Every finding on record at The Meadows

Based on facility policy review, observation, and interview, the facility failed to label food according to facility policy and failed to ensure food preparation and storage equipment were kept in a sanitary condition. The facility also failed to maintain dietary equipment in proper working order related to sanitation levels in the three-compartment sink and ice build-up in the walk-in freezer. The deficient practices had the potential to affect each resident who received nourishment from the kitchen. Findings included: A facility policy titled Refrigerator And Freezer Storage, reviewed/revised 06/2025, revealed Refrigerated and frozen foods will be stored properly for optimal product safety. The policy revealed 9. a) Each center will have a system for date marking. Foods will be stored in their original container or a NSF [National Sanitation Foundations] approved container or wrapped tightly in moisture-proof film, foil, etc. [et cetera, and so forth]. Foods should be clearly labeled with the contents with the use by date and/or the date opened. A facility policy titled Cleaning Equipment last reviewed 06/2025, revealed Equipment must be cleaned and/or sanitized after every use and according to manufacturer' directions. A facility policy titled, Preventive Maintenance last reviewed 06/2025, revealed Preventative maintenance will extend the life of FNS equipment and should be scheduled and preformed [sic] on a routine basis. The policy revealed, 1. Equipment shall be maintained in good repair and condition. The policy also indicated, 2. The FNS Manager/Dietician will schedule routine preventive maintenance with the Maintenance Department. The policy revealed, 4. Items in FNS requiring immediate attention/repair include: refrigeration or freezer equipment to maintain foods at safe temperatures, any equipment to hold food at 135 F [degrees Fahrenheit] or greater (hot food table), frayed cords, ice build-up, etc. [et cetera, and other similar things]. These situations should be reported to the Maintenance Department immediately. 1. An observation in the walk-in refrigerator on 06/22/2026 at 9:16 AM revealed the following: - Cooked whole potatoes covered in clear plastic wrap with no label or discard date. - An uncovered container of salad consisting of lettuce and tomatoes. During the same observation, the walk-in freezer revealed the following: - A bag of cooked rice with no label or discard date. - A tray of stuffed peppers with no label or discard date. - A bag of zucchini sticks with no label or discard date. During an interview on 06/22/2026 at 9:16 AM, the Dietary Manager (DM) stated that staff knew to label and cover items before leaving them in the refrigerator or freezer. During an observation on 06/24/2026 at 9:18 AM, there were nine plates of salad stored in the walk-in refrigerator with no label or discard date. During an interview on 06/24/2026 at 9:18 AM, the Registered Dietitian (RD) stated that food stored in the refrigerator and freezer should have a date on them. 2. During a concurrent observation of the high temperature dish machine and interview on 06/22/2026 at 8:55 AM, the top of the dish machine was covered with white dusty debris. The Dietary Manager (DM) stated that the dish machine was to be cleaned daily. An observation of the kitchen on 06/22/2026 at 9:11 AM revealed the following: - The food preparation table located in the kitchen in front of the stove had an open area on the left that was covered with debris. - There were three white storage containers with clear lids that stored cornmeal, sugar, and flour. All three containers were sticky and covered in grime. - The outside of the two-level convection oven was noted to be sticky and covered in grime. - The side-by-side dual entry reach-in refrigerator was sticky and covered in grime. An observation of the kitchen on 06/22/2026 at 9:16 AM revealed the walk-in refrigerator had two fans located in the back of the unit that was noted to be blowing air and covered in a white dusty substance. During an interview on 06/22/2026 at 9:34 AM, the DM stated that there was a schedule for cleaning the appliances but that he was unsure as to where the schedule was. An observation of the kitchen on 06/24/2026 at 9:13 AM revealed the following: - The left side open area of the food preparation table located in front of the stove was still covered with debris. - The outside of the convection oven was still sticky and covered in grime. - The side-by-side dual entry reach-in refrigerator was still sticky and covered in grime. During an observation on 06/24/2026 at 9:18 AM, the walk-in freezer still had a white dusty build-up on the two fans blowing from the back of the freezer. During an interview on 06/24/2026 at 9:15 AM, the Registered Dietician (RD) stated that she was unsure of the cleaning schedule. During an interview on 06/26/2026 at 7:10 AM, the DM stated that he had staff that should have been cleaning the equipment, but he did not have a deep cleaning schedule. The DM stated that the kitchen staff were trained to not put unlabeled and undated food in the refrigerator or freezer. The DM stated that no matter what time of day it was, food should be labeled and dated. He stated that he expected the kitchen to be cleaned on a daily basis, swept, mopped, and all of the sanitation needs taken care of. 3. A test strip guide titled, Sink & Surface Cleaner Sanitizer Test Strips How-To Guide, dated 2021, revealed, The test strips will only work with Sink & Surface Cleaner Sanitizer and cannot be used with other products. The guide indicated that the approved active range of dodecylbenzene sulfonic acid (DDBSA) was 272 to 700 parts per million (ppm). An observation of the facility's three-compartment sink on 06/22/2026 at 9:11 AM revealed the Dietary Manager (DM) used a test strip to test the contents of the sanitizer in the sink. The test revealed no reading on the strip. An observation on 06/22/2026 at 9:32 AM revealed Lead [NAME] (LC) #4 refilled the sanitizer section of the three-compartment sink, then retested the sanitizer solution using the test strips, and the test strips revealed no reading. During a concurrent interview on 06/22/2026 at 9:34 AM with the DM and LC #4, LC #4 stated that she had filled the sanitizer sink two times, and she was still not getting a reading with the test strips. LC #4 stated that the sanitizing chemical was put in the sanitizer section of the sink, and she did not know why it was not registering a reading. LC #4 stated that she washed all the pots and pans in the three-compartment sink. The DM stated that he was not sure why the strips were not reading the chemical in the sanitizer sink. An observation on 06/24/2026 at 9:04 AM revealed LC #4 ran the sanitizer mixture into the three-compartment sink. LC #4 dipped a test strip into the sanitizer compartment of the sink for approximately eight seconds and removed it. The observation revealed that the test strip did not reveal a reading. An observation on 06/24/2026 at 9:05 AM revealed LC #4 turned the knob on and off on the box that mixed and dispensed the water and sanitizer solution into the sink. The observation revealed LC #4 dipped another test strip into the sanitizer compartment of the sink for approximately eight seconds, and the test strip did not reveal a reading. The observation revealed the label on the test strip bottle indicated an expiration date of August 2022. During a concurrent interview with the Registered Dietician (RD) and LC #4 on 06/24/2026 at 9:06 AM, the RD stated that there was a newer bottle of strips, but those strips also did not read the chemical. LC #4 stated that if the three-compartment sink was not working, she let her supervisor know. During an interview on 06/24/2026 at 9:07 AM, the RD stated that at that point, she needed to reach out to the vendor who supplied the sanitizer and maintained the equipment in the kitchen. The RD stated that she was not sure how the items would be sanitized if the three-compartment sink was not working. An observation on 06/24/2026 at 9:10 AM revealed LC #4 placed a new test strip straight from the hose that dispensed a mixture of water and sanitizing chemical into the sink and was able to get an appropriate reading. LC #4 then used a new test strip and tested the mixture in the sink, which resulted in no reading on the strip. During an interview on 06/24/2026 at 11:25 AM, the Regional Dietician Consultant (RDC) stated that the tap may have been running while filling the sink and that it would have diluted the sanitizing mixture in the sink. She stated that if the test was not meeting appropriate levels, then the staff could add additional sanitizer directly from the bottle. During a concurrent interview and observation on 06/24/2026 at 11:30 AM, LC #4 stated that she had not left the tap running while filling the sanitizer sink. At this time, LC #4 used a new test strip to test the mixture in the sanitizer sink and obtained a result of up to 170 ppm. During an observation on 06/24/2026 at 11:40 AM, the sanitizer sink was noted to be empty. LC #4 filled the sink with the sanitizer and water mixture running directly from the mixing hose into the sink. LC #4 used a new test strip to stir the contents of the sink for approximately eight seconds, which resulted in a reading within the range of 272-700 ppm. At this time, the RDC stated that she had the vendor coming out to check the 3-compatment sink system. During an interview on 06/26/2026 at 7:10 AM the DM stated that he was not aware of the sanitizer section of the three-compartment sink testing incorrectly. The DM stated that the process was to ensure that the chemical was coming out correctly. The DM stated that the vendor that maintained the kitchen equipment came quarterly and checked areas of the kitchen, which included the three-compartment sink. The DM stated that he expected kitchen equipment to work correctly. The DM stated that maintenance staff should be contacted if something was not working. The DM stated that he expected the kitchen staff to let him know if something was not working. 4. An observation of the walk-in freezer on 06/22/2026 at 9:16 AM revealed ice build-up and icicles under the right fan, and water was leaking from the fan onto sealed food. During an interview on 06/22/2026 at 9:16 AM, the Dietary Manager (DM) stated that the walk-in freezer went into defrost mode automatically, and the defrost mode was set by maintenance staff. The DM stated he was not aware of water leaking into boxes. An observation of the walk-in freezer on 06/24/2026 at 9:20 AM revealed the freezer had ice build-up and icicles on the right fan. During an interview on 06/25/2026 at 11:15 AM, the Regional Plant Operations (RPO) stated that the walk-in freezer was programmed by the manufacturer to defrost every four hours. The RPO stated that once defrosted, the system automatically cut off the defrost switch unless it sensed more ice. The RPO stated that he could not diagnose the problem because he had not seen the walk-in freezer and that a vendor would be there that day. During an interview on 06/26/2026 at 7:10 AM, the DM stated that vendor that maintained the kitchen equipment came in quarterly and checked areas of the kitchen, which included the walk-in freezer. The DM stated that he was aware that there was ice build-up in the freezer and reported it in the centralized building operations, compliance, and maintenance system. The DM stated that he expected kitchen equipment to work correctly. The DM stated that maintenance staff should be contacted if something was not working. The DM stated that he expected the kitchen staff to let him know if something was not working. During an interview on 06/26/2026 at 7:55 AM, the Director of Nursing (DON) stated that there was a process in maintaining the kitchen and that the RD and DM worked hard at checking expirations dates and cleaning the kitchen. She stated that she expected the kitchen staff to follow the process and sanitation to be upheld. During an interview on 06/26/2026 at 8:08 AM, the Administrator stated that the facility process was to have regular cleaning and maintenance, which he deferred to the DM. He stated that the process was regular daily cleaning, and for staff to label and date food items when they were opened. He stated that he expected there to be proper supervision in the kitchen to get concerns remedied as soon as possible.

