, the surplus linen should be stored elsewhere to keep it sanitary.In an interview on 02/26/2026 at 4:23 PM, the Administrator stated clean linens should be stored on the linen cart or in clean linen baskets off the floor to keep them clean.

Based on observation, interview, and review of the facility's documents, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations made on 02/24/2026, 02/25/2026, and 02/26/2026 revealed mold contamination in the ice machine. Observations on 02/25/2026 revealed Ezer (an aide) 3's and Ezer 4's hair nets did not cover the front section of their hair.This deficient practice had the potential to affect all 26 current residents.The findings include:Review of the facility's document Kitchen Cleaning Schedule, not dated, revealed the ice machine was not included on the cleaning list or assigned a cleaning frequency. Review of the 'Maintenance Logbook revealed documented monthly cleaning entries from August 2025 through October 2025 and January 2026. However, there were no documented cleaning entries for November 2025, December 2025, or February 2026. 1. Observation on 02/24/2026 at 9:50 AM revealed the presence of mold inside the kitchen ice machine. Follow-up observations on 02/25/2026 at 10:03 AM and on 02/26/2026 at approximately 12:00 PM confirmed that mold was still present in the ice machine. In an interview on 02/26/2026 at 10:14 AM, Ezer 7 stated the ice machine was cleaned per the sheet from the dietitian, and the vents were cleaned daily. Ezer 7 stated the ice machine was cleaned on the inside last week because the ice was all gone. In an interview on 02/26/2026 at 11:25 AM, the Support Service Manager (SSM) stated maintenance did a cleaning on the ice machine quarterly. The SSM stated Ezers were responsible for cleaning based on the Kitchen Cleaning Schedule. In an interview on 02/26/2026 at 3:48 PM, the Director of Nursing/Infection Preventionist (DON/IP) stated cleaning of the ice machine is not in my realm, but I would hope it is cleaned weekly. The DON/IP stated mold in the ice machine was not acceptable and emphasized the importance of keeping it clean to protect residents' health. In an interview on 02/26/2026 at 4:23 PM, the Administrator stated the ice machine was cleaned quarterly by Maintenance with a special solution. The Administrator stated mold in the ice machine was unacceptable. The Administrator stated it was important to keep the ice machine clean to prevent resident illness.2. a. Observation on 02/25/2026 at 11:12 AM revealed Ezer 4 wore her hair net back from her forehead, leaving approximately three inches of hair exposed. Further observation revealed Ezer 4 walked around in the kitchen making tea and stirring a pot of food on the stove and did not adjust her hair net to cover her hair.In an immediate interview, Ezer 4 stated her hair was long and heavy, and hair nets sometimes pulled back from her forehead. Immediately following the interview, Ezer 4 pulled her hair back and secured it before replacing the hair net, which now covered all her hair.b. Observation on 02/25/2026 at 11:18 AM revealed Ezer 3's hair net did not cover the front section of her hair. In an interview on 02/26/2026 at 4:23 PM, the Administrator stated she did not believe the facility had a policy specific to wearing hair nets.In an interview on 02/26/2026 at 1:45 PM, the Dietary Manager stated staff should wear hair nets at all times in the kitchen. She further stated staff should ensure the hair nets covered all their hair to prevent hair from ending up in the resident's food.In continued interview on 02/26/2026 at 3:48 PM, the Director of Nursing (DON) stated staff should always wear hair nets that covered all their hair while in the kitchen.In an interview on 02/26/2026 at 4:23 PM, the Administrator stated staff in the kitchen should wear their hair nets covering their hair fully.

Based on observation, interview, and review of the facility's documents and policy, the facility failed to provide ongoing communication with residents about their rights to include not supporting and encouraging residents to organize and participate consistently in groups at the facility for 3 of 3 resident attendees present at the Resident Council meeting, Resident (R) R4, R5, and R25. The findings include:Review of the facility's policy titled, Grievance Policy, dated 07/01/2015, explained the procedures residents may follow in filing a complaint; however, there was no mention of residents being permitted to discuss concerns or complaints in Resident Council. Observation of the Resident Council meeting on 02/25/2026 at 10:30 AM revealed three residents were present, R4, R5, and R25. During the meeting, two of the residents expressed the desire to hold formal Resident Council meetings on a consistent basis. Furthermore, when asked about resident rights, all three participants stated they did not know what resident rights were and indicated that staff had not discussed their rights with them.Review of R4's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/20/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated the resident was cognitively intact. Review of R5's quarterly MDS, with an ARD of 01/22/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R25's quarterly MDS, with an ARD of 11/20/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of the Resident Council minutes obtained from the Administrator revealed on the dates of 11/25/2025,12/30/2025, and 01/29/2026, no formal Resident Council meetings were held. Further review revealed the notes for meetings on those dates were compiled from individual sessions with residents conducted by the Social Worker (SW).During an interview with the SW on 02/25/2026 at 4:10 PM, she stated no formal meetings had been held with residents for a few years. She further stated she had instead conducted individual meetings with the residents to discuss concerns or complaints, and that appeared to be their preference.During a follow-up interview with the SW on 02/26/2026 at 1:15 PM, when asked if she documented conversations from her individual meetings with the residents, she stated she provided that information to the Administrator.During an interview with the Director of Nursing (DON) on 02/26/2026 at 4:09 PM, she stated that no residents had expressed a desire to hold a Resident Council meeting. She stated that she thought the residents knew what a Resident Council was, but she was unsure if they had been provided with any information about resident rights. She further stated she did not know why the facility did not hold formal Resident Council meetings for the residents.During an interview with the previous Administrator on 02/26/2026 at 4:22 PM, she stated after Covid, the residents agreed to do one-on-one sessions with the SW; however, the residents had been given the opportunity to go to another house on campus for formal group meetings. She further stated resident rights were often discussed during care planning meetings or other care settings.During an interview with the Administrator on 02/25/2026 at 4:25 PM, she stated she had spoken previously with the Ombudsman and weighed options about holding a Resident Council meeting. She further stated due to the difficulty of getting a large group together, it was decided to keep it as it was, stating, If it's working for you don't change it.

Based on observation, interview, record review, and facility policy review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 out of 2 medication rooms observed, the Faith House Medication Room and the Hope House Medication Room.Observation on [DATE] of the Faith House Medication Room revealed three controlled substances belonging to Residents (R) 32 and R33, who no longer resided in the facility.Observation on [DATE] of the Hope House Medication Room revealed four controlled medication containers for R34 and two controlled medication containers for R35. Neither resident currently lived in the facility. The findings include:Review of the facility's policy titled, Medication Storage in the Facility, date revised 08/2014, revealed, Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems identified. Further review of the policy revealed, Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed. Review of Resident (R) 32's Face Sheet revealed the facility discharged the resident on [DATE]. Review of R33's Face Sheet revealed the facility moved the resident to an outpatient status on [DATE] and no longer resided in the facility. 1. Observation on [DATE] at 10:05 AM of the Faith House Medication Room revealed one controlled substance in the double locked medication cabinet belonging to R32, 25 tablets of alprazolam (an anti-anxiety agent) 0.25 milligram (mg). Further review revealed two controlled substances belonging to R33, 26 tablets of oxycodone (an opioid pain reliever) 5 mg and 32 tablets of alprazolam 0.25 mg. Additional observation on [DATE] at 10:18 AM revealed those controlled substances remained in the cabinet. In an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 10:10 AM, she stated R32 and R33 no longer lived at the facility, and she was unsure as to why the medications had not been collected and disposed of. Review of R34's Death Record Minimum Data Set [MDS], dated [DATE], revealed the facility admitted R34 on [DATE], and the resident died in the facility on [DATE].Review of R35's Discharge MDS, dated [DATE], revealed the facility discharged the resident as a planned discharge on [DATE]. 2. Observation on [DATE] at 11:04 AM of the Hope House Medication Room revealed the following controlled medications for R34 in the double locked medication cabinet: one bottle of liquid morphine (an opioid pain reliever), 38 tablets of tramadol (an opiate pain reliever) 50 mg, 57 tablets of lorazepam (an anti-anxiety agent) 1 mg, and 1 skid of lorazepam 5 mg. Further observation revealed the following controlled medications for R35: 40 tablets of gabapentin (a pain reliever) 300 mg and 42 tablets of oxycodone.In an immediate interview, Registered Nurse (RN) 1 stated the medications in the top shelf of the medication cabinet, where the above listed medications were located, was where nurses put medications for residents who had been discharged , or the physician had adjusted the dose of the medication. She further stated there should not be so many controlled substances not in use stored in the medication cabinet because every nurse for Hope House would have access to the cabinet, and the medications would be at risk for diversion or causing a medication error. RN1 stated the Director of Nursing (DON) and Staff Development Coordinator (SDC) used to audit and remove medications no longer in use from the cabinet, but she had noticed those audits were no longer occurring as frequently as they used to, leading to medications piling up in the cabinet.In an interview with RN3 on [DATE] at 10:18 AM, she stated the Schedule Coordinator and the DON made rounds sporadically. RN3 stated, I do not feel they collect controlled medications from residents who are discharged or have medication changes as often as they should. In an interview with the Scheduling Coordinator on [DATE] at 11:12 AM, she stated she and the DON collected controlled medications from the double locked cabinets and transported them to the Administration building, where they were placed in a double locked cabinet until it was full. She stated once that cabinet was full, they disposed of the controlled medications by placing the medications in a solution to break them down and then placing that solution into cat litter. She stated this process had occurred twice since [DATE]. She stated it was important to remove the medications in a timely manner to prevent medication errors. In an interview on [DATE] at 3:48 PM, the DON stated the facility's process for auditing the medication storage cabinets was for the SDC to go with the DON on a monthly basis to collect controlled medications no longer in use from each storage cabinet and destroy them. She stated it was important to follow this process to reduce the risk of drug diversion and medication errors. The DON stated the facility had been without an SDC for several months, so the medication audits had not been occurring as frequently as they needed to, leading to an accumulation of unused medications in the cabinet.In an interview on [DATE] at 4:23 PM, the Administrator stated her expectation for management of the controlled substance cabinets was for the DON and SDC to conduct frequent audits on the medication counts and remove and destroy medications no longer in use.

