Every finding on record at The Timbers Skilled Nursing and Therapy

On 02/26/26, an IJ situation was determined to exist related to the facility's failure to have a system in place to ensure residents with low blood sugar received treatments as ordered by a physician. On 11/27/24 at 8:00 p.m., Resident #129 was found to have a FSBS of 64 and was not given their ordered glucagon, the resident's physician was not notified of the low blood sugar as required by their order. RN #2 then administered 40 units of a long-acting insulin [Toujeo SoloStar subcutaneous solution] to Resident #129. On 11/28/24 at 09:07 a.m., Resident #129 was assessed to be unresponsive and 911 arrived and reported resident #129 blood sugar was 41. On 02/26/26 at 3:43p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 02/26/26 at 5:15 p.m., the Administrator was notified of the IJ situation and provided the IJ template.On 02/27/26 at 10:56 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health.Plan of Removal Request:a. How facility will ensure harm will not occur or recur;In-service all licensed nursing staff on signs and symptoms of hypoglycemia and treatment within the physician's orders. DON and/or designee. In service was done in person and phone with staff acknowledgment and verbalize understanding of parameters, treatments, and following physician's orders for hypoglycemia Residents. Completed 2/26/2026 @2020Audit all residents with hypoglycemia or diabetes ensuring Physician treatment orders with parameters are in place. DON and/or designee.Completed - 2/26/2026 @ 2210Monitoring orders will be added for appropriate residents for signs and symptoms of hypoglycemia. DON and/or designee.Completed - 2/26/2026 @ 2210Parameter orders placed instructed by Medical director for all residents with hypoglycemia below 70. Completed - 2/26/2026 @ 2210 b. Date of implementation - planned implementation (actions do not need fully resolved prior to the survey team exiting the organization);2/26/2026c. Identify those residents who have suffered or are likely to suffer, a serious adverse outcome as a result of the noncompliance; andResidents identified and monitoring orders are appropriate for signs and symptoms of hypoglycemia and/or diabetes. DON and/or designee 2/26/2026 d. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.In-service all licensed nursing staff on signs and symptoms of hypoglycemia and treatment. DON and/or designee 2/26/2026Review of all residents with hypoglycemia or diabetes ensuring all physician orders with parameters are in place. DON and/or designee 2/26/2026Compliance rounds initiated to ensure licensed nursing staff understand signs and symptoms of hypoglycemia and treatment following physician orders. DON and/or designee 2/26/2026The likelihood for serious harm to any resident no longer exists effective 2/26/2026f. How are you addressing assessment, intervention, documentation, and evaluation?Root Cause analysis of the eventCompleted 2/26/2026Audit residents 2/26/2026 with diagnosis of hypoglycemia and/or diabetes ensuring monitory physician orders are in place. By DON and/or designeeThe date of substantial compliance: 2/26/26.On 02/26/26, review of in-service training, review of audits and review of staff competencies, the IJ was lifted on 2/26/26 at 12:11 p.m., when all components of the plan of removal had been confirmed to have been completed. The deficiency remained at an isolated level with the potential for than minimal harm.Based on record review and interview, the facility failed to assess, monitor, and intervene for 1(#129) of 4 residents reviewed for hypoglycemia.The DON identified 25 residents receive insulin in the facility.Findings:A facility document titled Baseline Assessment and Care Plan, dated 11/18/24, showed Resident #129 diagnosis included type 2 diabetes mellitus with hyperglycemia.A facility document titled, Injections/Insulin/FSBS, showed on 11/27/24 at 8:00 p.m., Resident #129 had a blood sugar of 64 and was not given per physician orders Glucagon (a medication to treat very low blood sugar) to inject 1 dose intramuscularly (a shot into a muscle) as needed for FSBS (finger stick blood sugar) less than 71 give cola/orange juice and or high carb snack.A Nurses Progress Note, dated11/28/24, at 9:07 a.m., read in part, Focused assessment r/t need for send out for emergency services. Upon assessment it was noted pt was unresponsive. Pt not even reacting to sternal rub. VS obtained 130/73, 78, 96%, 12, 97.8. This nurse called 911, EMS arriving and reporting FSBS was 41. Pt then transported via stretcher to [hospital name withheld].A facility policy titled Blood Glucose Monitoring Guideline, dated 01/2026, read in part, Follow physician orders based on finger stick results. If no follow up orders are in place, notify the physician of noted signs/symptoms of hypo/hyperglycemia. A facility document titled, Injections/Insulin/FSBS, showed an order for Glucagon Emergency Injection Kit 1mg (a medication to treat very low blood sugar) to inject 1 dose intramuscularly (a shot into a muscle) as needed for FSBS (finger stick blood sugar) less than 71 give cola/orange juice and or high carb snack and notify physician.A document titled Quality Assurance and Performance Improvement, dated 02/26/26, showed the facility held a QA meeting to discuss and implement measures related to the failure to assess, monitor, and intervene for a resident with hypoglycemia.An in-service document, dated 02/26/26, showed all staff had been educated on assessing, monitoring, and intervening for residents with hypoglycemia.On 02/26/26 at 2:14 p.m., RN #2 stated if a diabetic resident was unresponsive, they called 911 and notified the physician and family.On 02/26/26 at 2:22p.m., RN #1 stated a resident with a blood sugar of 64 depending on how responsive the resident is they would give glucose tablets or fluids or a snack. If the resident can swallow, they are not going to give a shot.On 02/26/26 at 2:50 p.m., the DON stated if there were orders to notify the physician of blood sugar less than 71, they expected the nurses to follow the order and notify the physician.On 02/26/26 at 2:53p.m., RN #1 showed the November Injections/Insulin/FSBS administration record with Resident #129 blood sugar of 64. RN #1 stated their initials which indicated they administered 40 units of (Toujeo SoloStar subcutaneous solution) long-acting insulin to Resident #129.On 02/27/26 at 10:02 a.m., Medical Director stated if a resident had a blood sugar of 64 depending on the status of the resident if awake administer juice if unresponsive give Glucagon injection. They stated they would not expect the nurse to administer a long-acting insulin.On 02/27/26 at 11:12 a.m., RN #2 stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:15 a.m., LPN #1 stated they assisted in providing education for all staff regarding assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:16 a.m., LPN #2 stated they were educated on signs and symptoms of hypoglycemia and assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:17 a.m., LPN #3 stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.02/27/26 at 11:20 a.m., the assistant director of nursing stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:22 a.m., LPN #4 stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.