Based on facility policy review, observation, and interview, the facility failed to maintain 1 of 1 six-burner stove in safe operating condition. Findings included: A facility policy titled, Preventive Maintenance last reviewed 06/2025, revealed Preventative maintenance will extend the life of FNS equipment and should be scheduled and preformed [sic] on a routine basis. The policy revealed, 1. Equipment shall be maintained in good repair and condition. The policy also indicated, 2. The FNS Manager/Dietician will schedule routine preventive maintenance with the Maintenance Department. An observation of the six-burner stove in the facility's kitchen on [DATE] at 9:15 AM revealed that when the stove's knob for the rear middle burner was turned to the on position, the burner did not light, and there was no pilot light lit. During an interview on [DATE] at 9:15 AM, Lead [NAME] (LC) #4 stated that if the pilot light was out, she typically just got a lighter to light the burner with. During an interview on [DATE] at 7:10 AM, the Dietary Manager (DM) stated that he was not aware of the pilot light being out on the stove. The DM stated that the process was to put any issues in the electronic maintenance system to have maintenance staff look at it. The DM stated that a vendor that maintained the kitchen equipment came in quarterly and checked areas of the kitchen, which included the stove. The DM stated that he expected kitchen equipment to be working correctly. The DM stated that maintenance staff should be contacted if something was not working. The DM stated that he expected the kitchen staff to let him know if something was not working. During an interview on [DATE] at 8:08 AM, the Administrator (ADM) stated that there was a regular process for maintenance of the kitchen, and he deferred to the DM for that process. The ADM stated that he expected proper supervision in the kitchen to identify any malfunctioning equipment and get it fixed immediately. The ADM stated his expectation was for supervision to get concerns remedied as soon as possible.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper Personal Protective Equipment (PPE) was used when entering 1 of 5 Transmission Based Precautions (TBP) rooms, and failed to properly clean 1 of 4 TBP rooms on the Covid Unit. The facility also failed to ensure an indwelling urinary catheter collection bag was kept off of the floor for 1 of 8 sampled residents (Resident #240) reviewed who required an indwelling urinary catheter. Review of the facility's undated policy titled, Catheter Care, Urinary, revealed, .purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . Review of the facility's Infection Control Manual Volume 1, updated 2/2022, revealed, .Prevention of Infection .Infection Control policies and procedures are developed for practice by partners to aid in the prevention and control of infectious processes . Review of undated facility's policy titled, 502 Patient Rooms-Routine Cleaning (High-touch surfaces, floors, and bathroom) revealed, .With a clean microfiber mop or clean cotton mop, using Neutral Disinfectant Cleaner, mop the floor beginning in the far corner of the room. Be sure to move furniture, clean under the bed, moving toward the bathroom and the door . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Droplet/Contact isolation precautions (DX: PRESUMPTIVE COVID 19) Special instructions: All care provided in room by staff . Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed she was in the room with Resident #29, who was in isolation for Presumptive COVID-19. Observation and interview outside Resident #29 and #61's room on 9/19/2022 at 1:20 PM, revealed Licensed Practical Nurse (LPN) #4 exiting the room wearing a surgical mask and a face shield. When asked what the isolation sign on the door said, she stated, It says you should wear a N95 [NIOSH National Institute of Occupational Safety and Health] mask, gown, gloves and face shield. When asked where the Personal Protective Equipment (PPE) for the resident room was, she stated, I don't see any PPE outside of the room. Observation and interview outside Resident #29 and #61's room on 9/19/2022 at 1:30 PM, revealed the Social Service Director (SSD) for B Wing in the resident's room assisting Resident #61 up in the bed. The SSD was wearing a surgical mask and face shield. She was not wearing a gown or gloves. When asked what PPE she should be wearing she stated, I should have an N95 mask, a gown and gloves on. During an interview with LPN #1, also known as the Unit Manager, she confirmed Residents #29 and #61 were on Droplet Isolation precautions because they may have been exposed to Covid-19. She confirmed any staff member who entered the room should be wearing an N95 mask, gown, eye protection or face shield, and gloves. When asked if she had been in their room today she stated, I passed meds to them this morning and I did not wear an N95 mask or a gown. Observation in the Covid Unit on 9/19/2022 at 11:49 AM, Certified Nursing Assistant (CNA) #4 cleaned an empty TBP Room, #A-20, after a resident was transferred off of the Covid Unit. CNA #4 did not mop the floor. During an interview on 9/19/2022 at 11:52 AM, CNA #4 confirmed she did not mop the floor in Room #A-20. During an interview on 9/20/2022 at 10:55 AM, the Environmental Services Director stated she trained the nursing staff to clean the TBP rooms on the Covid Unit. She stated, When a room is empty the room should be deep cleaned, all surfaces cleaned with disinfectant, and floors swept and mopped per policy. During an interview on 9/21/2022 at 1:16 PM, the DON confirmed the CNAs were trained and responsible for cleaning the TBP rooms in the Covid Unit. She stated she expected the TBP rooms to be cleaned and the floor to be mopped prior to admitting new residents. Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident #240's room on 9/20/2022 at 10:38 AM, revealed her catheter bag was laying on the floor full of urine on the right side of the bed. Observation and interview in Resident #240's room on 9/20/2022 at 10:45 AM, revealed her catheter bag continued to be laying on the floor beside the bed. During an interview, the Director of Nursing (DON) confirmed the catheter bag was laying on the floor. Observation and interview in Resident #240's room on 9/20/2022 at 3:56 PM, revealed Resident #240 in bed with her catheter bag laying on the floor beside the bed. During an interview, Registered Nurse (RN) #3 confirmed the catheter bag was laying on the floor beside the bed.