Based on interview and record review, the facility failed to notify the resident and the resident's representative of the transfer and the reasons for the move in writing for 1 of 1 resident investigated for hospitalizations, Resident (R) 28.R28 was transferred to the hospital on [DATE]; however, the facility failed to send a written notice of transfer to the resident's representative. Furthermore, the facility failed to provide evidence of sending the resident's representative a written copy of the bed hold notice for that hospitalization. The findings include:Review of R28's admission Record revealed the facility admitted the resident on 01/09/2026 with diagnoses including hip fracture, Alzheimer's disease, and benign prostate hyperplasia (enlarged prostate).Review of R28's Nurse's Note, dated 01/12/2026, revealed the facility transferred the resident to the hospital for blood in his urine.Review of R28's medical record revealed no evidence the resident's representative received a written notice describing the destination and reason for transfer, resident rights related to appeals, and contact information for state agencies. Further review revealed no evidence the facility sent the resident's representative a written bed hold notice for that hospitalization.Review of the Summary of Episode Note, dated 01/12/2026, provided by the facility in response to the State Survey Agency request for transfer paperwork given to R28's representative, revealed the packet contained required clinical information for the hospital related to R28's care needs but no evidence of a bed hold notice or notice of transfer.In an interview on 02/26/2026 at 3:44 PM, R28's Power-of-Attorney (POA) stated the facility did not send him any paperwork related to R28's transfer to the hospital and the resident's rights related to transfers.In an interview on 02/26/2026 at 4:23 PM, the Administrator stated the facility process when a resident was transferred to the hospital was to call the family to consult them, but the facility did not send a written notice. She further stated she expected the written bed hold notice to go to the hospital with the resident upon transfer.

Based on observation, interview, and facility policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 22 current residents. The findings include: Review of the facility's Food Storage policy, revised [DATE], revealed, Raw meat is to be stored in drip proof containers. Any expired or outdated food products should be discarded. Observation in the kitchen on [DATE] at 9:07 AM, revealed the front refrigerator had a container of cottage cheese that expired on [DATE]. Continued observation at 9:09 AM revealed a package of hamburger lying on the middle shelf, and it was not in a container. There were two uncovered melons on the shelf below. During telephone interview with the Dietitian on [DATE] at 2:02 PM, she stated all meat should be stored in a container on the bottom shelf. She further stated if the meat juice dropped on the melons, it could put the residents at risk for illness. She stated she would expect staff to store the meat in a container on the bottom shelf. She also stated staff should dispose of expired food because a resident could potentially become ill if they ate expired food. During interview with the Director of Nursing (DON) on [DATE] at 4:13 PM, she stated staff was to check the refrigerators for any expired foods and to store foods correctly. She stated eating expired food could cause a resident to become ill. She further stated staff should store meat so it could not drip onto other foods. During interview with the Administrator on [DATE] at 4:34 PM, she stated she was not aware of the issue with the food. She stated when she was informed of issues and errors were made, she educated staff to prevent recurrence.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure health information was maintained in a private and confidential manner for 1 of 12 sampled residents, Resident (R) 16. On 04/08/2025, R16's Medication Administration Record (MAR) was observed unattended and exposed to public view. The findings include: Review of the facility's policy titled, HIPAA [Health Insurance Portability and Accountability Act] Privacy Addendum, dated 03/05/2018, revealed the facility shall not disclose any protected health information. Review of R16's Face Sheet revealed the facility admitted R16 on 03/18/2025 with diagnoses to include heart failure, stroke, and bipolar disorder. Observation, on 04/08/2025 at 12:01 PM, revealed an unattended medication cart on the 300 Unit between the kitchen and porch. Further observation revealed R16's Medication Administration Record (MAR) was visible on the computer screen and in plain view. Registered Nurse (RN) 1, who was in charge of the medication cart, was not in the hall. During interview with RN1 on 04/08/2025 at 12:04 PM, she stated she should not have left the resident's MAR pulled up on the computer screen because health information should be kept confidential. During interview with the Director of Nursing (DON) on 04/10/2025 at 4:13 PM, she stated staff should always keep their computers closed when they were not with the computer. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated she addressed each issue regarding resident privacy when they were brought to her attention. She stated she first established a time frame using a matrix. She stated the time frame for each incident varied according to the severity of the issue. She stated she then involved the Staff Development person to educate staff and followed-up to assure the issues were resolved.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 12 sampled residents, Resident (R) 28. The findings include: Review of the facility's policy titled, Discharge, last revised 09/29/2022, revealed for all discharges and transfers, including to an acute care facility, the Office of the State Long-Term Care Ombudsman was to be notified. Review of R28's Face Sheet in the electronic medical record (EMR) revealed the facility admitted the resident on 01/14/2025 with diagnoses to include dementia, stroke, and chronic kidney disease. Further review of the EMR revealed the facility transferred R28 to the hospital on [DATE], but there was no documented evidence the Ombudsman had been notified in writing. During interview with the Social Services Director (SSD) on 04/10/2025 at 1:47 PM, she stated she did keep a list of notifications to the Ombudsman of discharges from the facility. She stated they had a conversation about the discharges every time the Ombudsman was at the facility. During telephone interview with the Ombudsman on 04/10/2025 at 2:02 PM, she stated she was not notified of residents who were discharged . She stated, when she came to the facility every month or two, she asked for a list of current residents and those that had been discharged . During interview with the Director of Nursing on 04/10/2025 at 4:13 PM, she stated it was the responsibility of the SSD to notify the Ombudsman of all transfers/discharges. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated her role was to assure the facility's policies were followed and to review the polices and address any issues.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC)document, and review of the facility's policies, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 12 sampled residents, Resident (R) 2 and R16. Observation on 04/08/2025 revealed staff did not perform correct hand hygiene when providing care to R2. Observation on 04/08/2025 revealed staff did not correctly dispose of a gown worn during the care of R16, who was in Enhanced Barrier Precautions (EBP). The findings include: Review of the facility's Infection Prevention and Control and Surveillance Program policy, dated 11/01/2017, revealed staff was required to adhere to standard precautions and use personal protective equipment (PPE) according to infection control precautions. Review of the facility's Hand Hygiene policy, revised 04/01/2024, revealed alcohol-based hand sanitizers should be used immediately upon removal of gloves. The policy further stated alcohol-based hand sanitizers should be used when moving from a soiled body site to a clean body site of the same resident. Review of the CDC's document Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated July 12, 2022, revealed Enhanced Barrier Precautions (EBP) was an infection control intervention designed to reduce transmission of resistant organisms that employed targeted gown and glove use during high contact resident care activities. Per the document, signage needed to be posted, indicating the type of precautions and required PPE. It also stated to position a trash can inside the resident's room and near the exit for discarding PPE after removal, prior to exit of the room, or before providing care for another resident in the same room. 1. Observation on 04/08/2025 at 9:56 AM revealed R2 was lying in bed. Registered Nurse (RN) 1 was in the room getting medications. R2 asked to be cleaned, and the nurse called Certified Nurse Assistant (CNA) 1. CNA1 and RN1 cleaned R2's bowel movement. Per observation, CNA1 removed gloves and left the room to get linen. CNA1 opened the door then sanitized hands. Per observation of RN1, after cleaning R2's bowel movement, she cleaned the perineal area without changing gloves. During interview with CNA1 on 04/08/2025 at 10:13 AM, CNA1 stated staff should sanitize each time gloves were removed because there could be a hole in the gloves, and it could spread infection. During interview with RN1 on 04/08/2025 at 10:19 AM, she stated she should have changed her gloves when moving from R2's back to front. She further stated it could cause the resident to get an infection. 2. Observation on 04/08/2025 at 4:44 PM revealed a yellow gown (PPE) was on a chair outside R16's room, and there was no EBP sign on the door. During interview with RN1 at the time of the observation, she stated she must have placed it there. She stated she should have put it in a container in the room. She stated she had been trained in infection control, she just forgot. During interview with the Infection Preventionist (IP) on 04/10/2025 at 10:11 AM, she stated R16 was on EBP and she usually placed a sign on the resident's door indicating what type of precaution and what was required to care for residents, such as PPE and/or laundry restrictions. She stated the sign fell , and she had not replaced it. She stated she expected staff to either wash or sanitize their hands after changing gloves. She stated she would also expect staff to wash or sanitize their hands and change gloves when going from a dirty area to a clean area. During interview with the Director of Nursing (DON) on 04/10/2025 at 4:13 PM, she stated the IP trained staff to follow precautions to prevent the spread of infection. She stated anytime the resident was in infection control precautions, staff should remove their PPE prior to leaving the room. She further stated staff was taught to wash or sanitize their hands after they removed their gloves. During interview with the Administrator on 04/10/2025 at 4:34 PM, she stated her role in infection control was to be notified of any issues from staff, the IP, or the DON. She stated she expected staff to follow the facility's infection control policies, and her role was to assure the facility's policies were followed. She stated she reviewed the policies and made changes if needed. She stated, if there were problems, the Staff Development Coordinator educated staff.