On 02/26/26, an IJ situation was determined to exist related to the facility's failure to ensure the physician was notified of a resident's low blood sugar. On 11/27/24 at 8:00 p.m., Resident #129's blood sugar was 64 and the resident was administered 40 units of long-acting insulin (Toujeo SoloStar subcutaneous solution). Resident #129's physician was not notified of the low blood sugar as required by their order. On 11/28/24 at 9:07 a.m., Resident #129 was assessed to be unresponsive and 911 was called and emergency services arrived and reported Resident #129's blood sugar was 41. On 02/26/26 at 3:43 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On 02/26/26 at 5:14 p.m., the administrator was notified of the IJ situation and provided the IJ template.On 02/27/26 at 10:56 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. Plan of Removal Request:a. How facility will ensure harm will not occur or recur;In-service all licensed nursing staff on signs and symptoms of hypoglycemia and when to notify physician. DON and/or designee. In service was done in person and phone with staff acknowledgment and verbalize understanding of parameters and when to notify physician on change of condition for hypoglycemia Residents. Completed 2/26/2026 @2020Audit all residents with hypoglycemia parameters ensuring notification order is in place. DON and/or designee.Completed - 2/26/2026 @ 2210Monitoring orders will be added for appropriate residents for signs and symptoms of hypoglycemia with notification order attached. DON and/or designee.Completed - 2/26/2026 @ 2210Parameter and notification orders placed instructed by Medical director for all residents with hypoglycemia below 70 and notify. Completed - 2/26/2026 @ 2210 b. Date of implementation - planned implementation (actions do not need fully resolved prior to the survey team exiting the organization);2/26/2026c. Identify those residents who have suffered or are likely to suffer, a serious adverse outcome as a result of the noncompliance; andResidents identified and monitoring orders with appropriate parameters to notify physicians. 2/26/2026 DON and/or designee d. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.In-service all licensed nursing staff regarding prompt physician notification of change in condition/hypoglycemia. DON and/or designee 2/26/2026Review of all residents with hypoglycemia or diabetes ensure parameters are in place for notifying physician. DON and/or designee 2/26/2026 The likelihood for serious harm to any resident no longer exists effective 2/26/2026e. How are you addressing assessment, intervention, documentation, and evaluation?Root Cause analysis of the eventCompleted 2/26/2026Audit residents 2/26/2026 with diagnosis of hypoglycemia and/or diabetes ensuring parameters are in place to notify physician. DON and/or designee.The date of substantial compliance: 02/26/26.The IJ was lifted on 02/27/26 at 12:11 p.m., when all components of the plan of removal had been confirmed to have been completed. In-services and orders were reviewed, and staff were interviewed regarding hypoglycemic residents. The deficiency remained at an isolated level with the potential for than minimal harm. Based on record review and interview, the facility failed to ensure a physician was notified of a change in condition for hypoglycemia for 1(#129) of 4 sampled residents reviewed for changes in condition.The administrator identified 120 residents resided in the facility.The DON identified 25 residents received insulin in the facility. Findings:A facility policy titled Notification of Change, dated 07/2012, read in part, The facility will notify the resident, the resident's physician and the resident's representative (if applicable) promptly when there is: 1.A significant change in the residents' physical, mental or psychological status,2. An accident involving the resident that results in injury or has the potential for requiring physician intervention,3. A need to alter treatment significantly, and4. A decision to transfer or discharge the resident from the facility.An admission MDS for Resident #129, dated 11/24/24, showed the resident had a BIMS score of 10 which indicated moderate cognitive impairment and they received insulin injections.A Baseline Assessment and Care Plan for Resident #129, dated 11/18/24, showed the resident had diagnoses which included type 2 diabetes mellitus with hyperglycemia.A physician's order for Resident #129, date ordered 11/18/24, showed Glucagon Emergency Injection Kit 1 mg (a medication to treat very low blood sugar), inject one dose intramuscularly (a shot into a muscle) as needed for FSBS less than 71, give cola/orange juice and/or high carb snack, and notify physician.A document titled Injections/Insulin/FSBS for Resident #129, dated 11/27/24 at 8:00 p.m., showed the resident's blood sugar was 64. The physician was not notified of the FSBS below 71 per physician's order.A Nurses Progress Note for Resident #129, dated 11/28/24 at 9:07 a.m., read in part, Focused assessment r/t need for send out for emergency services. Upon assessment it was noted pt was unresponsive. Pt not even reacting to sternal rub. VS obtained 130/73, 78, 96%, 12, 97.8. This nurse called 911, EMS arriving and reporting FSBS was 41. Pt then transported via stretcher to [hospital name withheld].A facility policy titled Blood Glucose Monitoring Guideline, dated 01/2026, read in part, Follow physician orders based on finger stick results. If no follow up orders are in place, notify the physician of noted signs/symptoms of hypo/hyperglycemia.A document titled Quality Assurance and Performance Improvement, dated 02/26/26, showed the facility held a QA meeting to discuss and implement measures related to the failure of notification to physician.An in-service document, dated 02/26/26, showed all staff had been educated on physician and family notifications of changes, what constituted a change in condition, and how a change in condition would be communicated internally.On 02/26/26 at 2:14 p.m., RN #2 stated if a diabetic resident was unresponsive, they called 911 and notified the physician and family.On 02/26/26 at 2:22p.m., RN #1 stated if a diabetic resident was unresponsive, they checked a FSBS and notified the physician. On 02/26/26 at 2:50 p.m., the DON stated if there were orders to notify the physician of blood sugar less than 71, they expected the nurses to follow the order and notify the physician.On 02/26/26 at 2:53p.m., RN#1 was shown the November 2024 Injection/Insulin/FSBS administration record. They stated their initials indicated the blood sugar was 64. RN #1 stated they did not call the physician per orders.On 02/27/26 at 10:02 a.m., the medical Director stated if a resident blood sugar was below 71 nurses should notify the physician.On 02/27/26 at 11:12 a.m., RN #2 stated they were educated on identifying changes in condition for residents. They stated they were educated on notifying physicians and representatives of changes in condition. On 02/27/26 at 11:15 a.m., LPN #1 stated they assisted in providing education for all staff regarding changes in condition for residents. They stated they were a part of the quality assurance meeting.On 02/27/26 at 11:16 a.m., LPN #2 stated they were educated on signs and symptoms of hypoglycemia, identifying changes in condition in residents, and when to notify the physiciany of changes.On 02/27/26 at 11:17 a.m., LPN #3 stated they were educated on changes in condition and when to notify the physician of changes.02/27/26 at 11:20 a.m., the assistant director of nursing stated they were educated on notifications to the physician regarding changes in condition.On 02/27/26 at 11:22 a.m., LPN #4 stated they were educated on identifying changes in condition for residents. They stated they were educated on when to notify the physician and resident's representative regarding changes in condition.

Based on observation, record review, and interview, the facility failed to post the most recent state survey results of the facility in a place readily accessible to residents, family members, and legal representatives of the residents.The administrator identified 120 residents resided in the facility. Findings: On 02/24/26 at 2:05 p.m., there were no state survey results observed in any common area of the facility. There were no postings that indicated where they were located. On 02/26/26 at 8:21 a.m., a state survey binder was observed located at the front desk in a bin, tucked behind another binder. A review of the state survey results located in the binder were from 2019, 2020, and 2021. On 02/24/26 at 1:58 p.m., during a resident council meeting, Residents #32, 47, 65, 80, 106, and #111 stated they did not know where the state survey results were located or that they could view the results. On 02/26/26 at 8:26 a.m., the administrator stated they were not aware the updated binder was not accessible and was not sure where the new binder was located. They stated there were no postings for residents and visitors to identify where the survey results binder was located. On 02/26/26 at 8:44 a.m., the administrator stated the updated survey results binder had been in their office and was available to residents upon request. The administrator stated they knew it should have been available without asking.