Based on facility policy review, observations, and interview, the facility failed to maintain sanitary dietary equipment related to unclean dry food storage bins; failed to label dry food storage bins; and failed to label and date leftover food kept in the walk-in refrigerator. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, revealed, .Foods will be stored in their original packages, if possible. Products that are not easily identified should be clearly labeled with the common name of the food when removed from original packages .All ready-to-eat food prepped in-house and leftover, cooked food items must be labeled with the following information: name of food item and the date by which it should be eaten or discarded . Observation and interview in the Dietary Department on 9/19/2022 at 11:25 AM, the Registered Dietician (RD) confirmed 2 storage bins 1/4 full of food in the dry storage room were not labeled. Continued interview, the RD confirmed the storage bins had an accumulation of dried brown debris on the top of the bins. Observation and interview in the Dietary Department on 9/19/2022 at 11:27 AM, the RD confirmed a bowl of rice was not dated; 1/2 peanut butter sandwich and 1 bowl of broccoli were not dated or labeled. Observation and interview in the Dietary Department on 9/19/2022 at 2:00 PM, the Dietary Manager confirmed 2 of the dry storage bins were not cleaned or labeled and continued to have an accumulation of dried brown debris on top of the bins.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to obtain a physician's order for 1 of 42 sampled residents (Resident #61) reviewed. The findings include: Review of the facility's policy titled, Documentation Guidelines-Orders, reviewed and updated 10/2021, revealed, .The center must ensure that the written medical care of each patient is supervised by a physician. Written and verbal orders constitute the attending physician's directions for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . All written orders will be scanned into the EHR . Review of the medical record for Resident #61 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Physician Order Report for Resident #61 revealed no order for droplet isolation precautions. Observation on 9/19/2022 at 1:20 PM, revealed an isolation sign on the door of Resident #61's room indicating the staff must use precautions when entering the room and caring for residents on Droplet Isolation. During an interview on 9/19/2022 at 1:35 PM, with Licensed Practical Nurse (LPN) #1, also known as the Unit Manager, she confirmed Resident #61 was on Droplet Isolation precautions because she may have been exposed to Covid-19. She confirmed any staff member who entered the room should be wearing an N95 (NIOSH-National Institute of Occupational Safety and Health) mask, gown, eye protection or face shield and gloves. During an interview on 9/21/2022 at 9:49 AM, the Director of Nursing (DON) confirmed there was no physician's order for isolation for Resident #61.