Based on interviews and review of the facility's policy, it was determined the facility failed to ensure the individual assigned the responsibilities of the Infection Preventionist (IP) had received specialized training in infection control and prevention. This had the potential to affect all twenty-two (22) residents residing in the facility. The findings include: Review of the facility's policy titled, Infection Preventionist, dated 11/28/2017, revealed, 1. This facility will designate one (1) or more individual(s) as the infection preventionist(s) (IP)(s) who is responsible for the facility's IPCP [Infection Prevention and Control Program]. The infection preventionist will: Have completed specialized training in infection prevention and control. On 05/09/2022 at 9:24 AM, the entrance conference was conducted with the Executive Director (ED) and the Director of Nursing (DON). Interview, at this time, revealed the DON identified herself as the designated Infection Preventionist (IP) for the facility. Interview with the DON, on 05/11/2022 at 1:03 PM, revealed she was the IP, but she had not completed any training regarding infection prevention. The DON stated she was aware that she needed to complete the training, but had not completed it yet. The DON stated the facility's wound treatment nurse had previous infection prevention training but was not the designated IP. The DON indicated she became the DON in January 2022. Interview with the Director of Clinical Support (DCS), on 05/11/2022 at 3:00 PM, revealed that the previous DON had been trained on infection prevention, but she did not check to make sure the current DON had completed the training prior to becoming the designated IP. Interview with the ED, on 05/11/2022 at 4:39 PM, revealed her expectations for the IP would be for her to take the available infection prevention course and become certified.

Based on interview, review of manufacturer's directions for use, review of the Centers for Disease Control and Prevention (CDC) guidance, and the Occupational Safety and Health Administration (OSHA) requirements and the RB Sigma website, it was determined the facility failed to implement infection control procedures that included a respiratory protection program compliant with OSHA respiratory protection standards, including medical evaluations, training, and fit testing for the use of N95 respirators. This failed practice had the potential to affect all twenty-two (22) residents and occurred during the COVID-19 pandemic. The findings include: Review of the CDC's, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/2022, indicated, Source control options for HCP [healthcare personnel] include: A NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent or higher-level respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators. (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated). Review of Occupational Safety and Health Standard 1910.134, titled, Respiratory Protection indicated the following: - 1910.134(c)(1) - In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions of this section, as applicable: Procedures for selecting respirators in the workplace; Medical evaluations of employees required to use respirators; Fit testing procedures for tight-fitting respirators; Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance. - 1910.134(f) - Fit testing. This paragraph requires that, before an employee may be required to use any respirator with negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. - 1910.134(f)(2) - The employer shall ensure that an employee using a tight-fitting facepiece respirator is fit tested prior to initial use of the respirator, whenever a different respirator facepiece (size, style, model or make) is used, and at least annually thereafter. Review of the RB Sigma (medical supply company) website https://www.rbsigma.com, on 05/11/2022, revealed the N95 model RBS-95-DM002, which was the model used at the facility, was no longer available. The model RBS-FFR95-1013 was the only Sigma model listed as being NIOSH-approved. Review of the CDC website, https://www.cdc.gov, on 05/11/2022, revealed the guideline titled, NIOSH-approved N95 Particulate Filtering Facepiece Respirators, indicated the information was updated weekly. Further review revealed the only N95 respirator that had been approved for RB Sigma was the model RBS-FFR95-1013. Review of the RB Sigma N95 Filtering Facepiece Respirator - User Instructions RBS-FFR95-1013 indicated, Before occupational use of this respirator, a written respiratory protection program must be implemented meeting all the local government requirements. In the United States, employers must comply with OSHA 29 CFR 1910.134 which includes medical evaluation, training, and fit testing. Interview with the Director of Nursing (DON), on 05/11/2022 at 3:23 PM, revealed all staff members were to wear N95 masks and that none of the staff had been fit tested for the masks that were in use. The DON stated the facility had a fit testing kit available, but had not used it. The DON was unable to answer why the staff had not been fit tested on the current N95 masks that were in use. Interview with Ezer #4 and Ezer #5, on 05/11/2022 at 3:53 PM, who were both working the Best Friends House (100 Hall cottage), revealed both Ezer's were wearing N95 masks. Also, Ezer #4 and Ezer #5 stated they had not been fit tested for the masks they were wearing. Both stated they had been fit tested by the health department at the beginning of the COVID-19 pandemic for a different mask. They stated they had not received any training on how to properly wear the N95 mask. Interview with Registered Nurse (RN) #1 and RN #2, on 05/11/2022 at 3:57 PM, who were both working in the Hope House (200 Hall cottage), revealed they were wearing N95 masks. The RNs stated they had not been fit tested for the masks they were wearing. RN #2 stated they did not need to be fit tested for the current mask and that she had been fit tested for the duck bill type of N95 mask. RN #1 stated they did not have to be fit tested for the current mask because the bands went over the ears instead of around the head. Interview with Ezer #2, on 05/11/2022 at 3:59 PM, revealed she was working in the Hope House. She stated no fit testing or training had been provided for the N95 mask she was wearing. Interview with Ezer #6, on 05/11/2022 at 4:01 PM, revealed she was working in the Hope House. Ezer #6 stated she had not been fit tested for the N95 mask she was wearing. She stated that no training had been provided to her on how to properly wear the N95 mask. Interview with Ezer #7, Ezer #1, Activity Coordinator (AC), Ezer #8, Licensed Practical Nurse (LPN) #1, and Ezer #9, on 05/11/2022 at 4:05 PM, revealed they were working in the Faith House (300 Hall cottage). They stated they had not been fit tested for the N95 masks they were wearing. Also, they all stated no training had been provided to them on how to properly wear the N95 mask. Interview with the Executive Director (ED), on 05/11/2022 at 4:39 PM, revealed her expectations for education/training, before staff used an N95 mask, was that the facility would provide training for the proper donning/doffing (putting on and removal) of the mask. The ED stated the facility had done fit testing previously with a different brand/style but had not done any fit testing with the current N95 masks. The ED stated they had just gone back to using the N95 masks due to a recent outbreak, and they had previously been using surgical masks. The facility's policy for N95 use was requested. The ED stated the facility's infection control policies and procedures were all they had. However, review of the policies and procedures did not address the requirements before use of the N95 masks.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety in two (2) of three (3) kitchens (Faith Cottage and Hope Cottage kitchens). The failed practices had the potential to affect all twenty-two (22) residents. Observations, on [DATE], of the Faith Cottage kitchen, revealed a box of food stored on the floor; a dented can of food on the shelf for use; and, expired cans of food on the shelf for use. Observations, on [DATE], of the Hope Cottage kitchen, revealed an opened package of raw beef stored next to an opened package of shredded cheese; and expired food items and dented cans of food available for use. In addition, a kitchen staff member, while handling food, used antibacterial hand sanitizer instead of washing hands with soap and water. The findings include: Review of the facility's policy titled, Food Storage, updated [DATE], revealed, Upon delivery all food items should be inspected for safe transport and quality upon receipt. Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. Further review of the policy revealed, All products should be inspected for safety and be dated upon receipt, when open, and when prepared. Raw meat is to be stored in drip-proof containers separately from cooked meats and other raw foods. The policy also stated, Dented or bulging cans should be placed on the Damaged Goods Shelf and returned for credit. All foods should be stored away from the walls, off the floor, and clear of ceiling sprinklers, sewers/waste disposal pipes and vents. Review of the facility's policy titled, Handwashing and Glove Use, updated [DATE], revealed, Guidelines for handwashing and glove use to promote safe and sanitary conditions throughout the dietary department must be followed. Note: Antimicrobial hand gel cannot be used in place of proper hand washing techniques with soap and warm water. Review of the facility's Culinary Orientation packet, on [DATE], revealed no references to using hand sanitizer gel in place of handwashing in the kitchen. The instructions indicated handwashing must occur prior to putting on gloves and whenever gloves were changed. 1a. Observations in the Skilled 1-Faith Cottage (unit) on [DATE] at 10:17 AM, revealed one (1) unopened box of strawberry nutrition shakes stored on the floor between the stand-up freezer and pantry shelving. Interview with Ezer (a Certified Nurse Aide who received kitchen and housekeeping training) #1, on [DATE] at 10:32 AM, revealed the box on the floor between the stand-up freezer and pantry shelving was an unopened box of strawberry nutritional shakes. Ezer #1 stated nothing should be stored on the floor of the pantry. 