Based on record review and interview, the facility failed to transmit MDS assessment data to CMS in the required timeframe for 1 (#119) of 1 sampled resident reviewed for MDS assessments.The administrator identified 120 residents resided in the facility. Findings:An undated admission Record, showed Resident #119 was admitted to the facility on [DATE].Resident #119's discharge assessment dated , 11/07/25 was completed on 11/11/25, it was not submitted until 02/26/26.On 02/26/26 at 1:06 p.m. the MDS Consultant stated the process for transmitting was corporate followed the RAI manual. They stated the assessment was completed on 11/11/25 and transmitted on 02/26/26. They stated it was not transmitted per the guidelines of the RAI manual.On 02/26/26 at 1:09 p.m., corporate nurse consultant #1 stated it is our policy to follow the RAI manual.On 02/26/26 at 1:28 p.m., the Director of Long Term MDS services stated after completion assessments are required to be transmitted in 14 days.

Based on observation and interview, the facility failed to ensure a dryer in the laundry room was maintained in safe operating condition by cleaning out the lint trap for 1 of 2 dryers observed. The administrator identified 120 residents resided in the facility.Findings:On 02/26/26 at 10:07 a.m., a tour of the laundry room was conducted. The dyer on the left was observed to have lint hanging off of the lint trap almost touching the ground underneath. On 02/26/26 at 10:09 a.m., laundry attendant #1 stated the lint traps were to be cleaned every two hours, and their shift started at 7:00 a.m. They stated the lint traps had not yet been cleaned.On 02/26/26 at 11:27 a.m., the administrator stated they did not have a policy for lint traps for the dryer, and the process was to clean it three times a day. They stated it was their policy but did not have it in writing. The administrator was made aware of what laundry attendant #1 stated.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 10/24/24 related to the facility's failure to supervise and prevent a resident from elopement. The facility failed to prevent Resident #1 from eloping from the facility which had the potential to result in serious injury or harm. On 11/07/24, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to elopement. The past noncompliance IJ was removed effective 10/25/24 after the facility put measures in place to prevent recurrence. On 10/25/24 compliance rounds were initiated, the quality assurance committee met, a quality tip report was completed, an onshift notification message was sent to all employees, an inservice on elopement risk assessments were completed by all nurses, four delay egress locks with four keypads were installed, staff were assigned to the memory care door each shift, all staff were inserviced on elopement, and an inservice on the elopement drill was completed. Letters were mailed to families and posted at the memory care doors. On 11/05/24 at 3:25 p.m., a staff member was observed between two egress doors to allow visitors in/out after ringing the doorbell. Based on observation, record review, and interview, the facility failed to prevent and monitor a resident for elopement for one (#1) of two sampled residents with wandering behavior. Findings: Resident #1 was admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere with progressive neurological conditions. They were a high fall risk. Resident #1's MDS, dated [DATE], documented their cognition was severely impaired and they were independent with ambulation. It documented the resident was at significant risk of getting to a potentially dangerous place outside of the facility. It documented it was very important for the resident to do their favorite activities and to go outside to get fresh air when the weather was good. An initial incident report from, dated 10/24/24, documented at 8:49 p.m. the administrator was notified Resident #1 was unable to be found in the building. It documented they were last seen approximately 30 minutes prior to notification. It documented interventions initiated were an elopement drill, sweep of the facility and outside grounds initiated with no success, two vehicles dispatched to search in a one mile radius with no success, and search radius was increased to a two mile radius. It documented the resident's family, physician, and police were notified. It documented all residents in the building were accounted for except Resident #1. It documented the search was ongoing for the resident. A final incident report form, dated 10/25/24, documented the resident was found at approximately at 2:30 a.m. It documented the resident's family, provider, and police were notified the resident was located. It documented the resident was brought back to the facility and a head to toe and pain assessment were completed with no injury or dehydration noted. It documented the resident was placed one on one and will be evaluated after their interventions were in place. It documented a family member (of another resident) was dropping off their loved one and let the resident out and escorted them out of the front building. It documented to protect the residents they had reviewed and updated their elopement assessments. It documented correction measures to implement would be a door bell system inside the unit that families will ring to have staff escort them out of the system to prevent residents blending in with families. It documented there would be a sign that families would have to sign in and sign out with times. A incident note, dated 10/24/24 at 11:27 p.m., documented focused charting related to a missing resident. It documented upon conducting routine rounds the medication aide on the floor noticed the resident was not in their room. It documented the medication aide notified the nurse and the staff on the floor. It documented a code was called and every staff member in the building searched for the resident. It documented they were unable to locate the resident. It documented the nurse notified the administrator and they asked the nurse to call the emergency agency and the family. It documented the emergency agency responded by sending a police officer to the building. It documented the police officer came in and asked the nurse questions about the description of the resident and the last time the resident was seen in the building. It documented the resident's family arrived to the building and gave some information to the police officer and left the building. It documented the DON, ADON, and the corporate nurse for the facility arrived to the building and helped search for the resident. It documneted the resident was unable to be found. A incident note, dated 10/25/24 at 2:10 a.m., documented focused assessment related to the resident's return to the facility. It documented at about 2:10 a.m. the resident returned to the facility accompanied by a police officer and the DON and ADON were present. It documented the nurse initiated a head to toe assessment on the resident and the residnet was able to move all extremities. It documented there was no edema noted in the BUE and the BLE had 2+ edema. It documented the resident stated they walked a very long distance. It documented there was no bruising. It documented LCTA, no SOB or labored breathing noted. It documented HRR, BS-active in all quads. It documented ABD-soft and non-distended. It documented there was no pain upon palpation and no pain or discomfort. It documented there was no redness to the buttock or perineum. It documented the BLE had redness and protective cream was applied. It documented the resident had redness upon initial assessment of the BLE. It documented BLE were elevated for edema. It documented the BP was 140/74, O2 saturation was 99% on RA, pulse was 88, RR was 18, and temperature 97.8. It documented the resident was resting and placed on 1:1. On 11/05/24 at 11:30 a.m., the laundry/housekeeping supervisor assisted a visitor to the secured unit and off of the secured unit. They stated there were new codes and procedures for the secured doors since the elopement. On 11/07/24 at 8:15 a.m., Resident #1 stated they liked to go on walks. On 11/07/24 at 8:30 a.m., the regional director of operations stated they thought they had enough signage previously, Do NOT let out ANYONE that is not with YOUR party Thank you, but another residents family member thought they were the family of another resident and escorted them through the memory care door and out the front door.

Based on observation and interview, the facility failed to ensure staffing information was posted with the required components and was accessible to all residents. The Administrator identified 118 residents resided in the facility. Findings: On 06/17/24 from 8:20 a.m. through 06/20/24 at 8:15 a.m., this surveyor observed there was no staffing information posted with the required components and accessible to residents and visitors. On 06/20/24 at 9:00 a.m., Corp. Nurse Consultant #1 was asked where the facility daily staffing was posted. They stated it was in the binder at the nurses station. When asked if it was posted on the wall somewhere with the required components and accessible to residents and visitors. The Corp. Nurse Consultant acknowledged it was not.