Based on facility policy review, medical record review, observations and interviews, the facility failed to provide accurate documentation in the medical record for 1 of 42 sampled residents (Resident #240) reviewed. The findings include: Review of the facility's policy titled, Section VIII: NURSING SERVICES, reviewed and updated 10/2021, revealed, The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions, and responses in the patient's individual medical record .Documentation Purpose: Accurately reflect care given .What information should the nurse document? 6) All treatments and procedures noted after they have been done . Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for Resident #240 dated 9/1/2022-9/20/2022, revealed, .Perineal Drain-cleanse with normal saline, pat dry, apply drain sponge daily . had been documented as administered by Licensed Practical Nurse (LPN) #3 on 9/20/2022. Observation and interview in Resident #240's room on 9/20/2022 at 3:56 PM, revealed there was no dressing present on the Perineal Drain for Resident #240. During interview Registered Nurse (RN) #2 confirmed there was no sponge dressing present on the Perineal Drain for Resident #240. During an interview on 9/20/2022 at 10:55 AM, LPN #3 stated she had not been in room #B-34 to provide care for Resident #240 since beginning work at 6:00 AM. She stated the resident's medication was not scheduled during her shift. She stated the resident did not have any treatments ordered for her to provide. During an interview on 9/20/2022 at 3:16 PM, LPN #3 stated Resident #240 had been moved back to her room on B Closed Hall. She stated she did not provide any medications or treatments to the resident during her shift because all of the resident's medications were ordered at 5:00 AM. During interview on 9/20/2022 at 3:50 PM, the Director of Nursing reviewed Resident #240's TAR dated 9/1/2022-9/20/2022 with LPN #3 present, and confirmed LPN #3 had documented administration of a treatment due 6:00 AM-6:00 PM. She stated the documentation indicated the treatment had been done prior to being noted on the TAR. LPN #3 confirmed she had not completed the treatment administration.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide Activities of Daily Living (ADL) care for 1 of 42 sampled residents (Resident #240) reviewed. The findings include: Review of the facility's undated policy titled, Activities of Daily Living (ADL), Supporting, revealed, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed the assessment was coded for Discharge assessment-return anticipated. Continued review revealed Resident #240 had an indwelling catheter and an ostomy. Continued review revealed the resident had a continuously present altered level of consciousness and required extensive to total dependence with all ADLs. Review of the current Care Plan for Resident #240 revealed interventions for Activities of Daily Living: Limited ability to perform self-care. Goal included, .Will have clean, neat appearance daily . Observation and interview in Resident #240's room on 9/20/2022 at 10:38 AM, revealed she was lying in bed with her hair unkempt, with various fruit pieces and oatmeal scattered and smeared on her gown and bed linens. There was dried food debris on her fingers and around her mouth. Resident #240's catheter bag was lying on the floor full of urine on the right side of the bed. Observation and interview in Resident #240's room on 9/20/2022 at 10:45 AM, the Director of Nursing (DON) confirmed there was food scattered around the bed, on the resident's bed linens and gown, and the catheter bag was lying on the floor. During an interview on 9/20/2022 at 10:55 AM, Licensed Practical Nurse (LPN) #3 stated she had not been in Resident #240's room to provide care for her since beginning work at 6:00 AM. During an interview on 9/20/2022 at 10:56 AM, Certified Nursing Assistant (CNA) #3 stated she had not been in Resident #240's room since delivery of her breakfast meal sometime around or before 8:00 AM. She stated she did not assist Resident #240 with eating. She stated she waits until after she has provided care to everyone else to enter the isolation rooms to provide routine care of the residents.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASARR), dated on 11/2016, revealed, .For those patients found nursing facility appropriate under the Level II review, the Center should incorporate the recommendations from the PASSAR Level II determination and evaluation report into the patient's assessment, care planning, and transitions of care. Center should refer any patient for Level II resident review upon a significant change in status/condition such as newly evident or possible serious mental disorder, intellectual disability or a related condition . Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the resident received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #35 received an antipsychotic over the last 7 days. Review of Resident #35 current Order Summary Report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35 Level II PASARR dated 2/21/2017 revealed, .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/20/2022 at 1:08 PM, the Social Services Director confirmed Resident #35 had a Level II PASARR completed on 2/21/2017 for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, medical record review, and interviews, the facility failed to report an injury of unknown source for 1 of 42 sampled resident (Resident #7) reviewed. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with revision date 12/11/2017 revealed .Injuries of Unknown Source: An injury should be classified as a [injury of unknown source] when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and, the injury is suspicious because of the extent of the injury or the location of the injury [ .the injury is located in an area not generally vulnerable to trauma] or the number of injuries observed at one particular point in time or the incidence of injuries over time .Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect .any allegation [or] indication of possible willful infliction of injury to include unexplained bruising .any partner having either direct or indirect knowledge of any event that might constitute abuse .must report the event immediately, but no later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury .It is the policy of this facility that [abuse] allegations [abuse, neglect, exploitation or mistreatment, including injuries of unknown source] .are reported immediately, but not later than 2 hours . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 required extensive assistance of two+ persons for bed mobility and transfers. Further review of the MDS revealed Resident #7 required total assist of one person physical assist with toileting and two+ person assist with bathing. Review of the current Care Plan for Resident #7 revealed care plans which included risk for behaviors, rejection of care, risk for falls, and cognitive loss/Dementia. Review of the Resident Progress Notes dated 6/20/2022 through 6/21/2022, revealed, .6/20/2022 10:20 AM Right leg noted with increased warmth, swelling an [and] discoloration from knee to ankle .Nurse Practitioner [NP] here to see new order received .venous ultrasound of right lower extremity .Premier Radiology notified and states they cannot obtain until Tuesday or Wednesday .6/20/2022 8:01 PM Resident continues to display bruising to interior thighs and BLE [Bilateral Lower Extremities]; FNP [Facility Nurse Practitioner] visited resident earlier in the day regarding bruising concerns .6/21/2022 6:52 AM Right Lower Extremity continues with increased warmth, [CONDITION(S)] from right knee to right foot and discoloration from right inner thigh to right inner ankle .6/21/2022 12:45 PM Results of x-ray obtained on 6/21/2022 with the following impression: Evaluation .findings are concerning for an acute lateral tibial plateau fracture . Review of the Resident Progress Notes for NP dated 6/20/2022 at 2:33 PM, revealed, .6/20/2022 at 2:33 PM .Patient seen for right lower extremity [CONDITION(S)], [CONDITION(S)] and warmth. Patient has multiple bruises in various stages of healing noted to her right ankle lower extremity extending from her medial ankle, calf, knee and thigh. Right knee has swelling and warmth .staff report no recent trauma .Patient unable to verbalize pain related to her cognitive status but did grimace during exam with palpation to RLE [Right Lower Extremity] areas .New orders .X-ray right knee for increased swelling, decreased ROM [Range of Motion] . Review of the SNF/NF [Skilled Nursing Facility] Transfer Form dated 6/21/2022, revealed, .Reason for transfer Fracture of right lower extremity . Review of the hospital computed tomography dated 6/21/2022, revealed, .Acute fractures of the RIGHT proximal tibia and fibula . During an interview on 9/21/2022 at 1:05 PM, the Director of Nursing confirmed, We treated the incident as an injury of unknown origin, so we investigated the injury. During an interview on 9/21/2022 at 3:00 PM, the Administrator confirmed, I was notified of the injury. I was unaware of how it occurred. The Administrator confirmed the State Agency was not notified of the injury.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment for 1 of 66 rooms (room B-34) reviewed. The findings include: Review of the facility's undated policy titled, 502 Patient Rooms-Routine Cleaning (High-touch surfaces, floors, and bathroom), revealed, .Routine cleaning of patient areas occurs while the patient is admitted , focuses on patient zones, and aims to remove organic material and reduce microbial contamination to provide a visually clean environment .At least once daily, high-touch surfaces, floors, and handwashing sinks should be cleaned .Clean other surfaces of the bathroom, including grab bars, shower fixtures, walls .check restroom for toilet tissue . Review of the facility's policy titled, Quality of Life-Homelike Environment, revised 5/2017, revealed, .Residents are provided with a safe, clean, comfortable and homelike environment .Staff shall provide person-centered care that emphasizes the residents' comfort .clean, sanitary and orderly environment . Review of the medical record revealed Resident #21 was admitted on [DATE] with diagnoses which included Acute Respiratory Disease, Hypertensive Heart Disease, and Cerebral Infarction. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Observation of room #B-34 on 9/20/2022 at 8:00 AM, revealed the room had debris on the floor and was sticky and there was a meal tray on top of the trash can. The tops of the overbed tables were dirty with shiny dried substance. Observation and interview in room #B-34 on 9/20/2022 at 10:38 AM, revealed a bag of dirty linen and a bag of trash beside the door sitting on the floor. Debris which included spilled water and milk, various fruit pieces and oatmeal was scattered on the floor around B bed. Fruit pieces were smeared across the wall on the left side of the bed. There were cartons containing the leftovers from breakfast on the bedside table. Resident #240's catheter bag was lying on the floor full of urine on the right side of the bed. There was not a trash can beside the door to dispose of used Personal Protective Equipment (PPE). Observation in the bathroom revealed black and red debris around the base of the shower walls and on the floor of the shower. The equipment used to hold the shower head was off of the bracket and lying on the soap dish. There were two empty toilet paper rolls on the holder and a small roll of toilet paper placed on top of the handrail. During an interview, Resident #21 stated no one had cleaned the room in several days. She stated she tried to keep things picked up off the floor and around her side of the room. Observation and interview in room #B-34 on 9/20/2022 at 10:45 AM, revealed the room continued to be dirty, Resident #240's catheter bag continued to be laying on the floor beside the bed. During an interview, the Director of Nursing (DON) confirmed there was food scattered around the bed, on the bed and the catheter bag was laying on the floor. She confirmed there was black and red debris, which had the appearance of mold, around the bases of the shower wall and on the floor of the shower. Observation and interview in room #B-34 on 9/20/2022 at 10:50 AM, the Environmental Services Director stated the black and red debris around the base of the shower and shower floor appeared to be mold or mildew. She confirmed there were two empty toilet paper rolls in the holder.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement a Care Plan for 3 of 42 sampled residents (Residents #29, #61 and #240) reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Incorporate identified problem areas .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The Interdisciplinary Team must review and update the care plan: When the resident has been readmitted to the facility from a hospital stay; and at least quarterly . Review of the medical record for Resident #29 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Droplet/Contact isolation precautions (DX: PRESUMPTIVE COVID 19) Special instructions: All care provided in room by staff . Review of the Care Plan for Resident #29 revealed no care plan problem for droplet isolation precautions. Review of the medical record for Resident #61 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current Care Plan for Resident #61 revealed no care plan problem for isolation precautions. Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #240 had an Indwelling catheter and an Ostomy. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Routine Ostomy Care . Review of the Care Plan for Resident #240 revealed no care plan problem for a Suprapubic Catheter and/or Ostomy. Observation on 9/19/2022 at 1:20 PM revealed an isolation sign on the door of Residents #29 and #61's room indicating the staff must use precautions when entering the room and caring for residents in Droplet Isolation. During an interview on 9/19/2022 at 1:35 PM with LPN 1, also known as the Unit Manager, she confirmed Residents #29 and #61 were on Droplet Isolation precautions because they may have been exposed to Covid-19. During an interview on 9/20/2022 at 4:20 PM, MDS Coordinator/Licensed Practical Nurse (LPN) #5 confirmed Resident #240's care plan did not have an indwelling catheter or ostomy problem. During an interview on 9/20/2022 at 4:25 PM, the Director of Nursing (DON) confirmed there was not an indwelling catheter or ostomy problem on the care plan for Resident #240. During an interview on 9/21/2022 at 9:49 AM, the DON confirmed there was no care plan problem for droplet isolation precautions for Residents #29 and #61.