1b. Observations in the Skilled 2 - Hope Cottage kitchen, on [DATE] at 11:41 AM, revealed the refrigerator in the pantry contained an opened five-pound (5-lb.) roll of raw ground beef that was stored on a cookie sheet in the bottom drawer. The ground beef was next to an opened bag of shredded mozzarella cheese and a sealed bag of mashed potatoes. Interview with Ezer #2, on [DATE] at 12:40 PM, revealed meat should be thawed and stored on a tray by itself and not with other food products. She noted that the raw ground beef was on the cookie sheet next to the open bag of cheese and sealed bag of potatoes in the pantry refrigerator. Ezer #2 stated the meat could cross-contaminate the cheese and should be stored on its own. Interview with the Support Services Manager (SSM), on [DATE] at 1:17 PM, revealed she oversaw the Ezer training in the cottage kitchens. She stated nothing should be stored on the floor. The SSM stated raw meat, such as ground beef, should be thawed and stored in the bottom drawer of the refrigerator, on a cookie sheet, by itself, and should not be touching other food items. She stated raw meat could cross-contaminate food items stored with it. Interview with Ezer #3, on [DATE] at 10:13 AM, revealed raw meat should be thawed in the lowest drawer of the refrigerator, away from any other food items. He stated unsafe thawing of raw meats could introduce foodborne illness to the residents. Interview with the Executive Director (ED), on [DATE] at 12:12 PM, revealed raw meat should be stored in the bottom of the refrigerators away from other food items to prevent cross-contamination. Interview with the Director of Nursing (DON), on [DATE] at 12:28 PM, revealed raw ground beef should be thawed and stored in the bottom drawer of the refrigerator away from other food items. She stated the meat drippings could contaminate other foods. The DON stated the improper thawing of meat could introduce foodborne illness to the residents of the facility. 2a. Observations in the Skilled 1-Faith Cottage kitchen and pantry, on [DATE] at 10:17 AM, revealed one (1) six-pound can of pears that was dented along the seal and bottom of the can; three (3) three-pound cans of cream of potato soup, with a printed expiration date of [DATE]; one (1) three-pound can of vegetable soup, with a printed expiration date of [DATE]; and two (2) forty-six (46)-ounce containers of prune juice, with a printed expiration date of [DATE]. There was no shelf designated for storage of dented cans for disposal. Observations of the main pantry on [DATE] at 3:31 PM, revealed a designated dented can removal shelf. Interview with Ezer #1, on [DATE] at 10:32 AM, revealed the Ezers were responsible for the kitchen when assigned. She stated she was assigned to the kitchen that day. Ezer #1 stated opened items should be dated and that she checked daily for dates and expired items. She stated the printed expiration date determined when an item should be thrown out. Continued interview revealed if an item was past the printed expiration date, it should be tossed out. At this time, she acknowledged the two (2) expired juice containers and four (4) expired cans of soup. She threw away the expired juice and pulled the expired cans to be returned to the main pantry storage area for disposal. She stated dented cans should be returned to the main kitchen pantry for return or disposal. Ezer #1 stated dented cans were handled by the Support Services Manager (SSM). 2b. Observations in the Skilled 2 - Hope Cottage kitchen, on [DATE] at 11:41 AM, revealed the cottage had two (2) refrigerators (one in the kitchen area and one in the pantry). Observations of the refrigerator in the kitchen area revealed a five (5)-pound container of cottage cheese with no opened date and a printed expiration date of [DATE]. In addition, there were two (2) opened packages of processed summer sausage. The opened date on the first package was [DATE], and the opened date on the second package was [DATE]. Observation, on [DATE] at approximately 11:41 AM, of the pantry, revealed six (6) dented cans, including one (1) three (3)-pound can of brown gravy, one (1) fifteen (15)-ounce can of mixed beans, one (1) ten and a half (10.5)-ounce can of cream of chicken soup, one (1) ten and a half (10.5)-ounce can of chicken noodle soup, one (1) six (6)-pound can of chili hot dog sauce, and one (1) forty-six (46)-ounce can of tomato juice. Further observation of the pantry revealed one (1) expired forty-six (46)-ounce container of grape juice, with a printed expiration date of [DATE]. There was no shelf designated for storage of dented cans for disposal. Observation, on [DATE] at approximately 11:41 AM, of the refrigerator in the pantry revealed an unopened five (5)-pound container of cottage cheese with a printed expiration date of [DATE]. Follow-up observations, of the pantry in the Skilled 2 - Hope Cottage, on [DATE] at 1:51 PM, revealed the dented cans discovered on [DATE] remained in the pantry. At 2:00 PM, the ED (Executive Director) and the DON (Director of Nursing) were notified of the dented cans remaining in the pantry of the Hope Cottage. Interview with Ezer #2, on [DATE] at 12:40 PM, revealed dented cans were not to be used and were to be thrown out if found in the pantry. She stated, if expired food items were found in the pantry or refrigerator, they should be thrown out. She stated opened food items should be labeled when opened and be kept in the refrigerator for three (3) days, then thrown away. At this time, she acknowledged the dented cans, expired items, and opened food items in the pantry and refrigerators. Interview with the Support Services Manager (SSM), on [DATE] at 1:17 PM, revealed that all canned goods should be checked for dents upon arrival so they could be returned. She stated each shift was supposed to check the canned goods in the pantry and remove dented cans. She stated dented and expired cans should not be used when preparing meals for the residents. She stated the Ezers received training about removing expired food items and dented cans from the pantry and refrigerators. Continued interview revealed expired food items should be thrown away. She stated that after packaged food was opened, it should be thrown away seven (7) days later. The SSM stated, if the food item was homemade or dairy, it should be thrown away three (3) days after being opened. Interview with Ezer #3, on [DATE] at 10:13 AM, revealed the Ezers received classroom training and shadowed other Ezer's who were cooking and working in the kitchen. He stated all staff members who worked in the kitchens checked daily for expired food items and dented cans. Ezer #3 stated if a can was slightly dented, it would be kept and used, but if it was a large dent it would be returned or disposed. He stated most of the dented cans should be screened out at the main pantry when they were delivered. He stated the printed expiration date on a package determined when an item needed to be thrown away if it was unopened, and, if the food item was opened. He stated the kitchen Ezer would check for expired items in the pantry and the refrigerators at the end of the shift and throw them out. He stated serving food from dented cans or expired items could introduce foodborne illness to the residents. Interview with Ezer #10, on [DATE] at 10:22 AM, revealed the lead Ezers checked the pantries and refrigerators for expired foods and beverages twice a week when the food orders were placed. She stated expired food items were disposed of when found and dented cans were returned to the main pantry for disposal. Interview with the Director of Nursing (DON), on [DATE] at 12:28 PM, revealed dented cans should not be used or stored in the pantries. She stated dented cans should be returned or discarded. She also indicated expired items should be discarded. She stated opened food items should be labeled with the opened date. The DON stated the type of food item determined how long it was good in the refrigerator after opening. Continued interview revealed a binder was kept in the kitchens that was used to determine how long an opened food item was good. She indicated dented cans and expired food and beverage items could introduce foodborne illness to the residents. Interview with the Executive Director (ED), on [DATE] at 12:12 PM, revealed the facility used the ServSafe program to train the Ezer's in the kitchens. She stated opened food was expected to be labeled with the opened date, and printed expiration dates should be checked, with the expired items discarded. 3. Observations of the lunch meal service in the Skilled 2 - Hope Cottage kitchen, on [DATE] between 12:14 PM and 12:40 PM, revealed Ezer #2 was performing kitchen duties in the cottage, including plating food for the meal service. Ezer #2 used antibacterial hand sanitizer instead of washing with soap and water in between glove changes on three (3) occasions during the meal service and while pureeing a resident's meal. Interview with Ezer #2, on [DATE] at 12:40 PM, revealed she had started employment with the facility two (2) weeks prior and had completed the ServSafe kitchen training during orientation. She stated this training covered infection control and hand hygiene. Ezer stated hand hygiene training included using antibacterial hand sanitizer and handwashing while working in the kitchen. She stated that during meal service, hand sanitizer was to be used between each plate and between glove changes, with handwashing to be performed after the third glove change. Interview with the Support Services Manager (SSM), on [DATE] at 1:17 PM, revealed hand hygiene training was provided to all staff members who worked in the kitchens. She stated handwashing should be performed immediately upon entering the kitchen and in between glove changes. She stated antibacterial hand sanitizer should not be used in place of handwashing while working with food in the cottage kitchens. Interview with Ezer #3, on [DATE] at 10:13 AM, revealed hand hygiene should be completed immediately upon entering the kitchen and in between glove changes, as well as before and after assisting a resident with personal care. He stated staff could use antibacterial hand sanitizer in place of handwashing if needed, but that handwashing was always preferred. Ezer #3 stated the training included the use of hand sanitizer and that other staff had advised the use of hand sanitizer while working in the kitchen. Interview with the Director of Nursing (DON), on [DATE] at 12:28 PM, revealed staff working with food in the kitchen should always perform handwashing and were not to use hand sanitizer. She stated the hand sanitizer could get into the food and that improper hand hygiene in the kitchen could introduce foodborne illness to the residents. Interview with the Executive Director (ED), on [DATE] at 12:12 PM, revealed handwashing should be performed in the kitchen by staff members handling food prepared for residents.