Based on observation and interview, the facility failed to: (1) sanitize their hands when moving between residents for four (#8, 9, 10, and #11) of six residents observed during the collection of blood pressures, and (2) sanitize reusable equipment after use for six (#6, 7, 8, 9, 10, and #11) of six residents observed during the collection of vital signs. The Resident Census and Conditions of Residents report, dated 08/30/23, documented 102 residents resided in the facility. Findings: A facility in-service education submitted by RN Consultant #1, dated 05/17/23-05/21/23, read in part, .Infection Control .complete hand hygiene between residents .Cleaning of medical equipment between of residents . A Hand Hygeine policy, revised 07/13/20, read in parts, .When to use an Alcohol Based Hand Rub .Immediately before touching a resident .After touching a resident or the resident's immediate surroundings . On 09/26/23 at 8:30 a.m., LPN #1 was observed while taking Resident #6's vital signs. Once completed, LPN #1 returned the vital sign devices to the basket on the vital sign cart, exited Resident #6's room and parked the vital sign cart in the hallway. LPN #1 did not sanitize the vital sign devices before leaving the area. On 09/26/23 at 8:59 a.m., CMA #1 was observed as they removed a wrist B/P cuff from the top drawer of the medication cart and placed it on Resident #7's wrist. Once the reading was obtained, CMA #1 removed the B/P cuff and placed it back in the top drawer on the medication cart. CMA #1 did not sanitize the blood pressure device before leaving the area. On 09/26/23 at 10:46 a.m., CMA #2 was observed as they removed an electronic B/P machine and cuff from the top of the medication cart and placed the cuff on Resident #8's arm. Once the reading was obtained, CMA #2 removed the B/P cuff, documented the reading, and walked over to Resident #9. CMA #2 placed the cuff on Resident #9's arm. Once the reading was obtained, CMA #2 removed the B/P cuff, documented the reading, and walked over to Resident #10. CMA #2 placed the cuff on Resident #10's arm. Once the reading was obtained, CMA #2 removed the B/P cuff, documented the reading, and walked over to Resident #11. CMA #2 placed the cuff on Resident #11's arm. Once the reading was obtained, CMA #2 removed the B/P cuff, documented the reading, and walked over and placed the B/P machine and cuff on top of the medication cart. CMA #2 did not sanitize their hands nor the blood pressure device between residents. On 09/27/23 at 10:25 a.m., CMA #2 was asked about the facility infection control policy on the use of re-usable medical equipment. CMA #2 stated the policy was to sanitize between each person. CMA #3 was made aware of observation made on 09/26/23 and was asked if they had sanitized their hands or the blood pressure cuff between each person. They stated, No. On 09/27/23 at 2:00 p.m., the DON was asked about the facility infection control policy on the use of re-usable medical equipment and staff sanitizing their hands when moving between residents. They stated staff should sanitize their hands when moving between residents and re-usable medical equipment was to be sanitized with Sani-wipes after use on each resident. The DON was given a description of this surveyors' observation of LPN #1, CMA #1, and CMA #2 in the collecting of vital signs. The DON acknowledged they did not follow the facility's infection control policy.

Based on record review and interview, the facility failed to clarify a new medication order to facilitate a resident receiving an increased dosage of medication to treat opioid dependence as ordered for one (#2) of three sampled residents reviewed for physician's orders. The Census and Conditions of Residents report, dated 07/26/23, documented there were 101 residents residing in the facility. Findings: Res #2 had diagnoses that included PTSD, auditory hallucinations, and opioid dependence. A visit report from Res #2's NeuroWellness physician, dated 07/11/23, read in parts, .Subjective: .I am going to increase her buprenorphine to 5 doses a day .I am going to increase her Klonopin to 1mg twice a day but we will not do both at the same time .Plan: .klonoPIN 1mg tablet, 1 po bid .buprenorphine HCL 8mg sublingual tablet, 1/2 sl 5 times daily . Res #2's July MAR documented they were currently receiving klonopin 1mg tablet, 1 po twice a day as of 07/13/23, and buprenorphine HCL 8mg sublingual tablet, 1/2 sl 4 times daily as ordered on 05/12/23. On 07/31/23 at 5:10 p.m., the DON was asked how information from a resident's appointment with an outside physician would be communicated to the facility. They stated physician visit reports were faxed to the facility or sent back with the resident and reviewed by the nurse for any new orders. The DON was asked to review the visit report from Res #2's NeuroWellness visit on 07/11/23 and compare it to their current MAR. After reviewing the report and Res #2's current MAR, the DON acknowledged the medication order written by the NeuroWellness physician should have been clarified when received.

Based on observation, record review and interview, the facility failed to provide timely incontinent care to dependent residents for two (#60 and #75) of six sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents report, dated 05/10/23, documented 101 residents resided in the facility. It documented 67 residents were occasionally or frequently incontinent of bladder and 54 residents were occasionally or frequently incontinent of bowel. Findings: A Perineal Care policy, revised 03/03/06, read in parts, .To keep the resident clean, dry and comfortable and to retain the maximum amount of dignity .Urinary tract infections are frequently caused by inadequate or inappropriate pericare [sic] . 1. Resident #60 had diagnoses which included dementia and anxiety disorder. A Quarterly Resident Assessment, dated 04/10/23, documented the resident's cognition was severely impaired and they required extensive assistance of two person physical assist for transfer, toilet use, and personal hygiene. It documented the resident was always incontinent of bowel and bladder. On 05/10/23, at 4:39 p.m., Resident #60 was observed seated in a geriatric chair in the living room located between hall 100 and hall 200. Resident #60 stated, I got a pull up. The Resident was observed wearing a pair of red pants and the right and left groin region of the pants were observed to be a deeper red. The smell of urine was present. On 05/10/23, at 4:50 p.m., MDS Coordinator #1 was observed talking to Resident #60. Resident #60 was seated in the geriatric chair with their legs elevated. The soiled groin region of their pants was clearly visible as you approached the resident. MDS Coordinator #1 was observed to walk away from the resident, who was still visibly soiled. On 05/10/23, at 5:14 p.m., CNA #1 went over to Resident #60 and pushed them in their geriatric chair into the dining room located on hall 200 and walked away. The soiled groin area of the Resident's pants was still visible. The resident remained in the dining room for the dinner meal service with visibly soiled pants on. On 05/10/23, at 6:11 p.m., CNA #1 pushed Resident #60 in their geriatric chair from the dining room on hall 200 back to the living room area, locked the wheels, and walked away. On 05/10/23, at 6:16 p.m., the resident was taken to their room by staff. On 05/10/23, at 6:33 p.m., CNA #2, the AD, and DON assisted Resident #60 from their geriatric chair to their bed using the mechanical lift. On 05/10/23, at 6:36 p.m., CNA #2 removed Resident #60's red pants which were visibly soiled from the outside. The resident's brief was observed to be completely saturated to the point it was almost translucent. There was visible brown feces observed leaking outside the left side of the brief. CNA #2 opened the brief from the front and folded it down between the resident's legs. [NAME] feces was observed covering the front of the resident's groin area all the way up to their lower abdomen. On 05/10/23, at 6:39 p.m., staff were observed to provide incontinent care to Resident #60. On 05/10/23, at 6:53 p.m., CNA #2 was asked the policy for providing incontinent care. They stated staff would gather supplies, provide peri care, and ensure residents were completely cleaned up. CNA #2 was asked how often incontinent care was provided. They stated it was supposed to be provided after every time they changed the resident. CNA #2 was asked how often residents were changed. They stated, Every two hours. They were asked if they knew the last time Resident #60 was changed. They stated, No, I do not. On 05/10/23, at 6:55 p.m., CNA #2 was asked what the policy was when a residents' clothes were observed to be wet. They stated, Supposed to take them and get them cleaned up immediately. 47453 2. Resident #75 had diagnoses which included dementia. An Admission Resident Assessment, dated 03/09/23, documented the resident's cognition was severely impaired and they required extensive assistance of one person physical assist for transfer, toilet use, and personal hygiene. It documented the resident was frequently incontinent of bladder. On 05/12/23, at 5:26 a.m., Resident #75 was observed in bed. A strong urine odor was present upon entering the resident's room. CNA #6 was observed to provide incontinent care to Resident #75. Resident #75's brief was observed heavily saturated with urine. On 05/12/23, at 5:35 a.m., CNA #6 was asked when the last time Resident #75 had been checked for incontinence. They stated they thought around 3:00 a.m., but hadn't looked at a clock.