Based on facility policy, cleaning schedule, observation and interview the facility failed to keep 4 of 4 ice machines clean and sanitized. The findings included: Review of the facility Work History Report revealed, .Ice Machines/Ice Bins: Check filters (if present), clean coils, sanitize interior, delime as necessary .Marked done on-time by [Named Maintenance Director] on 8/3/2021, again on 4/8/2021, and again on 1/31/2021. Review of facility Kitchen Checklist revealed the kitchen staff is responsible for cleaning the exterior of the ice machine. During an observation on 10/6/2021 at 09:04 AM on A Wing Left in Clean Utility Room, revealed an ice machine was noted to have multicolored debris on the plastic parts located in water trough. The plastic piece across the vertical trough had visible debris. The back wall of the interior of the ice machine, had specks of brown/black debris. During observation on A Wing Right hall on 10/06/2021 at 9:04 AM, the ice machine was noted to have multicolored debris on the plastic parts located in water trough. The plastic piece across the vertical trough had visible debris. The left side wall (inside) has visible brown/black debris and there are multiple specks of black debris across the back wall, below the water trough. There was debris in the bottom of the ice scoop bin. During an observation on 10/6/2021 at 9:07 AM on B Wing Closed in Clean Utility Room, revealed an ice machine that was out of order. Observation and interview on 10/6/2021 at 9:35 AM in the kitchen with the Dietary Manager, revealed an ice machine with a dark colored spot of debris inside the ice machine at the ice level. When the Dietary Manager was asked what the spot was, he took his thumb and wiped it, looked at the spot on his finger and stated, It's dirt. Observation of the ice scoop bin attached to the ice machine revealed debris in the bottom of the bin. When the Dietary Manager was asked what he saw in the ice scoop bin, he stated, Debris. I will get it cleaned right away. When asked who was responsible for cleaning the ice machine and ice scoop bin, he replied, The kitchen staff is. During observation and interview on 10/06/2021 at 10:13 AM, in the clean utility room on B wing open hall, the Regional Administrator confirmed there was discolored areas present on the plastic piece located in a water trough of the ice machine and along the vertical plastic piece in the water trough. He confirmed the bottom of the ice scoop bin had debris present. During observation in the A wing right hall clean utility room, the Regional Administrator confirmed there is discoloration of the left inside wall of the ice machine then confirmed there was dirt or dust present on the paper towel he used to wipe the area. During observation in the clean utility room on A wing left hall, the Regional Administrator confirmed there is debris along the vertical plastic piece in the water trough.

Based on facility policy review, medical record review, review of facility investigation, and interviews, the faciity failed to ensure a resident was safe and free from physical abuse when Resident #2, with a history of physical aggression, impaired cognition, and wandering, entered the room of Resident #1 and struck her on the arm causing a skin tear as well as anxiety, resulting in harm to Resident #1. The harm affected 1 of 3 residents (Resident #1) reviewed for abuse. Findings include: Review of facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 12/11/2017, revealed .the patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation .abuse is defined as the willful infliction of injury .instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .misappropriation of patient property: the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a patient's belongings or money without the patient's consent .the facility will provide supervision and support services designed to reduce the likelihood of abusive behaviors .patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict .identification of patients whose personal histories render them at risk for abusing other patients or partners .assessment of appropriate intervention strategies to prevent occurrences .monitoring the patient for any changes that would trigger abusive behavior .dementia management program as needed. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, dated 7/18/2020, revealed Resident #1 exhibited changes in mood due to her anxiety disorder, with interventions including: to encourage the resident to effectively express sadness, anger, and feelings of loss; to honor preferences; to observe the environment for stressors and to intervene as needed. Medical record review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. No [CONDITION(S)] or delusions noted. Extensive, two-person assistance was required for bed mobility and toileting. Review of the Weekly Skin Observation, dated 3/7/2021, revealed Resident #1 did not have a skin tear and no other skin issues were noted. Review of the Facility's Investigation, dated 3/12/2021, revealed on 3/11/2021 at 6:20 PM, '' .staff overheard Resident #1 yelling from her room. Upon entering the room, Resident #1 stated, he hit me. Resident #1 was observed to have a skin tear, located on the left forearm, measuring 2.5 centimeter (cm). The residents were immediately separated .Resident #2 was transferred to a local emergency room (ER) for evaluation and awaited psychiatric placement. The local police department was notified of the incident. Review of a Nursing Progress Note, dated 3/11/2021 at 6:20 PM, revealed the nursing staff reported Resident #1 had a skin tear, located on her left arm, a result of another resident (Resident #2) hitting her. Upon entering the room, Resident #1 stated, that man was going to hit me in the face and I raised my arm and he hit my arm. Review of a Nursing Progress Note, dated 3/11/2021 at 9:32 PM, confirmed during bedtime medication administration (following the incident), Resident #1 was anxious and worried about someone coming into her room, when she heard noises coming from the hallway. Further review revealed [MEDICATION(S)] and Tylenol were administered and effective. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tablet, by mouth, as needed for anxiety. Review of the Weekly Skin Observation, dated 3/11/2021 at 8:40 PM, revealed Resident #1 had a skin tear, located on the top, left forearm, measuring 2.5 cm. Review of a Nursing Progress Note, dated 3/12/2021 at 12:20 AM, revealed the resident complained of left shoulder pain; that it hurt when she elevated her arm. Review of the Treatment Administration Record (TAR), revealed the treatment order, dated 3/11/2021, for a skin tear to top of left forearm, monitor for signs/symptoms of infection every shift until healed. Resident #1 received treatment to the skin tear on 3/11/2021 through 3/24/2021. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored 99 on the BIMS indicating the interview was unable to be completed. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, dated 7/17/2020, revealed Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for complications related to Alzheimer's Disease and Dementia, dated 11/19/2018, with interventions including: to administer medications as ordered; to check frequently for need, whereabouts, and redirect as needed when wanders into others' rooms/spaces; and to assess behavior and try to determine cause. Review of a Psychiatric Progress Note, dated 11/3/2020, revealed Resident #2 had 2 separate psychiatric hospitalization s, one in July and one in September of 2020, both times for significant agitation and aggression. His behavior included episodes of impulsive behavior and he was almost always confused. Further review revealed his judgement appeared to be poor. Review of an Event Note, dated 3/11/2021 at 8:09 PM, confirmed Resident #2 hit a female resident, resulting in a skin tear to the other resident's forearm. During an interview conducted on 4/28/2021 at 4:35 PM, the Administrator confirmed the facility investigation concluded an incident did occur when Resident #2 entered Resident #1's room without staff supervision. During an interview conducted on 4/29/2021 at 9:34 AM, the (Director of Nursing) DON confirmed Resident #2 was transferred to the emergency room (ER) for evaluation following the incident and hospitalized for psychiatric care due to aggression. The DON further stated, He would pace in his room and hallway with his eyes closed. During further interview she stated,He was complicated. During an interview conducted on 4/29/2021 at 10:40 AM, CNA #1 confirmed Resident #2's behaviors had escalated approximately two weeks before the incident with Resident #1. During continued interview she stated Resident #2 required two staff members to provide care due to his behaviors. CNA #1 confirmed Resident #2 frequently wandered up and down the hall and would often enter other residents' rooms. During an interview on 4/29/2021 at 3:50 PM, the DON confirmed Resident #2 was unsupervised when he entered Resident #1's room. The DON further confirmed Resident #2 required supervision and assistance during ambulation.