Based on observation, interview, and review of the facility's procedure on mechanically altered diets, it was determined the facility failed to ensure pureed food was blended to a smooth consistency to meet the needs of residents who required a pureed diet, during one (1) of one (1) meal service observed. The failure had the potential to affect three (3) residents who required pureed diets out of twenty-two (22) facility residents. The findings include: Review of the facility's Mechanically Altered Diet Explanation procedure, revised 05/06/2019, revealed, Puree all foods to the consistency of smooth, moist mashed potatoes or pudding-like consistency. Observations of the lunch meal, on 05/09/2022 between 12:14 PM and 12:40 PM, revealed Ezer (a Certified Nurse Aide who received kitchen and housekeeping training) #2 preparing to puree meatloaf for a resident who required pureed meats. At 12:24 PM, Ezer #2 cut a piece of meatloaf from the pan and placed it into the food processor to blend. No moisture was added to the food processor at this point. She blended the meatloaf for a couple of minutes then plated the meatloaf. Chunks of vegetables as well as pieces of unblended meat were visible in the finished product. During the observation, Ezer #2 was asked if the meatloaf was blended enough. Ezer #2 stated that it was, then retrieved Ezer #6 to verify the texture. Ezer #6 noticed the chunks of vegetables and meat and suggested Ezer #2 add some vegetable broth to the meatloaf to help blend it to a smoother consistency. Ezer #6 pointed out to Ezer #2 the importance of a smooth, consistent, pureed texture to prevent aspiration and choking. Ezer #2 acknowledged Ezer #6's comments, then added some vegetable broth to the meatloaf and re-blended it to a smooth, consistent texture. Interview with Ezer #2, on 05/09/2022 at 12:40 PM, revealed she received culinary training provided by the Support Services Manager (SSM) during orientation. She stated she also shadowed an Ezer in the kitchen of the cottage before performing the kitchen tasks herself. She stated she completed the ServSafe training on the computer, which covered kitchen sanitation and textures. Ezer #2 stated she demonstrated pureed texture to the SSM during kitchen orientation. Interview with Ezer #3, on 05/10/2022 at 10:13 AM, revealed the Ezers received classroom training and shadowed other Ezers who were cooking and working in the kitchen. He stated pureed texture was supposed to be smooth, with no chunks of food. Interview with Ezer #10, on 05/10/2022 at 10:22 AM, revealed classroom kitchen training was provided and she also shadowed others who were cooking. She stated pureed texture was supposed to be smooth and consistent. Interview with the SSM, on 05/10/2022 at 12:34 PM, revealed she oversaw the culinary orientation provided to the Ezers. She stated the daily prep sheet described menu items, ingredients needed, the recipes, and the different preparations for textures of the food items. She stated the texture training included a return demonstration during the hands-on training in the kitchen. The SSM also stated she supervised Ezer #2 and two (2) other Ezers in training during the hands-on kitchen training on 04/22/2022. She stated she observed Ezer #2 correctly blend and prepare the mechanical soft and pureed texture diets. Continued interview revealed Ezer #2 also shadowed a seasoned Ezer before being assigned as a kitchen Ezer. Interview with the Director of Nursing (DON), on 05/11/2022 at 12:28 AM, revealed the pureed diet texture should be smooth with no chunks. The DON stated improper consistency could lead to choking or aspiration. Interview with the ED, on 05/11/2022 at 12:12 PM, revealed pureed foods should be blended until smooth and consistent, with no chunks.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on the Skilled 2 Cottage Kitchen, on [DATE], revealed the refrigerator contained a five (5) pound Sysco Pimento Cheese container and a thirty-two (32) ounce container of whipping cream; both of which had been opened and not marked with an open date. In addition, there was a foil container of left over food, dated [DATE], which was not labeled with the resident's name and was expired as per facility policy. In addition, observation on [DATE], on the Skilled 2 cottage, revealed the back room storage refrigerator contained a thirty-two (32) ounce container of Hidden Valley Honey Mustard Dressing which had been opened and was not marked with the open date; one (1) box of four (4) count frozen Outshine fruit bars which had been opened and was not marked with the open date; and five (5) containers of Chobani Strawberry Greek four (4) ounce yogurts with an expiration date of [DATE]. The findings include: Review of the facility Food Safety Requirements- Use and Storage of Food and Beverage Brought in for Residents, Food Procurement, effective date [DATE], revealed it is the policy of the facility to provide safe and sanitary storage, handling and consumption of all foods including those brought to the resident by family and visitors. Any person working in the kitchen is responsible to adhere to food safety requirements. Continued review of the Policy, revealed for food brought in for residents, foods requiring refrigeration will be received by the facility designee, dated upon receipt, and discarded after three (3) days. Further review of the Policy, revealed the facility will store and label food according to state and local laws and regulations, which would include when food, food products or beverages are delivered to the nursing home. The facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. 1. Observation on the Skilled 2 Cottage Kitchen, on [DATE], at 11:30 AM, revealed the refrigerator contained a five (5) pound Sysco Pimento Cheese container which had been opened and was not marked with the open date. Additionally, there was a thirty-two (32) ounce container of whipping cream which had been opened and was not marked with the open date. Further, there was a foil container of left over food, dated [DATE], which was not labeled with the resident's name and was expired as per facility policy. 2. Observation on [DATE] from 11:,[DATE]:45 AM, on the Skilled 2 cottage, revealed the back room storage refrigerator contained a thirty-two (32) ounce container of Hidden Valley Honey Mustard Dressing which had been opened and was not marked with the open date; one (1) box of four (4) count frozen Outshine fruit bars which had been opened and was not marked with the open date; and five (5) containers of Chobani Strawberry Greek four (4) ounce yogurts with an expiration date of [DATE]. Interview with State Registered Nurse Aide (SRNA) #2, on [DATE] at 12:05 PM, revealed all food brought into the facility by family should be dated, and should only be kept in the facility for three (3) days. Continued interview revealed other foods supplied by the facility should be dated upon arrival and should be discarded at expiration date for the safety of the residents to prevent foodborne illnesses. Per interview, facility staff did receive training related to expectations regarding food handling safety. Interview with the Dietary Manager (DM) on [DATE] at 5:30 PM, revealed staff should follow policy related to food storage including labeling foods with the dates foods were opened or brought in by resident families. The DM further stated, staff should ensure expired food items were discarded in order to prevent food borne illness. Per interview, all staff handling food had been trained related to food handling and preparation and were expected to know the rules and regulations related to marking food items with names and dates. Per interview, as Dietary Manager, it was her responsibility to be aware of the food inventory in the refrigerators of each cottage. Interview with the Staff Development Coordinator, on [DATE] at 10:00 AM, revealed staff should follow facility policy related to food storage and labeling. Further interview revealed expired foods should be discarded and not accessible for use. Continued interview revealed the SRNAs took turns preparing food in the cottages, and they were all trained in proper food storage, labeling and food safety. Per interview, this education began at orientation and continued annually, and as needed. Interview with the Director of Clinical Support/Acting Administrator, on [DATE] at 11:30 AM, revealed it was her expectation for all staff to follow facility policy related to safe food handling practices. Continued interview revealed prepared food brought in from families should be labeled with the resident's name and date it was brought in, and should be discarded after three (3) days. Per interview, all food should be marked with an open date and should be discarded when expired for resident safety and to prevent food borne illnesses.

Based on observation, interview, record review and review of facility Policies, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of thirteen (13) sampled residents (Resident #11 and # 19). Resident #11 had a [DIAGNOSES REDACTED]. Also, observation of peri care for Resident #11 on 06/04/18, revealed the nurse performed peri care; however, failed to wash hands and don new gloves after performing the peri care and prior to handling the tube of barrier cream. During the observation, it was noted the nurse and the State Registered Nurse Aide (SRNA) who was assisting the nurse, threw soiled linens and soiled chux in the floor. After the peri care was complete, staff failed to remove their soiled gloves and wash hands. Staff proceeded to reposition the resident, pull the resident's covers up, touch the resident's face and hair, and obtain the resident's oral temperature with the same soiled gloves. In addition, observation of perineal care for Resident #19, on 06/04/18, revealed staff provided peri care and then failed to remove soiled gloves and perform hand hygiene prior to removing the Sky Lift motorized unit from the resident's room. Furthermore, observation of peri care for Resident #19, on 06/05/18, revealed following peri care, staff failed to remove soiled gloves and perform hand hygiene prior to removing the packet of clean wipes from the bed, opening the dresser drawers to obtain clothes for the resident, dressing the resident, and moving the Sky Lift motorized unit out of the resident's room. The findings include: Review of the facility Nursing - Peri Care, Policy, undated, revealed the purpose of the policy was to provide perineal care according to Standard Precautions and Blood Borne Pathogen Standards to eliminate the risk of spreading pathogens. The policy stated gloves were donned prior to providing perineal care, removed immediately after care, hands washed, and clean gloves donned prior to applying barrier cream to the perineal area. Further review revealed hands should be washed before and after task. Further review revealed soiled linen was to be placed in a plastic bag. Review of the facility Standard and Transmission Based Precautions Policy, undated, revealed precautions for contact precautions include gloves, gown and containment of microorganism; private room preferred; door may remain open; and contain or cover site of infection before transport. Per Policy, Handwashing is the single most effective means in preventing transmission of infection from one person to another. Review of the form titled Homeplace Inservice Training, dated 01/11/18 and subtitled Infection Control, revealed twenty-two (22) staff members attended an inservice covering hand hygiene, types of infection control precautions, infection control set-up, laundry, and biohazard waste disposal. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 02/12/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set Assessment ((MDS) dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status Score of two (2) out of fifteen (15), indicating the resident was severely cognitively impaired. Further review of the MDS, revealed the facility assessed the resident as having [MEDICATION NAME] due to [MEDICAL CONDITION] (bacterium that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon). Review of Resident #11's Hospital Discharge Summary, dated 05/23/18, revealed the resident had active Clostridum Difficle infection and was discharged to the facility on oral [MEDICATION NAME] (antibiotic medication) to treat [MEDICATION NAME] due to [MEDICAL CONDITION]. Record Review of physician's orders [REDACTED]. Review of Resident #11's (MONTH) Medication Administration Record [REDACTED]. Continued record review revealed the resident had been receiving the medication since 5/23/18. Review of the Resident #11'S Comprehensive Care Plan, initiated 5/16/18 revealed an active problem of [MEDICAL CONDITION] and a goal stating [MEDICAL CONDITION] will resolve. The interventions included toilet every two (2) hours; administer antibiotics as ordered and monitor effectiveness; and contact isolation precautions. Observation on 06/03/18 at 12:45 PM, revealed Resident #11 was sitting in a wheelchair at the Bar counter in front of of the kitchen. The resident was served lunch including sweet and sour chicken and rice, in Styrofoam containers with plastic tableware. Resident #2 was sitting to the right of Resident #11 at the counter. No staff members were observed to be wearing gowns or gloves in the dining room or to be assisting the resident with the lunch meal. Continued interview with SRNA #2, on 6/05/18 at 3:15 PM, revealed she was often assigned to Resident #11. She stated even though the resident was in contact isolation, he/she could be out of the room for meals. However, she stated when assisted with meals in the room, staff had to wear a gown, and gloves. Interview on 06/05/18 at 3:35 PM, with RN #2, revealed she was not sure what the facility policy was related to contact precautions. She stated she thought a resident on contact precautions such as Resident #11 could be out of the room for meals. Further interview revealed she did not understand why staff had to wear gowns and gloves to assist Resident #11 with meals in the room, but did not have to take any precautions outside of the room. Observation on 06/04/18 at 12:30 PM, revealed a sign on Resident #11's door stating visitors were to speak to the nurse before entering the room. Upon entering the room by the door, a cart with Personal Protective Equipment was available with gowns, masks and gloves, and a red biohazard container for trash was also by the door. State Registered Nursing Aide (SRNA) #2 applied gown, and gloves as she entered the resident's room prior to delivering the lunch tray to Resident #11. Further observation on 6/04/18 2:00 PM, revealed RN #2 and SRNA #2 donned gloves and gowns as they were entering Resident #11's room. RN #2 revealed she was going to perform peri care and was observed to cleanse the resident's peri-area with wipes while SRNA #2 held the resident over on his/her right side. After cleansing the resident's peri area, RN #2 failed to wash hands and don new gloves. RN #2 opened the tube of barrier cream and squeezed the cream out of the tube onto her fingers with soiled gloves, and then applied the barrier cream to the resident's perineal area. Continued observation revealed after the barrier cream was applied, the nurse removed the pillow case from the bed which was soiled with stool and threw it on the floor. RN #2 did not wash hands or change gloves after throwing the pillow case on the floor. SRNA #2 then removed the chux soiled with stool and threw them on the floor. SRNA #2 did not wash hands or change gloves after throwing the soiled chux on floor. Additional observation of RN #2 and SRNA #2, revealed while wearing soiled gloves, they repositioned the resident in the bed. RN #1 pulled covers up over the resident. RN #2 then with soiled gloves touched the resident's face and hair. Subsequently at the request of RN #2, SRNA #2 retrieved a thermometer from the resident's dresser and put it in Resident #11's mouth to take his/her temperature. RN #2 and SRNA #2 did remove gloves and wash hands prior to exiting the resident's room. Interview with SRNA #2 on 6/05/18 at 3:15 PM, revealed she had been employed at the facility for one (1) year. She further stated she received training related to hand hygiene and contact precautions as well as perineal care; however, she stated the facility did not have many residents with contact precautions. Per interview, when assisting RN #2 with perineal care for Resident #11 on 6/04/18, she should have put the soiled chux in a bag and not on the floor. Per interview, she should have removed her soiled gloves and washed her hands after handling dirty linen and chux. Further interview revealed she should have washed her hands and applied new gloves prior to obtaining the resident's temperature. She stated this was an infection control issue which could have a negative impact for the resident or staff members. Further interview revealed she should follow the facility's policies related to hand hygiene, perineal care and contact precautions. Interview on 06/05/18 at 3:35 PM, with RN #2, revealed she had been employed by the facility for three (3) months. Per interview, she should have followed policy related to hand hygiene, contact precautions and perineal care while performing perineal care for Resident #11. Interview further revealed she should have washed hands and changed gloves after cleansing stool off the resident and before applying the barrier cream. Per interview, this would be important to prevent the contamination of the barrier cream container. Continued interview revealed she should have changed gloves and washed hands after applying barrier cream. Per interview, it would be against facility policy to put linens or chux soiled with stool from a resident with [MEDICAL CONDITION] on the floor, for infection control reasons, and the items should have been placed in the red biohazard bags. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 10/04/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status of six (6) out of fifteen (15) indicating the resident was severely cognitively impaired. Observation on 06/04/18 at 10:13 AM, revealed SRNA #1 provided peri care for Resident #19 and then failed to remove soiled gloves and perform hand hygiene prior to removing the Sky Lift motorized unit from the resident's room. Observation on 06/05/18 at 10:55 AM, revealed SRNA #1 provided peri care for Resident #19. Following peri care, the SRNA failed to remove her soiled gloves and perform hand hygiene prior to removing the packet of clean wipes from the bed, opening the dresser drawers to obtain clothes for the resident, dressing the resident, and moving the Sky Lift motorized unit out of the resident's room. Interview with SRNA #1, on 06/05/18 at 10:55 AM, revealed she knew her gloves should have been removed immediately after providing perineal care and prior to touching clean objects. She stated this was important to prevent the spread of infections. She further stated she forgot to take off the contaminated gloves following the perineal care. Interview with RN #1, on 06/05/18 at 2:12 PM, revealed it was his expectation for staff to adhere to infection control policies and remove gloves and perform hand hygiene after perineal care to prevent the spread of infectious agents. Interview with the Staff Development/Infection Control Nurse, on 06/06/18 at 8:42 AM, and 9:25 AM, revealed she had been employed by the facility for three (3) years. Per interview, staff were educated regarding hand hygiene, hand washing skills, perineal care, correct use of Personal Protective Equipment (PPE), isolation precautions, proper cleaning of equipment, and Infection control when hired and at least annually. She further stated she provided on the spot infection control education on an ongoing basis for staff. Per interview, good infection control practices and adherence to infection control policies protected residents and staff from the spread of infectious disease. She stated facility policies were available to all staff to review. Continued interview with the Staff Development/Infection Control Nurse, revealed Resident #11 who had a [DIAGNOSES REDACTED]. Per interview, staff should wash hands with soap and water and apply clean gloves when going from dirty to clean for a resident with [MEDICAL CONDITION], or any resident. She stated, soiled linens should be bagged and not placed on the floor. She further stated if proper hand hygiene was not utilized during perineal care and administration of barrier cream, the barrier cream could become contaminated. Per interview, staff should always use proper hand hygiene and glove usage before, during and after performing peri care to prevent the spread of infection. Interview on 06/06/18 at 11:00 AM and 2:30 PM, with the Director of Nursing (DON) revealed she had been employed at the facility for a year and a half. She stated it was her expectation for all staff to follow the facility policies related to hand hygiene, contact precautions and perineal care. She stated this was important for the safety of the residents and the staff to prevent the spread of infection. Per interview, all staff were educated on facility policies at orientation and annually. The DON stated the policies were updated annually and signed by the Medical Director and kept in a binder accessible for staff to use. Continued interview with the DON, revealed a resident with a [DIAGNOSES REDACTED].#11, should be kept in his/her room and assisted with dining in his/her room as the [MEDICAL CONDITION] could not be contained outside of his/her room. Per interview, perineal care should be performed by washing hands, applying gloves, cleansing the resident, and then placing soiled linens and chux in a plastic bag. She stated after cleansing the perineal area, staff were to remove gloves, wash hands and don clean gloves before applying barrier cream in order to keep from contaminating the container. She revealed subsequently gloves should be removed and hands washed before any further care was provided to the resident. Continued interview revealed soiled items such a pillowcases, chux or linens should never be placed on the floor as this could be a potential source of infection for the resident or the staff. She further stated contaminated gloves should always be removed prior to contact with equipment and clean surfaces. Interview with the Administrator, on 06/06/18 at 2:22 PM, revealed it was her expectation for staff to follow facility policies related to infection control. She stated the infection control policies were to minimize the spread of infections for residents and staff and prevent facility acquired infections.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure Comprehensive Care Plans were revised to reflect residents' care needs for two (2) of thirteen (13) sampled residents (Residents #8, and #19) Resident #8's Comprehensive Care Plan was not revised related to increased depression resulting in an increased dosage of [MEDICATION NAME] antidepressant medication. In addition, Resident #19's Comprehensive Care Plan was not revised to reflect the resident no longer had to wear prevalon boots in the bed at all times, and was to wear the boots only at night. The findings include: Review of the Policy and Procedure titled Nursing Care Planning, undated, revealed each resident should have a comprehensive, person centered care plan reflecting the resident's psychosocial needs. 1. Review of Resident #19's medical record revealed the facility admitted the resident on 10/04/17 with [DIAGNOSES REDACTED]. Observation of Resident #19 on 06/03/18 at 11:22 AM, revealed an open area to the left side of the nose. Interview with Resident #19 at the time of observation, revealed he/she picked the skin and caused the abrasion. Observation of Resident #19 on 06/04/18 at 10:45 AM, during medication administration, revealed the resident stated he/she was anxious and requested anti-anxiety medication. When Licensed Practical Nurse (LPN) #1 administered medications, the resident stated he/she was pleased to get medication for anxiety symptom relief. Review of Resident #19's current Comprehensive Care Plan, initiated 10/19/17, revealed a problem of potential actual behaviors of picking at the face and body when triggered by anxiousness. The stated goal was to avoid medication side effects. The interventions included: assist with transfers; administer medications as ordered; use information from the resident's life story to identify interventions; medications for anxiety and depression; consistent care givers; redirection; calm environment; explanation of care; and therapeutic communication. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status of six (6) out of fifteen (15) indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as having no behaviors and no decreased mood. Further review revealed the facility assessed the resident as having [DIAGNOSES REDACTED]. Review of the Social Work Notes, dated 04/09/18, revealed at the last conversation with Resident #19's representative, no behavior pattern of picking at the skin nor changes in mood were discussed. Review of the Psychiatric Services, Psychiatric Follow-Up Evaluation, dated 04/10/18, revealed Resident #19 stated his/her depression had increased. Further review revealed the practitioner increased the dosage of [MEDICATION NAME] from 10 milligrams (mg) daily to to 20 mg daily. Further review of the Comprehensive Care Plan, revealed there was no documented evidence of a revision related to the resident's increased depression as per the Psychiatric Follow-Up Evaluation dated 04/10/18. In addition, there was no revision of the Care Plan for an intervention to monitor for the effectiveness of [MEDICATION NAME] medication following the increased dosage. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 12/10/15 with [DIAGNOSES REDACTED]. Review of the current Comprehensive Care Plan, initiated 11/14/17, revealed Resident #3 was at risk for impaired skin integrity. The goal stated the resident would be free of pressure ulcers. There were several interventions including Prevalon boots to bilateral feet while in bed. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having both short and long term memory loss and as severely cognitively impaired. Further review of the MDS, revealed the facility assessed the resident as at risk for pressure ulcers and as having no unhealed pressure ulcers. Observation of Resident #3, on 06/06/18 at 9:52 AM, revealed the resident was not wearing prevalon boots and staff assisted the resident to move heels off the mattress surface. During the observation, State Registered Nursing Assistant (SRNA) #1 stated the Prevalon boots were only applied at night because the resident kicked the boots off during the day. Interview with Registered Nurse (RN) #1 on 06/04/18 at 2:59 PM, who was assigned to Resident #3, revealed the resident no longer had heel wounds. Per interview, Heel protectors were only used at night to keep the resident's heels off the mattress surface. Further interview on 06/06/18 at 1:54 PM, with RN #1, revealed changes in residents were recorded in the Nursing Assistant Communication Book or the Twenty-Four (24) Hour Communication Book for nurses. RN #1 further stated he attended resident care meetings and discussed changes for specific residents. Interview with SRNA #3, on 06/06/18 at 1:15 PM, revealed she was a Care Coordinator for Faith House (the resident building where Residents #19, and #3 resided). She stated she documented general information and changes in the elders in her building. She further stated she attended clinical meetings and shared resident information with the clinical team. Interview with SRNA #4, on 06/06/18 at 1:50 PM, revealed if the Care Coordinator was not available the SRNA could document resident changes in the Communication Book. The Communication Book was used during clinical meetings to relay pertinent resident information to the clinical team. She further stated the Care Coordinator communicated care updates from the clinical meetings back to staff. Interview with the Minimum Data Set (MDS) Coordinator, on 06/06/18 at 3:07 PM, revealed she was new to her position. Per interview, her daily responsibilities included gathering the Twenty Four (24) Hour Report each morning, noting any significant resident changes, and taking the report to the daily morning clinical meeting for review. Per interview, the Report was used to communicate clinical changes to the team and to update Care Plans. The MDS Coordinator revealed she was not at the facility at the time of changes in Resident #19's depressed mood, and Resident #3 changes in skin care. However, she stated significant resident changes were important to include on the Care Plan to provide person centered care with the best resident outcomes. Interview with the Social Worker, on 06/06/18 at 10:45 AM, revealed she routinely discussed resident care with resident representatives. Per interview, the last conversation she had with the representative for Resident #19 was held prior to the reported increase in depression and change in medication. Per interview, Resident #3's care conference on 05/15/18 at 3:00 PM, included discussion of proper resident positioning. The Social Worker revealed the expectation of family representatives included care planning and implementation of identified changes in care from Care Plan Conferences. Interview on 06/06/18 at 8:19 AM, with the Director of Nursing (DON), revealed resident care needs were discussed daily in the morning clinical meeting and weekly at the Clinically At Risk meeting. She stated the initial Care Plan was completed by the admitting nurse, the Infection Control Practitioner, the MDS Coordinator, or the DON. The DON stated Care Coordinators in each resident house were responsible for communicating changes in residents to the team during morning clinical meetings. She further stated care plan changes in response to residents changing needs were made during those meetings by the MDS Coordinator or by the DON. Continued interview with the DON, revealed symptoms of depression and medication changes for Resident #19 should have resulted in an updated Care Plan and were just missed. The DON further stated since Resident #3 was currently wearing the Prevalon boots only at night, the timing for application of Prevalon boots should have been reflected on the Care Plan. Per interview, Care Plans were used as a communication tool by staff to ensure person centered care for each resident. She stated the Care Plan policy should be followed and Care Plans should be updated to reflect resident changes to obtain optimal outcomes for residents. Interview with the Administrator, on 06/06/18 at 2:22 PM, revealed she expected staff to follow the Care Plan Policy and update resident Care Plans when new problems were identified. The Administrator stated she would have expected increased depression, and changes in skin integrity approaches to be reflected in an updated Care Plan. She stated the Care Plan was used by staff to guide resident care and should have reflected significant resident changes. The Administrator further revealed the purpose of resident Care Plans was to ensure all significant resident care areas were communicated to staff and implemented to ensure optimal person centered care.