Based on observation, record review, and interview, the facility failed to ensure staff: A. performed proper hand hygiene, and B. cleaned vital sign machines after they were used on a contact isolation resident. A Resident Census and Conditions of Residents report, dated 05/10/23, documented 101 residents resided in the facility. Findings: The Hand Hygiene policy, dated 07/13/20, read in part, .When to use a Alcohol based hand rub, immediately after glove removal. When to use soap and water, when hands are visibly soiled . An Infection Control and Isolation Policy, dated 03/16/20, read in part, .Hands of healthcare personnel may transmit pathogens after touching an infection .patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient .C. difficile is .spore-forming .This pathogen is a major cause of healthcare-associated diarrhea and has been responsible for many large outbreaks in healthcare settings that were extremely difficult to control. Important factors that contribute to healthcare-associated outbreaks include environmental contamination, persistence of spores for prolonged periods of time .hand carriage by healthcare personnel to other patients .Gloves are used to prevent contamination of healthcare personnel hands when .anticipating direct contact .potentially infectious material . 1. Resident #75 had diagnoses which included dementia. On 05/12/23, at 5:10 a.m., CNA #6 was not observed performing hand hygiene after taking their gloves off and after providing incontinent care to Resident #75. On 05/12/23, at 5:30 a.m., CNA #6 was asked when were they to perform hand hygiene. They stated usually after two to three residents. On 05/12/23, at 5:33 a.m., LPN #7 was asked what the process was for washing their hands. They stated before and after resident care. On 05/16/23, at 1:02 p.m., the DON was asked what the process was for completing hand hygiene. She stated before entering the room and after glove removal. 41318 2. On 05/12/23, at 5:41 a.m., LPN #1 was observed to go into Resident #84's room. There was a sign observed on the resident's door which documented, Please see nurse before entering. Gloves and gown required for direct care. Wash hands thoroughly. There was a three drawer dresser observed outside the room which contained gloves, gowns, and face shields. LPN #1 was not observed to don any PPE prior to going into the resident's room. On 05/12/23, at 5:46 a.m., LPN #1 was observed to come out of Resident #84's room and prepare medications at the medication cart. LPN #1 was observed to go back into the resident's room and administer the medication. LPN #1 was not observed to don any PPE. LPN #1 was not observed to wash their hands when exiting Resident #84's room. On 05/12/23, at 5:52 a.m., LPN #1 was observed to stop by room [ROOM NUMBER] and placed their hand on a resident's back. On 05/16/23, at 1:46 p.m., CMA #2 was asked what PPE was to be worn when administering medication to a resident who was on contact precautions. They stated gloves and gown. On 05/16/23, at 2:00 p.m., the DON was asked what PPE was worn when administering medication to a resident who was on contact precautions. She stated gloves and gowns. 3. Resident #84's physician order, dated 05/06/23, read in part, .Contact isolation R/T C-diff . On 05/12/23, at 5:41 a.m., LPN #1 was observed to go into Resident #84's room with vital sign machine #1. LPN #1 was observed to place the blood pressure cuff on Resident #84's left forearm and obtained the resident's blood pressure. LPN #1 was observed to remove the blood pressure cuff from the resident's arm, rolled the cuff up, placed it in the basket attached to the vital sign machine, and took the vital sign machine out into the hall. LPN #1 was not observed to clean the blood pressure cuff or vital sign machine #1. On 05/12/23, at 5:48 a.m., LPN #1 was observed take the vital sign machine #1 down the hall and plugged it in outside room [ROOM NUMBER]. LPN#1 was not observed to clean the blood pressure cuff or vital sign machine #1. On 05/12/23, at 5:50 a.m., LPN #1 was observed to walk to hall 400, got vital sign machine #2, and took vital sign machine #2 back to Resident #84's room. On 05/12/23, at 5:52 a.m., LPN #1 was observed to take Resident #84's blood pressure with vital sign machine #2. On 05/12/23, at 5:54 a.m., LPN #1 was observed to remove vital sign machine #2 from Resident #84's room, took it back to hall 400, and plugged it in outside room [ROOM NUMBER]. LPN #1 was not observed to clean vital sign machine #2. On 05/12/23, at 6:05 a.m., LPN #1 was observed to unplug and take vital sign machine #1 to Resident #96's room and obtained the Resident's blood pressure. LPN #1 was observed to take vital sign machine #1 out of the resident's room and plugged it in outside room [ROOM NUMBER]. LPN #1 was not observed to clean vital sign machine #1. On 05/12/23, at 7:03 a.m., LPN #1 was asked what the procedure was for taking vital signs on a resident on contact precautions. They stated there was supposed to be a blood pressure machine with a disposable cuff. They stated they didn't see one in Resident #84's room. They stated the blood pressure cuff used on Resident #84 was not a disposable cuff. LPN #1 stated they did not clean the vital sign machines after they used it on Resident #84. LPN #1 stated the blood pressure cuff was to be cleaned. On 05/12/23 at 7:34 a.m., LPN #2 was observed to take vital sign machine #2 into Resident #53's room and obtained the resident's blood pressure. Vital sign machine #2 was observed from 5:54 a.m. to 7:34 a.m. There was no observation of staff cleaning vital sign machine #2. On 05/12/23 at 7:45 a.m., LPN #2 was asked when the vital sign machines were to be cleaned. They stated between each resident and they used disposable disinfectant wipes. LPN #2 was asked what the procedure was for taking vital signs on a resident on contact precautions. They stated the resident would have their own dedicated equipment. On 05/16/23 at 2:00 p.m., the DON was asked how staff were to take vital signs on a resident on contact precautions. She stated disposable equipment would be in the resident's room. The DON was asked to describe the process of cleaning the vital sign machines. She stated they used disposable disinfectant wipes, after each use on a resident.