Based on facility policy review, observations and interview the facility failed to follow transmission based precautions for 1 resident of 3 residents observed on the COVID unit. The findings include: Review of the facility policy dated 12/98 Infection Control Manual showed The infection Prevention and Control Program is comprehensive in that it addresses detection, control and prevention of infections among patients and partner .The Infection Control Committee will meet at least quarterly, or more if needed , to ensure a safe, sanitary and comfortable environment which will help prevent the development and transmission of disease and infections . Review of the facility Memorandum regarding Emerging Infectious Disease Response-Emergency Procedures Plan Manual, dated 3/4/2020 showed .Healthcare must always be prepared to protect people within our buildings and residents, families, and staff from harm resulting from exposure to an emerging infectious disease while they are in the facility . Contact precautions are used for residents with known or suspected epidemiologically important infections or colonization with resistant organisms transmitted by direct or indirect contact with residents or environment. Gloves and gowns must be worn when caring for a resident. Discard PPE before leaving the room. Hand hygiene is a critical step after care is completed .Droplet precautions prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Standard precautions apply. Healthcare workers should wear a mask when entering the room and if coming into close contact with the resident who is infectious. Hand hygiene is required after completing care . Continued review showed .Dining Services as necessary, ensure staff utilize necessary PPE if delivering meals or interacting with residents who may be infectious . Review of the undated facility documentation Guidance for Meal Delivery to COVID unit showed .All meals served on disposable ware for in-room dining. Trays for the COVID unit are sent on a separate cart. Dietary delivers the cart to the COVID barrier. Nursing staff removes all trays from the cart and places them on a speed rack that is kept on the COVID unit. This rack never leaves the unit. After the meal, all disposable is placed in the trash on the unit which goes to the designated COVID trash . Observation on 1/14/2021 at 11:57 PM showed a tray delivered to the COVID unit on a regular plastic tray, dietary staff was wearing an N95 mask and face shield. Continued observation showed the plastic tray was put on the speedcart on the COVID unit. Further observation showed CNA (certified nursing assistant) #2 wearing only a face shield and N95 mask but not a gown or gloves. Continued observation showed the Styrofoam tray items items were removed from the plastic tray and taken into the resident's room. Further observation showed CNA #2 removed the drinks from the plastic tray and re-entered the resident's room with a face shield and N95 mask but no gown and gloves were used. During an interview on 1/14/2021 at 12:19 PM, CNA #2 confirmed she did not don gown when entering COVID resident's room with a food tray. During continued interview she stated she got sidetracked and did not gown up before delivering the tray. During further interview she stated the proper procedure was to wear gown, N95 mask and face shield before entering a patient's room on the COVID unit. During continued interview CNA #2 stated she has just been off with COVID and this was her first day back. During an interview on 1/14/2021 at 12:28 PM, on the corridor to the A hallway with the Infection Control Nurse she confirmed staff on the COVID unit are required to wear a gown, N95 mask, face shield and gloves before entering a resident's room, no exceptions. During an interview on 1/14/2021 at 5:00 PM with the DON she stated on the COVID unit staff can wear the same gown in each room or a patient specific gown. During continued interview she confirmed all staff must wear gowns and gloves in patient rooms on the COVID unit.

Based on facility policy review, observation and interview the facility failed to clean exhaust filters and a food processor in the kitchen. The findings include: Facility policy review, Safety and Sanitation Best Practice Guidelines, revised 1/2011, revealed .Place filters and drip pan on dish rack and run through automatic dish machine, using complete wash and rinse cycle. Allow to air dry . Facility policy review, Food Processor, Blender, Chopper, Cutting Boards, revised 1/2011 revealed .Disassemble parts and take the bowl, lid and blade assembly to pot and pan sink. Flush with water to remove loose soil. Wash and sanitize parts in three-compartment sink. After each use . Observation on 6/3/19 at 9:03 AM and 11:27 AM in the kitchen revealed the filters over the stove had a build-up of dark brown debris. Observation on 6/3/19 at 12:07 PM in the kitchen revealed food processor blades and base were dirty with white paste-like dried debris. Interview with the Certified Dietary Manger (CDM) on 6/3/19 at 11:27 AM in the kitchen revealed he would expect the filter to be clean. Continued interview revealed when asked if the facility could clean the filters, the CDM confirmed Yes. Interview with the CDM on 6/3/19 at 12:07 PM in the kitchen confirmed .We use it (the food processor) for pureed meals, and it should be cleaned after each use . Interview with Administrator on 6/3/19 at 11:26 AM in the conference room confirmed he expected staff to follow the facility policy when it came to cleaning equipment.

Based on facility policy review, record review and interview, the facility failed to have abuse registry checks for 8 of 8 employee personnel files reviewed. The findings include: Facility policy review, Personnel File Maintenance, revised 4/1/15, revealed .Specific documents relating to individuals' employment with the company are maintained in their personnel files. The following may be maintained in a separate file: company and/or state required criminal background check report . Record review on 6/5/19 at 12:00 PM revealed 8 employee personnel files did not obtain abuse registry checks until 6/4/19. Interview with the Payroll/Bookkeeper on 6/5/19 at 3:10 PM in her office confirmed it was a miscommunication problem between the staffing coordinator and her (payroll/bookkeeper) as to who was to complete and place the abuse registry checks in the personnel files. Interview with the Administrator on 6/5/19 at 3:30 PM in his office confirmed confirmed 8 of 8 records reviewed did not contain abuse registry checks prior to the survey.