Based on observation, interview and review of the facility policy, it was determined the facility failed to store, prepare and serve food under sanitary conditions as determined by observations on 07/05/17 which revealed the sanitizer tests were not documented for Skilled Nursing Unit 1 and Skilled Nursing Unit 2. Continued observations on 07/06/17 of staff during lunch meal and snack preparation in the Skilled Nursing Unit 1 kitchen revealed staff did not have hair fully restrained or covered. Observation on 07/05/17 at 11:07 on Skilled Nursing Unit 2 and 07/05/17 at 12:00 PM on Skilled Nursing Unit 1 revealed there was no documentation of the sink sanitizer being tested . Observation on 07/06/17 at 8:30 PM on Skilled Nursing Unit 1 revealed State Registered Nursing Assistant (SRNA) #6 did not have her hair fully covered while in the kitchen. Continued observations on 07/06/17 at 12:15 PM revealed SRNA #5 was making cupcakes for the residents in the kitchen with no hair restraint. The findings include: 1. Review of facility policy titled Sanitizer Use Concentrations for Food Service and Food Production Communities dated 09/01/14, revealed quaternary solution should register two-hundred 200 Parts Per Million (PPM). The policy does not address documentation after using the test strip. Review of facility policy titled Pots and Pans-Sanitizing Solution dated 07/01/14 revealed, the sanitizer concentration should be tested with a test strip and to record the results on the designated form. Review of the Safety Data Sheet (SDS) titled Steramine 1-G tablets dated 09/24/13 revealed the tablets were dissolved at the ratio of one tablet per gallon of water to produce the two-hundred (200) Parts Per Million (PPM) concentration of Quaternary sanitizing solution required for sanitizing food contact articles and surfaces. Observation on 07/05/17 at 11:07 AM of the Skilled Nursing Unit 2 and on 07/05/17 at 12:00 PM of the Skilled Nursing Unit 1 revealed no documentation was in place to record the results of the sanitizer test. Interview on 07/05/17 at 11:07 AM and 07/05/17 at 1:19 PM with SRNA #2 and SRNA #1 on Skilled Nursing Unit 2, revealed they had been educated on the correct way to mix and test the sanitizer solution; however, was not educated on documentation of the test results. Interview on 07/05/17 at 2:33 PM with SRNA #3 on Skilled Nursing Unit 2, revealed the Chef/Support Services Manager brought a new form to document the results of the sanitizer tests. Interview on 07/05/17 at 12:00 PM with SRNA #4 revealed they used four (4) tablets in the sink to sanitize and the range should be one-hundred fifty (150) to four-hundred (400) PPM. The results of the sanitizer test were not documented. Interview on 07/06/17 at 8:30 AM with SRNA #6 on Skilled Nursing Unit 1, revealed there was no documentation of the sanitizer test results and could not prove the test has been done. Interview on 07/06/17 at 3:00 PM with the Chef/Support Services Manager, revealed his expectations was for the test results using the sanitizer strip to be recorded. The sanitizer test results should be two-hundred (200) to four-hundred (400) PPM. If the results of the sanitizer strip were not document then there was no proof the sanitizer was working according to industry standards and preventing a possible food-borne outbreak. 2. Review of facility policy titled Personal Hygiene dated 032/01/14, revealed facility guidelines should be followed to promote personal hygiene for a safe and sanitary department. Head coverings worn should be clean and cover the hair completely. Interview on 07/06/17 at 2:40 PM with SRNA #6 revealed she tried to keep her hair up and restrained while in the kitchen. Hair should be kept restrained to prevent hair coming in contact with residents' food which would be unsanitary and unpleasant for the residents. Observation on 07/06/17 at 8:30 PM on Skilled Nursing Unit 1 revealed SRNA #6 did not have her hair fully restrained while in the kitchen. Her pony tail was hanging unrestrained out of the hair restraint and down her back. Continued observations on 07/06/17 at 12:15 PM of SRNA #5 revealed she was making cupcakes for the residents in the kitchen with no hair restraint. Interview on 07/07/17 at 2:54 PM with SRNA #5 revealed she should have been wearing a hair restraint while she was making cupcakes because hair could fall into the cupcakes. Interview on 07/06/17 at 3:00 PM with the Chef/Support Services Manager revealed his expectations was for all staff to wear hair nets and have hair restrained in the hair nets while handling food supplies and preparing food. Interview on 07/07/17 at 3:40 PM with the Director of Nursing (DON) revealed her expectations was for the staff to follow policies for food preparation, hair restraints and use of sanitizer. Staff have received skills training in the areas of culinary skills, and safe food handling through Serve Safe. Staff also have been trained to wear hair nets while in the kitchen and she has reminded staff at different times to wear their hair nets. Interview on 07/07/17 at 4:00 PM with the Administrator revealed it was important for staff to wear hair nets to keep hair from falling into the food. The results of the sanitizer checks should be documented. If the results were not documented, it was not known if the sanitizer level was checked or if the sanitizer was at the correct strength.

Based on observation, interview and review of facility policies, it was determined the facility failed to properly store drugs and biologicals. Observation of the medication refrigerator on Skilled Unit 1, on 07/05/17 at 9:30 AM, revealed an opened bottle of Influenza vaccine which had no opened-date, and had an expiration date of April 2017 on the manufacturer's label. The findings include: Review of the facility's policy titled Influenza (Flu) Vaccination Information For Resident, undated, revealed residents will be offered the influenza vaccination each year between October and March 31st as recommended by the Centers for Disease and Prevention and as required by applicable state rules and regulations. Influenza vaccination will also continue to be offered if influenza is active in the area. Review of the facility's policy titled Medication Storage In The Facility, Pharmacy Services for Nursing Facilities, Revised August 2014, revealed when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be (30) days unless the manufacturer recommends another date or regulations/ guidelines require different dating. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. Observation of the medication refrigerator on the Skilled Unit 1, on 07/05/17 at 9:30 AM, revealed an opened, undated, multi-dose/ten (10) dose vial of Seqirus Fluvirin Influenza Vaccine Lot # 01 Expiration April 2017; the vial was approximately 75% full. The vaccine was immediately removed by the Director of Nursing (DON) after the observation. Interview with the DON, on 07/05/17 at 9:30 AM, revealed the pharmacist was supposed to check and remove any expired medications. She further stated the nurses would not have used the flu vaccine after it expired, and none was given after the flu season in March 2017. Interview with the Licensed Practical Nurse/Staff Development Coordinator/Infection Control Nurse, on 07/07/17 at 9:48 AM, in the medication room on the Skilled Unit 1, revealed the Influenza vaccine should have been thrown out by the nursing staff when it expired April 2017. Interview with Registered Nurse #1, on 07/05/17 at 11:30 AM, revealed flu season was over in March 2017, and no resident would have received a vaccine from the vial of Fluvirin that expired April 2017. She stated it should have been removed and discarded at the end of the flu season. Interview with the Pharmacist, on 07/07/17 at 10:40 AM, revealed he did not provide the facility with vaccines, like Influenza and Pneumonia, and he stated they were ordered by the facility from another supplier. He further stated since the vaccines were not products he supplied, he did not regulate, monitor, check them for expiration, or remove them from the active supply. Interview with the DON, on 07/07/17 at to 4:15 PM, revealed nurses should write the opened-date on all multi-dose medications when they are opened. Continued interview revealed it was the responsibility of both Nursing and the Pharmacy to monitor and remove any expired medications. She further stated nursing should have gotten rid of the Flu vaccine when it expired, and that no Flu vaccine had been given since it expired April 2017. She additionally stated she had just recently been made aware the facility could return expired vaccine to the manufacturer for credit, even if the vial had been opened. Further interview revealed even if the facility could return the opened and expired vaccine for credit, nursing should have removed it from the refrigerator. Interview with the Executive Director, on 07/07/17 at 4:18 PM revealed it was her expectation the nurses would follow their policy and date multi-dose medications when they were opened. Continued interview revealed regarding Influenza vaccine, she expected the nurses would check the expiration date before giving it; once they were sure the Flu season was over, and it was no longer recommended to be given, she expected the nurses would take the vaccine out the refrigerator to send it back to the supplier for credit.