Based on observation, record review, and interview, the facility failed to ensure staff administered peg tube medications appropriately to prevent the peg tube from clogging for one (#104) of one sampled resident observed for peg tube medication administration. The DON identified five residents received medication through a peg tube. Findings: An Enteral Medication Administration policy, dated 07/09/08, read in part, .Tablets and capsules are to be crushed and diluted in a suitable liquid . Resident #104 had diagnoses which included dementia and dysphagia (difficulty swallowing). A Resident Assessment, dated 04/12/23, documented Resident #104 was severely impaired with daily decision making. It documented the resident was total dependent on staff for eating, and the resident had a feeding tube. On 05/12/23, at 9:57 a.m., CMA #1 was observed to crush seven tablets, open two capsules of medication, and placed them in nine individual medication cups. CMA #1 did not mix the medications with water. On 05/12/23, at 10:10 a.m., CMA #1 was observed to connect a syringe to Resident #104's peg tube and administered water. The water was observed to flow into the peg tube. CMA #1 was observed to pour dry medication contents into the syringe. CMA #1 was observed to put more water into the syringe. The water was not observed to flow down the peg tube. CMA #1 was observed using the syringe's plunger to gentle push the water. On 05/12/23, at 10:18 a.m., CMA #1 stated they thought the peg tube was clogged. CMA #1 alerted LPN #5. LPN #5 was able to unclog the peg tube. On 05/12/23, at 10:22 a.m., CMA #1 was observed to pour water then the dry contents of a medication into the syringe. The water/medication was not observed to flow into the peg tube from the syringe. LPN #5 was observed to attempt to unclog the peg tube. On 05/12/23, at 10:25 a.m., LPN #5 stated, It's not going in. On 05/12/23, at 10:32 a.m., LPN #6 was observed to use a straight declogging tool to push into the peg tube. LPN #6 stated they were feeling resistance and removed the declogging tool. The tip of the tool was observed to be bent. On 05/12/23, at 10:35 a.m., the DON was observed to use the declogging tool and was unsuccessful at declogging the peg tube. She stated the peg tube needed to be changed. On 05/12/23, at 10:45 a.m., CMA #1 was asked how often Resident #104's peg tube became clogged. They stated it was clogged a couple of days ago, but did not need to be changed. CMA #1 stated the peg tube was clogged at least once a week. On 05/12/23, at 11:08 a.m., the DON was observed to replace Resident #104's peg tube. On 05/12/23, at 11:25 a.m., the DON instructed CMA #1 to put water into the cups of crushed/opened medications for the medications to start to dissolving. The DON stated, Or else it will keep clogging. On 05/12/23, at 11:30 a.m., CMA #1 was asked if they had mixed water into the medications prior to the peg tube becoming clogged. They stated, I didn't know we had to dissolve each one. On 05/16/23, at 2:00 p.m., the DON was asked to describe the process for administering peg tube medications. She stated crush the medication and dissolve it in water. The DON was asked how often Resident #104's peg tube had been clogged. She stated it had been a few times.

Based on observation, record review and interview, it was determined the facility failed to ensure five (#315, 316, 413, 416 and #421) of ten residents' rooms maintained comfortable air temperatures. The facility identified 88 residents who resided in the facility. Findings: On 02/13/20 from 8:55 a.m. to 9:39 a.m., the following observations were made: ~ the ambient air temperature in room [ROOM NUMBER] was 70.1 degrees Fahrenheit, ~ the resident in room [ROOM NUMBER] was observed sitting in his wheelchair wearing a coat with four blankets on his bed and an ambient air temperature of 67.8 degrees Fahrenheit, ~ the resident in room [ROOM NUMBER] was observed asleep under three blankets with her head covered, two blankets were observed on the roommates bed and the ambient air temperature was 70.1 degrees Fahrenheit, ~ the resident in room [ROOM NUMBER] stated sometimes it was hot in the room and sometimes it was cold, the room was a little warm now but it would get cold during the night. The ambient air temperature was 82.3 degrees Fahrenheit, ~ the resident in room [ROOM NUMBER] was observed to be asleep under three blankets, two blankets and a quilt were observed on the roommates bed and the ambient air temperature was 67.0 degrees Fahrenheit, The facility's ambient air temperature logs from 01/03/20 through 02/12/20 were reviewed. There was no documentation to indicate the temperatures had been monitored in the residents' rooms. At 9:51 a.m., the maintenance supervisor was asked if he monitored the temperatures in the residents' rooms. He stated if they had a complaint the room would be checked. He stated they monitored the common areas and tried to keep the temperatures between the required 71 to 81 degrees Fahrenheit. The maintenance supervisor stated if a complaint was received from a room he would immediately work to correct the issue and keep checking until it was within the required range but it was not something he usually logged. The maintenance supervisor was notified of the observations and temperatures from the five rooms. He was asked if the temperatures were acceptable. He stated, Not according to state regs.

Based on record review and interview, it was determined the facility failed to ensure grievances were investigated and/or resolved in a timely manner for five of six grievances reviewed from 11/01/19 through 02/13/20. The facility identified 88 residents who resided in the facility. Findings: A facility policy titled Q2 Policy and Procedure, effective 02/14/17, documented, .Document any grievances/complaints from residents or families and track on the Family/Resident Grievance Log .until resolved . On 02/11/20 at 3:00 p.m., a group meeting was held with the residents. The residents were in agreement that the facility did not act upon or respond to grievances in a timely manner. The facility grievance logs were reviewed from 11/01/19 to 02/13/20. There was no documentation to indicate the facility investigated or resolved five of the six grievances made during the timeframe. On 02/13/20 at 10:41 a.m., the administrator was shown the grievance logs and asked if there was any other documentation regarding the investigations and resolutions for the grievances. He provided one grievance report and stated he had no other reports documented. The administrator was asked if there should have been further documentation of the investigations and follow-ups for each grievance. He stated yes, the details of the resolution should have been documented.

Based on observation, record review and interview, it was determined the facility failed to provide timely assistance with bathing for dependent residents for one (#11) of two sampled residents who were reviewed for activities of daily living. The facility identified 86 residents who required assistance with bathing. Findings: Resident #11 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/01/19, documented the resident was moderately impaired in cognitive skills for daily decision making. He was totally dependent for bathing. The activities of daily living task sheet documented he had received two baths from 01/09/20 through 01/23/20 (15 days). On 02/10/20 at 2:18 p.m., the resident was observed in his bed. He stated he was supposed to receive a bath three days a week, but he had received a bath once a week recently. On 02/12/20 at 2:52 p.m., CNA #1 stated the resident was supposed to receive a bath three times a week. At 2:55 p.m., LPN #1 stated the resident was supposed to receive a bath three times a week. She stated she monitored baths by the documentation the aide provided to her at the end of the shift. She stated the resident had not received a bath three times a week per the documentation in January. At 3:55 p.m., the DON stated the resident was supposed to receive a bath three times a week. She stated the resident had received two baths from 01/09/20 through 01/23/20. She stated it was not acceptable for a resident to receive two baths during a two week period.