Based on facility policy review, medical record review, facility documentation review, observation and interview, the facility staff failed to timely report an allegation of verbal abuse to facility administrative staff for 1 of 3 residents (#1) reviewed for abuse. The findings include: Review of the facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/17, revealed .Abuse, Neglect, Misappropriation of Property and exploitation .will not be tolerated by anyone including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center .Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury . Medical record review revealed Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to a psychiatric hospital 6/28/18 and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had minimal difficultly hearing, clear speech, usually made himself understood, he sometimes understood others and had impaired vision. He was severely cognitively impaired as indicated by the 0 out of 15 Brief Interview for Mental Status (BIMS) score. He had no change in acute mental status, was inattentive and had disorganized thinking which changed in severity. He experienced delusions, was verbally abusive for 1-3 days, and refused care and wandered for 1-3 days of the review period. The resident required extensive 2+ staff assistance with bed mobility transfers, dressing, toileting, and hygiene. He was always incontinent of bladder and frequently incontinent of bowel. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #1 had moderate difficulty hearing, had unclear speech, sometimes made himself understood, rarely understood others, and had moderately impaired vision. He had a 4 out of 15 BIMS score indicating severe cognitive impairment. He had had an acute change in mental status, no [MEDICAL CONDITION], had an appetite change in the past 2-6 days, was verbally and physically abusive in the past 1-3 days and refused care for the past 2-6 days of the review period. He required total 2+ staff assistance for bed mobility, transfer, toileting; required extensive assistance of 2+ staff for dressing, hygiene; and was always incontinent of bowel and bladder. Review of facility documentation of the event revealed on 8/8/18 at 1:40 PM Certified Nurse Aide (CNA) #2 informed Licensed Practical Nurse (LPN) #2/Assistant Director of Nursing (ADON) of an allegation of verbal abuse involving CNA #1 and Resident #1 on 8/7/18 at about 10:00 AM-10:30 AM. Further documentation revealed CNA #1 reportedly told Resident #1 if the resident hit her she would hit him back and she would drop him to the floor. Review of the facility documentation of the event included a written statement by CNA #2, the witness, dated 8/8/18 revealed .I was helping (CNA #1) clean up (Resident #1) .(Resident #1) was being combative, calling names and hitting. (CNA #1) was telling (Resident #1) she would hit (Resident #1) back and it would be the last time he ever hit anyone. (CNA #1) told him she would drop him in the floor . Observation on 8/20/18 at 9:05 AM revealed Resident #1 in his room in bed facing the hallway door with his eyes shut and softly snoring. The bed was in the lowest position, and the head of the bed was elevated, with two ¼ side rails up bilaterally at the head of head. Observation on 8/20/18 at 11:45 AM revealed CNA #3 in the process of positioning Resident #1 in the bed onto his back. The resident jerked his arms and head when the CNA lowered the head of the bed and again when she raised the bed height. The resident never made any attempt to touch, reach for, bite, hit or kick at the CNA during the repositioning and continence check. Observation on 8/21/18 at 8:00 AM revealed Resident #1 in bed with his eyes shut and softly snoring was positioned on his back using round pillows bilaterally at his sides. The bed was in a low position, and two ¼ side rails were up bilaterally at the head of the bed. Telephone interview with CNA #2, on 8/20/18 at 12:50 PM revealed CNA #1 asked her for help on 8/7/18 about 10:00 AM to 10:30 AM in Resident #1's room to provide care to the resident. Further interview revealed CNA #2 had not worked with CNA #1 with providing resident care prior to that day. .We both went in room to give him bath and he was hitting, biting, cursing, and she told him 'if you hit me I'll hit you back and I'll drop you on the floor' . When asked why the CNA had not reported the incident immediately after the event occurred the CNA stated .I was scared. I know that's not an excuse but I was nervous about it. I thought it was wrong what she said but I had to think about it. I knew it was directed at the resident and was wrong. I know I was to report it immediately. I knew if I reported it she could be removed, fired, lose her job and that's serious and I was just scared . Interview with LPN #2/ADON on 8/20/18 at 2:25 PM in her office revealed CNA #2 came to the LPN/ADON's office the afternoon of 8/8/18 and told the LPN/ADON she had concerns involving CNA #1. Further interview revealed CNA #2 told LPN #2/ADON during rounds on 8/7/18 around 10:00 AM with CNA #1 they went into Resident #1 room. CNA #2 stated the resident was .out of it and combative during care . and CNA #1 made a remark .if you hit me I'll hit you back, last thing you'll do, and stop hitting me or I'll drop you to the floor . Interview with the Administrator/Abuse Coordinator and the DON on 8/21/18 at 1:30 PM in the conference room agreed CNA #2 failed to report the allegation of verbal abuse immediately after the event to the facility administrative staff per facility policy.

Based on medical record review, observation and interview, the facility failed to follow the care plan for securing the smoking materials for 1 of 43 residents (#53) reviewed. The findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Miniminum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Medical record review of Smoking Risk assessment dated [DATE] revealed resident #53 assessed to safely use cigarettes and lighter. Further review revealed resident with a score of 2 indicating low risk. Medical record review of the plan of care, dated 1/18/18 and updated 7/16/18 revealed resident #53 may keep cigars without lighter in drawer. Observation on 7/30/18 at 3:00 PM in the smoking area revealed Resident #53 had a cigar and a lighter in a pouch around his neck. Interview with Resident #53 on 7/30/18 at 3:00 PM in the smoking area revealed the resident kept smoking materials in his room. Interview with Certified Nursing Assistant (CNA) #1 on 7/30/18 at 4:54 PM on B Hallway revealed, I did not attempt to take the lighter from the resident after returning from smoking and I should have taken the lighter from the resident when he returned from smoking. Interview with the Director of Nursing (DON) on 7/30/18 at 4:43 PM in her office stated Resident #53 should not have a lighter in his room. Further interview with the DON in B Hall with CNA #1 present revealed CNA#1 should have taken the lighter from the resident and had the nurse to lock it up in the medication cart.

Based on facility policy review, medical record review, observation, and interview, the facility failed to report an injury of unknown origin for 1 resident (#20) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Administrative Procedures Manual revised 12/11/17 revealed .The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Medical record review of the Facility Investigation dated 6/27/18 revealed an injury of unknown origin was found on the back of Resident #20's head. Further review revealed the physician, family and the corporate office was notified on 6/27/18. Interview with Director of Nursing (DON) on 7/31/18 at 3:18 PM in her office revealed the DON had notified the regional nurse and the administrator immediately. The DON stated We did not notify the state, but the Ombudsman was made aware, we would never not report something intentionally, we felt we were following the steps we were supposed to follow. Interview with the Administrator on 8/1/18 at 4:54 PM in the DON's office confirmed the facility failed to report an injury of unknown origin. The Administrator stated correct when questioned if the facility had failed to report an injury of unknown origin to the state agency.

Based on the facility policy review, medical record review, and interview, the facility failed to conduct a completed investigation for 1 resident (#20) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Administrative Procedures Manual revised 12/11/17 revealed .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of the patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Interview with the Administrator on 7/31/18 at 8:30 AM in the conference room revealed a request was made to the Administrator to view the facility's investigation. Review of the facility investigation dated 7/27/18 revealed the facility investigation failed to demonstrate interviews for cognitive residents and determination of the root cause analysis for the injury of unknown origin. Interview with the Administrator on 8/1/18 at 4:54 PM in the Director of Nursing's (DON) office confirmed the facility failed to report an injury of unknown origin. The Administrator stated correct when questioned if the facility had failed to have a completed investigation for a injury of unknown origin.