Based on interview, record review and review of facility's policy, it was determined the facility failed to provide the location to which the resident was to be transferred or discharged in the Notice of Intent to Discharge for one (1) of four (4) sampled residents (Resident #1). A Notice of Intent to Discharge, dated 02/01/17, was presented to Resident #1's Power of Attorney (POA) on 02/01/17, stating the facility was writing to inform the POA of intent to discharge Resident #1 from the facility. However, the Notice failed to include in the contents of the letter the location to which the resident was to be transferred or discharged . The findings include: Review of facility Policy titled Christian Care Communities Discharge Policy, undated, under procedures five (5) Contents of the Notice, section (c) revealed the transfer and discharge requirement written notice shall include the location to which the resident is transferred or discharged . Review of Resident #1's medical record revealed the facility admitted the resident on 04/12/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 04/04/16, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #1's Notice of Intent to Discharge, dated 02/01/17, revealed the facility was writing to inform the Power of Attorney of intent to discharge Resident #1 from the facility as a result of ongoing concerns related to family conduct towards staff members creating an intimidating and harassing environment. Further review of the Notice, revealed the facility failed to include in the contents of the letter the location to which the resident was to be transferred or discharged . Interview on 02/09/17 at 4:32 PM, with the one of Resident #1's Power of Attorneys (POA's), revealed the Executive Director (ED) telephoned him on 01/27/17 and informed him both of the resident's POAs would be placed on supervised visits and would need to call before visiting to ensure a member of the management team was present for the visit. The POA further revealed the ED set up a meeting to discuss the issues in person and the meeting was held on 02/01/17 at 5:00 PM. The POA stated, during the meeting the ED handed him a Notice of Intent to Discharge. He further stated the letter did not provide information related to the location in which the resident would be discharged , and he was afraid the facility would send Resident #1 somewhere far away where he would not able to visit. Resident #1's POA revealed he transferred the resident to another facility because he was scared of where the resident might end up if the facility was in charge of the placement. Interview on 02/09/17 at 4:01 PM with the facility's ED, revealed as a result of concerns related to Resident #1's family/POAs behavior towards staff members, both the resident's POA's were placed on supervised visits. She stated, due to the POAs creating an intimidating and harassing environment, it was determined a member of the management team would need to be present whenever the POAs visited Resident #1 to ensure a safe environment for staff and residents, because the POA's were making the staff feel uncomfortable. The ED further stated the Notice of Intent to Discharge was only a draft to present to the POAs as an option because the facility could not sustain supervised visits over time. Further interview with the ED, revealed Resident #1's POAs requested a referral to another Nursing Facility and per family request, Resident #1 was discharged on [DATE] to the Nursing Facility in Lexington. Further Interview on 02/10/17 at 2:10 PM, with the facility's ED, revealed she was aware the Notice of Intent to Discharge which was given to the resident's POA's failed to contain the required location to which the resident was transferred or discharged because she meant for the discharge to be presented as an option. The ED revealed if no other options could be decided upon, she planned to draft a formal letter. The ED revealed the letter was given to the legal representative in error. Interview on 02/10/17 at 1:05 PM, with the Ombudsman, revealed the ED called and requested her attendance at the care plan meeting with the family of Resident #1 to discuss supervised visits. The Ombudsman stated, it was her impression the safety of the residents was not a concern and the facility had not attempted to take steps to address the staff concerns. Additional interview revealed it was her impression the ED intended for the Resident to be discharged and the facility was only willing to have supervised visits for the thirty (30) days until the discharge.

Based on interview, record review and review of facility's policy, it was determined the facility failed to permit residents to remain in the facility, and not discharge the residents from the facility unless the safety or health of the individuals in the facility were endangered due to the clinical or behavioral status of the resident; the transfer or discharge was necessary for the resident's welfare; or the resident's needs could not be met at the facility for one (1) of four (4) sampled residents (Resident #1). A Notice of Intent to Discharge, dated 02/01/17, was presented to Resident #1's Power of Attorney (POA) at a Care Plan meeting on 02/01/17 due to ongoing concerns related to family conduct towards staff members creating an intimidating and harassing environment. However, there was no documented evidence the safety or health of the individuals in the facility were endangered due to the clinical or behavioral status of the resident; or that the discharge was necessary for the resident's welfare; or that the resident's needs could not be met at the facility. The findings include: Review of facility policy titled Christian Care Communities Discharge Policy, undated, under procedures (c) revealed the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. Record review revealed the facility admitted Resident #1 on 04/12/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 04/04/16, revealed the facility assessed Resident #1 as having moderate cognitive impairment with a Brief Interview for Mental Status score of twelve (12) out of fifteen (15). Review of Resident #1's Notice of Intent to Discharge, dated 02/01/17, revealed the facility was writing to inform the Power of Attorney (POA) of the intent to discharge Resident #1 from the facility as a result of ongoing concerns related to family conduct towards staff members creating an intimidating and harassing environment. Interview on 02/09/17 at 4:32 PM, with one (1) of the POA's for Resident #1, revealed the Executive Director (ED) called him at home on 01/27/17 and informed him that due to concerns expressed by staff, both of Resident #1's POAs would be placed on supervised visits because they were asking probing questions of the staff and had made staff feel uncomfortable. The POA revealed, as a law enforcement officer, you better believe I am going to ask the names of who is taking care of my parent. The POA further revealed the ED told him it was inappropriate for him to go to the bathroom in front of staff members and not pull the curtain between the resident's bedroom and bathroom. The POA revealed he was in a wheelchair and it was difficult to pull the curtain. Per interview, the fact that I cannot go to the bathroom in my parent's private room is just ludicrous. The POA stated he was told both POAs would need to call before visiting to ensure a member of the management team was present during their visits with the resident. Further interview with Resident #1's POA, revealed he was confused upon receiving the phone call from the ED and requested additional information as he had not been informed of any concerns prior to 01/27/17. The POA stated the ED then set up a meeting to discuss the issues in person and the meeting was held 02/01/17 at 5:00 PM. The POA stated during the meeting, the ED handed him a Notice of Intent to Discharge. Resident #1's POA revealed he transferred Resident #1 to another facility because he was scared of where the resident might end up if the facility was in charge of the placement. Interview with Ezer (direct care staff) #1 on 02/09/17 at 3:09 PM, revealed one of Resident #1's POAs asked her first and last name and where she lived. She stated he probed for her exact street address and it made her feel uncomfortable. Ezer #1 revealed, on more than one occasion, she went to answer the call light for Resident #1 and one of the POAs was using the toilet without the curtain pulled. Interview with Ezer #2, on 02/09/17 at 3:29 PM, revealed both of Resident #1's POAs asked her name and where she lived. She stated when she indicated the city, one of them asked what street and she told him. She stated she told him she was moving soon and he asked where to? She revealed his questions made her feel uncomfortable. Interview on 02/09/17 at 4:01 PM, with the facility's Executive Director (ED), revealed as a result of ongoing concerns related to Resident #1's family/POAs towards staff members, the family/ POAs were placed on supervised visits. She stated, due to the resident's family/POAs creating an intimidating and harassing environment and making the staff feel uncomfortable, it was determined a member of the management team would need to be present whenever the family/POAs visited Resident #1. The ED revealed she did not take steps to correct the intimidating and harassing environment caused by Resident #1's family/POAs because the staff was already uncomfortable and she did not know what steps to take. Further interview on 02/10/17 at 2:10 PM, with the facility's ED, revealed staff did not fill out written Incident Reports related to Resident #1's family/POAs behavior and she had no documented evidence of the staff's concerns. The ED stated the staff talked with her verbally and she coached the staff on how to handle the intimidating behavior. The ED further revealed it was only staff that were uncomfortable and to her knowledge the residents had not been made uncomfortable. Continued interview revealed the Notice of Intent to Discharge was drafted to present to the family at Resident #1's care plan meeting only as an option because the facility could not sustain supervised visits over time. The ED revealed if no other options could be decided upon, she planned to draft a formal letter. Per interview, the letter was given to the legal representative in error. Continued interview with the ED, revealed Resident #1's family/POAs requested an admission referral to another Nursing Facility and per the request Resident #1 was discharged on [DATE] to that Nursing Facility. Interview on 02/10/17 at 1:05 PM, with the Ombudsman, revealed the ED called her on 01/31/17 and requested her attendance at the care plan meeting with the family/POAs of Resident #1 to discuss the supervised visits and the meeting took place on 02/01/17 at 5:00 PM. The Ombudsman revealed it was her impression the safety of the residents was not a concern and the facility had not attempted to take steps to address the staffs' concerns. Continued interview revealed it was her impression the ED intended for the Resident to be discharged and the facility was only willing to have supervised visits for the thirty (30) days until the discharge.