Based on observation, record review and interview, it was determined the facility failed to provide assistance with turning, repositioning and incontinent care for three (#1, 2, and #3) of four sampled residents who were reviewed for assistance with activities of daily living. The facility identified 59 residents who required assistance with activities of daily living. Findings: 1. Resident #1 had [DIAGNOSES REDACTED]. The ADL Task form, dated 07/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 07/01/19 through 07/31/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for ten of 31 opportunities on the day shift, three of 31 opportunities on the evening shift, and 11 of 31 opportunities on the night shift. A quarterly assessment, dated 07/22/19, documented the resident was moderately impaired in cognitive skills for daily decision making and was totally dependent on staff for assistance with bed mobility and toileting. It was also documented she was always incontinent of bowel and bladder. The ADL Task form, dated 08/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 08/01/19 through 08/31/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for 19 of 31 opportunities on the day shift, 12 of 31 opportunities on the evening shift, and 21 of 31 opportunities on the night shift. A physician's orders [REDACTED]. A care plan, updated on 08/29/19, documented the staff was to provide incontinent care and repositioning assistance to the resident frequently to promote good skin care and circulation. The ADL Task form, dated 09/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 09/01/19 through 09/02/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for either of the two opportunities on the day shift or the two opportunities on the evening shift. On 09/05/19 at 9:08 a.m., certified nursing assistant (CNA) #1 was asked how much assistance the resident required with ADL care. She stated staff assisted her with repositioning and incontinent care every two hours. She was asked if the care provided to the resident would be any different if the family was at the resident's bedside. She stated, No, I still reposition and do incontinent care every two hours. At 9:20 a.m., registered nurse (RN) #1 was asked the care provided to the resident according to her plan of care. She stated the resident should be turned and repositioned, and provided incontinent care every two hours and as needed. She was asked if care was to have been provided if the family was at the bedside. She stated, Yes. The RN was asked to review the ADL tasks forms for the resident. She was then asked if staff had provided incontinent care and and repositioning every two hours to the resident. She stated, No. She was asked if staff had followed the plan of care. She stated, No. 2. Resident #2 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/28/19, documented the resident was severely impaired in cognitive skills for daily decision making and she required extensive assistance with bed mobility and toileting. It was also documented she was always incontinent of bowel and bladder. A care plan, dated 05/30/19, documented the staff was to provide frequent turning and repositioning as needed. Staff was also to offer toileting before and after meals, at bedtime and as needed per resident's request. The ADL Task form, dated 07/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 07/01/19 through 07/31/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for 8 of 31 opportunities on the day shift, 7 of 31 opportunities on the evening shift, and 15 of 31 opportunities on the night shift. The ADL Task form, dated 08/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 08/01/19 through 08/31/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for 17 of 31 opportunities on the day shift, 21 of 31 opportunities on the evening shift, and 12 of 31 opportunities on the night shift. The ADL Task form, dated 09/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 09/01/19 through 09/04/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for two of four opportunities on the day shift, two of four opportunities on the evening shift, and two of four opportunities on the night shift. On 09/05/19 at 11:40 a.m., RN #1 was asked if the staff had provided assistance to the resident with incontinent care and repositioning every two hours according the ADL documentation. She stated, They did not document it. She was asked what was indicated if the care was not documented. She stated, If it's not documented, they didn't do it. 3. Resident #3 had [DIAGNOSES REDACTED]. A care plan, dated 03/06/19, documented the resident had a self care deficit and required assistance from staff with bathing, dressing, hygiene and toileting. She was non verbal and staff was to anticipate her needs. It was documented for staff to assist the resident with turning and repositioning frequently and toilet and provide incontinent care frequently. The ADL Task form, dated 07/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 07/01/19 through 07/31/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for 11 of 31 opportunities on the day shift, three of 31 opportunities on the evening shift, and 12 of 31 opportunities on the night shift. A quarterly assessment, dated 07/10/19, documented the resident was severely impaired in cognitive skills for daily decision making. She was dependent on staff for bed mobility, transfers, dressing and toileting. It was also documented the resident was always incontinent of bowel and bladder. The ADL Task form, dated 08/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 08/01/19 through 08/31/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for 19 of 31 opportunities on the day shift, 15 of 31 opportunities on the evening shift, and 20 of 31 opportunities on the night shift. The ADL Task form, dated 09/2019, documented staff was to assist the resident with incontinent care, turning and repositioning every two hours and as needed. From 09/01/19 through 09/04/19 there was no documentation on the ADL Task form to indicate ADL care was provided to the resident for one of four opportunities on the day shift, one of four opportunities on the evening shift, and one of four opportunities on the night shift. On 09/03/19 at 1:50 p.m., the resident was observed in bed. She was positioned on her right side facing the wall with her eyes closed. At 2:45 p.m., the resident was observed laying in bed in the same position. A private sitter was observed sitting in the resident's room. At 3:30 p.m., the resident was observed laying in bed in the same position. At 4:00 p.m., the resident was observed laying in bed in the same position. At 4:30 p.m., the resident was observed laying in bed in the same position. At 5:00 p.m., the resident was observed laying in bed in the same position. From 1:50 p.m. to 5:00 p.m., the resident was observed in the same position. No observations were made of staff repositioning the resident or providing incontinent care. On 09/04/19 at 1:50 p.m., CNA #2 was asked how often repositioning and incontinent care were provided to the resident she stated, Every two hours and PRN for the toileting. It used to be turning every hour but now it is every two hours. She was asked who was responsible for providing and documenting the care. She stated the care was usually provided by the CNAs and documented on the ADL Task form. CNA #2 was asked if the private sitters would ever provide care to the resident. She stated some of the sitters would and some would not. The CNA was asked if a time period of greater than three hours was too long for repositioning and incontinent care. She stated, Yes. At 2:00 p.m., CNA #3 was asked how often repositioning and incontinent care were provided to the resident. She stated every two hours, on a schedule during the evening shift it was 4:00 p.m., 6:00 p.m., 8:00 p.m., and 9:30 p.m. before shift change. She was asked who was responsible for providing the care. She stated the CNAs. She was asked if three hours was too long between checks and repositioning. She stated, Yes. At 2:30 p.m., the private sitter was asked how often staff checked on the resident. She stated they were supposed to every two hours but that never happened. On 09/04/19 at 12:00 p.m., RN #1 was asked how often staff were to provide repositioning and incontinent care. She stated every two hours. She was asked if a time period of greater than three hours was acceptable for repositioning and incontinent care. She stated no. The RN was asked if it was the responsibility of the private sitter to provide the care. She stated the sitter was to provide comfort and companionship and call for assistance if necessary. She was asked if it was acceptable for staff to not check or provide care to a resident with a sitter for a period of over three hours. She stated, No. At 12:10 p.m. RN #1 stated the resident's sitter was able to provide care. She was asked how they ensure the care was provided. She stated the staff checks on them. She was asked if it was the responsibility of the staff to ensure the care was provided and documented. She stated yes.