Based on policy review, medical record review, observation and interview, the facility failed to provide care that promoted a resident's dignity when 1 of 18 (Resident #16) sampled residents included in the stage 2 review was left in a soiled brief for an extended period of time. The failure of the facility staff to provide incontinent care when requested, resulted in actual harm when Resident #16 cried after being left in a soiled brief. The findings included: Review of the facility's "Diarrhea and Fecal Incontinence" policy documented, "...Residents must be cleaned after each episode of incontinence... " Medical record review revealed Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/15 Section C documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact and section H documented the resident was incontinent of bowel and bladder. Review of the care plan dated 2/18/15, documented a problem of "...irregular bowel patterns, diarrhea (due to) [DIAGNOSES REDACTED] ([MEDICAL CONDITION]), large amount of antibiotics... isolation due to [DIAGNOSES REDACTED]... at risk for alteration in comfort..." with appropriate treatments including, "...Provide incontinent care on rounds and PRN (as needed)..." Observation and interview in Resident #16's room on 3/3/15 at 8:35 AM, revealed Resident #16 lying in bed. Resident #16 stated, she had a bowel movement in her depends and had not been cleaned up yet. Resident #16 stated she asked a 8:00 AM, when they brought her tray in to have her depends changed and they have not done it yet. Resident #16 was in contact isolation due to infection of [DIAGNOSES REDACTED]. Observation and interview in Resident #16's room on 3/3/15 at 9:00 AM and 9:54 AM revealed Resident #16 lying in bed. Resident #16 stated, "No one has cleaned me up yet." Resident #16 stated, "Have trouble getting someone to clean me up every morning because they are passing trays and feeding other residents. They came in to get me for therapy this morning, but I couldn't go because I haven't been changed. And I don't like eating when I have dirty depends on." In an interview with the the Physical Therapist Assistant (PTA) on 3/3/15 at 9:00 AM, in the therapy department, the PTA was asked about Resident #16's therapy session this morning. The PTA stated, "I came in at 9:00 AM, initially and resident was still in the bed. She (Resident #16) likes to come to therapy early. I told her that as soon as they get you dressed you can bring yourself down, because once she is in the wheelchair she can bring herself to therapy. When I didn't hear anything from her, I went to check on her at 11:00 AM. There were 2 techs (technicians) getting her dressed. I could tell she was upset." Interview with Resident #16 on 3/3/15 at 11:20 AM, in Resident #16's room, Resident #16 stated, "I called again at 10:00 (AM). They answered the call light and told me they would be right back." Resident #16 was asked what time did they come and clean her up. Resident #16 stated, "At 10:45 (AM). They put some cream on me (her bottom)." In an interview with Certified Nurse Technician (CNT) #1 on 3/3/15 at 3:30 PM, at the nurses' station, CNT #1 was asked, "What happened with Resident #16 this morning?" CNT #1 stated, "I went to help her. She was crying. I asked what is going on? I think her tech (technician) didn't show up. I went to look for her tech (#2) because it takes 2 people to change her with the sit to stand. We changed her. She (Resident #16) was crying because she was wet and wanted to be changed." Interview with CNT #2 on 3/3/15 at 3:45 PM, at the nurses' station, CNT #2 was asked what happened today with Resident #16. CNT #2 stated, "She was upset this morning when I got in there. She was upset because it took so long for someone to get her up. I answered her call light this morning. I told her I would be back to get her up. This was around 10 o'clock." CNT #2 was asked, "Was 10:00 AM, the first time you went in today?" CNT #2 stated, "I went in earlier..." Interview with CNT #2 on 3/3/15 at 5:11 PM, at the nurses' station, CNT #2 was asked how often was incontinent care provided to residents. CNT #2 stated, "Every 2 hours."

Based on policy review, medical record review, observation and interview, the facility failed to provide the care necessary to promote good personal hygiene when 1 of 18 (Resident #16) sampled residents included in the stage 2 review was left in a soiled brief for an extended period of time. The failure of the facility staff to provide incontinent care when requested, resulted in actual harm when Resident #16 cried after being left in a soiled brief for an extended period of time. The findings included: Review of the facility's "Diarrhea and Fecal Incontinence" policy documented, "...Residents must be cleaned after each episode of incontinence... " Medical record review revealed Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/15 Section C documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact and section H documented the resident was incontinent of bowel and bladder. Review of the care plan dated 2/18/15, documented a problem of "...irregular bowel patterns, diarrhea (due to) [DIAGNOSES REDACTED] ([MEDICAL CONDITION]), large amount of antibiotics... isolation due to [DIAGNOSES REDACTED]... at risk for alteration in comfort..." with appropriate treatments including, "...Provide incontinent care on rounds and PRN (as needed)..." Observation and interview in Resident #16's room on 3/3/15 at 8:35 AM, revealed Resident #16 lying in bed. Resident #16 stated, she had a bowel movement in her depends and had not been cleaned up yet. Resident #16 stated she asked a 8:00 AM, when they brought her tray in to have her depends changed and they have not done it yet. Resident #16 was in contact isolation due to infection of [DIAGNOSES REDACTED]. Observation and interview in Resident #16's room on 3/3/15 at 9:00 AM and 9:54 AM revealed Resident #16 lying in bed. Resident #16 stated, "No one has cleaned me up yet." Resident #16 stated, "Have trouble getting someone to clean me up every morning because they are passing trays and feeding other residents. They came in to get me for therapy this morning, but I couldn't go because I haven't been changed. And I don't like eating when I have dirty depends on." In an interview with the the Physical Therapist Assistant (PTA) on 3/3/15 at 9:00 AM, in the therapy department, the PTA was asked about Resident #16's therapy session this morning. The PTA stated, "I came in at 9:00 AM, initially and resident was still in the bed. She (Resident #16) likes to come to therapy early. I told her that as soon as they get you dressed you can bring yourself down, because once she is in the wheelchair she can bring herself to therapy. When I didn't hear anything from her, I went to check on her at 11:00 AM. There were 2 techs (technicians) getting her dressed. I could tell she was upset." Interview with Resident #16 on 3/3/15 at 11:20 AM, in Resident #16's room, Resident #16 stated, "I called again at 10:00 (AM). They answered the call light and told me they would be right back." Resident #16 was asked what time did they come and clean her up. Resident #16 stated, "At 10:45 (AM). They put some cream on me (her bottom)." In an interview with Certified Nurse Technician (CNT) #1 on 3/3/15 at 3:30 PM, at the nurses' station, CNT #1 was asked, "What happened with Resident #16 this morning?" CNT #1 stated, "I went to help her. She was crying. I asked what is going on? I think her tech (technician) didn't show up. I went to look for her tech (#2) because it takes 2 people to change her with the sit to stand. We changed her. She (Resident #16) was crying because she was wet and wanted to be changed." Interview with CNT #2 on 3/3/15 at 3:45 PM, at the nurses' station, CNT #2 was asked what happened today with Resident #16. CNT #2 stated, "She was upset this morning when I got in there. She was upset because it took so long for someone to get her up. I answered her call light this morning. I told her I would be back to get her up. This was around 10 o'clock." CNT #2 was asked, "Was 10:00 AM, the first time you went in today?" CNT #2 stated, "I went in earlier..." Interview with CNT #2 on 3/3/15 at 5:11 PM, at the nurses' station, CNT #2 was asked how often was incontinent care provided to residents. CNT #2 stated, "Every 2 hours."