Based on observations and interviews, it was determined the facility failed to ~ ensure the tea urn was covered with a lid, ~ serve lettuce at the proper temperature to prevent food-borne illness; and ~ serve food under sanitary conditions to prevent cross-contamination. This had the potential to affect all 96 residents who received their meals from the kitchen. Findings: On 09/12/17 at 9:20 a.m., the tea urn in the dining room was observed to be full of tea without a lid covering the top. The lid was observed to be propped up behind the tea urn. DA (dietary aide) #1 was in the dining room cleaning tables. She was asked if the tea urn was supposed to have the lid on it. She stated yes, it should have the lid on it to keep anything from flying inside and to keep the residents from putting their hands inside it. At 11:58 a.m., cook #1 was observed removing a pan of chopped lettuce from the refrigerator. She obtained the temperature of the chopped lettuce to be 58F (Fahrenheit). She scooped ice into a large shallow pan and placed the pan of lettuce on top of the pan of ice. At 12:20 p.m., the RD (registered dietician) stated to this surveyor the lettuce had been chopped at around 11:00-11:15 a.m. and placed back into the refrigerator. She further stated the lettuce had not had time to come back down to temperature, so they had decided to place ice under it. At 12:30 p.m, the staff was observed placing the lettuce on plates in the service line. Cook #2 was observed reaching into a bag of hamburger buns and removing the buns with her gloved hand. She was also observed touching the plates, ladles and tongs of other foods with her gloved hands. Cook #1 was observed on the service line preparing plates without gloves. She was observed to have one long fingernail on her right pinkie finger with white polish on it. At 12:40 p.m., the DM (dietary manager) took the place of cook #2 on the service line. He reached into the bag of hamburger buns with his bare forearm/gloved hand and removed the buns for each plate. At 12:50 p.m., the DM opened a new bag of buns and continued to reach into the bag and remove the buns with his gloved hand. At 1:00 p.m., cook #1 was observed using tongs with her bare hands then the DM was observed to use the same tongs with his gloved hand. The DM also touched the plastic bag with his gloved hand while he used tongs to remove cheese slices. At 1:02 p.m., the DM opened another bag of buns and reached into the bag with his bare forearm/gloved hand and removed the buns for each plate. At 1:52 p.m., cook #2 was asked what their policy was related to how they handled bread. She stated they could handle bread with tongs or gloved hands. She was asked why they used tongs for the other items during lunch. She stated so they would not cross-contaminate. She was asked why they did not use the tongs for the bread. She stated they might be short of tongs. She further stated it was probably cross-contamination when she used her gloved hands to handle the bread. At 1:55 p.m., the DM, with the RD present, was asked what the temperature of cold vegetables should be when they were served. He stated under 40 degrees. The RD stated the lettuce had not had time for the temperature to go back down after they had chopped it and placed it back in the refrigerator. She further stated they had placed ice under it for this reason. The DM was asked what their policy was related to long fingernails and nail polish. He stated they were not supposed to have long nails and they could only have clear polish. He was asked if he was aware cook #1 had one long fingernail with white nail polish on it. He stated he was not aware of this. He was asked if the long nail with white polish was acceptable practice. He stated, No. The DM was asked what their policy was related to how they handled bread. He stated they were not supposed to handle the bread with their bare hands, but they could use gloved hands. He was made aware of cook #2 and himself touching the buns with their gloved hands, placing his bare forearm into the bags and also touching other items, which resulted in cross-contamination. He stated he did not realize it and he could see how that was an issue. He further stated they were not supposed to touch any food item period with their hands, except for bread. The RD stated they had talked about using the gloved hands for just one task, like handling the bread. At 2:05 p.m., cook #1 was asked what the temperature of the lettuce should be to serve it. She stated 30-32 degrees. She was asked if the temperature should be more than 40 degrees. She stated no. She was asked what the temperature of the lettuce was when she checked it. She stated 58. She was asked if they had served it to the residents at that temperature. She stated yes, but they had spread it out in a pan and placed it over ice before they served it. She was asked what their policy was related to long fingernails and nail polish. She stated if they had long fingernails they had to wear gloves. She was asked if she served lunch today without gloves while having one long fingernail with white polish on it. She stated, Yes. She was asked why that was a problem. She stated the nail polish could get into the food and it could be a contamination problem.

Based on observation, record review and interviews, it was determined the facility failed to provide timely incontinent care to one (#7) of 10 sampled residents who were observed for incontinent care. The director of nursing (DON) identified 82 residents who resided in the facility were incontinent. Findings: Resident #7 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/09/17, documented she required extensive assistance with bed mobility, transfers, dressing and toilet use. She was always incontinent of urine and bowel. On 03/15/17 at 7:10 a.m., the resident was observed lying in bed. Her brief was observed to be soaked with urine and soiled with a large amount of stool. Her incontinent pad, draw sheet, and bottom sheet were also soaked with urine. At 7:20 a.m., CNA #1 was asked when the resident was last changed. She stated the night shift should have done their rounds at five. She did not know because she worked the day shift and she just got to work. She was asked what she observed of the resident's brief and bedding. She stated it was very soiled, like it had not been changed in awhile, not two hours ago. She was asked how often the resident should be checked/changed. She stated at least every two hours. She was asked if she thought she had been changed at 5:00 a.m. She stated, No. At 11:20 a.m., the DON was made aware of the observation of the resident's brief and bedding. She was asked how often the staff should provide incontinent care. She stated every two hours and as needed. She further stated the resident voided a lot when she went and she has had stomach problems too. At 12:00 p.m., the resident was asked if the staff provided timely incontinent care. She stated they came in maybe once at night, if that often. She was asked why she was so wet this morning. She stated probably because she did not have anybody come in all night. They usually checked her at bedtime around 10:30-11:00 p.m. and they did not come in and wake her up after that.

Based on interviews, the facility failed to answer call lights in a timely manner for six (#6, 7, and #8-#11 ) of nine sampled residents who were asked about their call lights. This had the potential to affect all 107 residents who resided in the facility. Findings: On 03/15/17 at 12:00 p.m., resident #7 was asked if staff answered her call light in a timely manner. She appeared to be cognitively intact and able to answer the question appropriately. She stated sometimes it took up to half an hour for the staff to answer her call light. 2. At 12:10 p.m., resident #6 was asked if staff answered her call light in a timely manner. She appeared to be cognitively intact and able to answer the question appropriately. She stated sometimes it took up to twenty five minute for the staff to answer her call light. 3. At 12:18 p.m., resident #8 was asked if staff answered her call light in a timely manner. She appeared to be cognitively intact and able to answer the question appropriately. She stated sometimes it took up to fifteen to forty-five minutes to answer her call light. 4. At 12:23 p.m., resident #9 was asked if staff answered her call light in a timely manner. She appeared to be cognitively intact and able to answer the question appropriately. She stated sometimes it took up to forty-five minutes to an hour for the staff to answer her call light. 5. At 12:26 p.m., resident #10 was asked if staff answered her call light in a timely manner. She appeared to be cognitively intact and able to answer the question appropriately. She stated sometimes it took up to thirty minutes for the staff to answer her call light. 6. At 12:35 p.m., resident #11 was asked if staff answered his call light in a timely manner. He appeared to be cognitively intact and able to answer the question appropriately. He stated sometimes it took up to fifteen minutes for the staff to answer his call light. At 3:40 p.m., the DON (director of nurses) was made aware of the call lights not being answered in a timely manner. She was informed the residents stated it sometimes took up to 45 minutes to have their lights answered. She asked the location and shifts involved to better address the problem. She was made aware no particular hallway or shift was identified. The problem was facility-wide. She had no comment.

Based on clinical record review, interviews, and review of facility policies, it was determined the facility failed to ensure the residents' right to choose a hospice provider was not violated for one (#1) of three sampled residents who had been on hospice services or were currently on hospice services. The facility identified ten residents who were currently on hospice services. A facility policy titled, Resident's Rights & Family Handbook, documented, .HOSPICE POLICY .It is the Facility's policy that hospice services are provided only through contractual arrangements with other hospice providers. The names of contracted hospice providers are listed below .(named hospice) . Resident #1 was admitted to facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/05/16, documented the resident was severely impaired in cognition and required extensive assistance with activities of daily living. The resident was frequently incontinent of bladder and always incontinent of bowel. On 09/06/16 at 9:30 a.m., a family member of the resident stated the family had been notified by the facility they were exclusive regarding hospice providers and the resident would have been relocated in order to use a different provider. The family member stated the facility had refused to allow another hospice provider into the facility to conduct a resident evaluation. At 11:15 a.m., the medical records/social services director was asked about the hospice admission process and how a hospice provider was selected by a resident. She stated the facility only contracted with one hospice provider. If another hospice provider had been requested by a resident or family, the facility would assist in finding another facility that contracted with that hospice provider. At 11:19 a.m., the director of nursing was asked the process for selecting a hospice provider. She stated the facility had a contract with one hospice provider. If a resident had wanted to use another hospice provider the facility would have helped refer and discharged the resident to another facility. At 11:30 a.m., the administrator stated the facility allowed other hospice providers to evaluate the residents and if the resident or family would have chosen the other provider the facility would have assisted them in finding another facility.