Every finding on record at The Village at Heritage Oaks

Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and clinical records for 15 (Resident #1, Resident # 2, Resident #3, #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14 and Resident #15) out of 15 residents on 200 Hall of the facility. A. The personal health information of 15 residents was left unlocked and displayed on the charting kiosk's screen on the hallway wall by CNA L. This failure could result in fifteen residents' personal information being exposed to unauthorized individuals. The findings included:Observation on 12/09/2025 at 9:35 a.m. revealed the charting kiosk #2's screen on the 200 Hall was open and unlocked with Resident #1, Resident # 2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14 and Resident #15's personal information displayed. When Resident #1's name was clicked, it opened more detailed clinical information which could be done for other 14 residents displayed on the screen. After 7 minutes the charting kiosk was open, RN G approached the kiosk and attempted to shut down the screen. During the observation of the kiosk's screen from 9:35 a.m. to 9:42 a.m. the confidential information of 15 residents was opened for anyone such as visitors or other residents to see. During an interview on 12/09/2025 at 10:34 a.m. with CNA F, she stated that she had an in-service on HIPAA last month and it included not discussing residents' private clinical information with unauthorized people and locking the computer screen when leaving to do something else. She stated that everybody who works with charting kiosks was responsible for closing it and locking it when not in attendance. She stated that CNA L was responsible for shutting down the charting kiosk and locking the screen. She said that she was not sure why CNA L left the screen unlocked. She stated that leaving the screen unlocked with clinical information displayed on it could be harmful for residents as anybody can see it. During an interview on 12/09/2025 at 10:42 a.m. with RN G, she stated that CNA L was responsible for shutting down and locking the charting kiosk's screen when CNA L left for her break or was called by a resident for assistance. She stated that she received HIPAA training one month ago. She said that everybody who works on the hallway and uses a charting kiosk was responsible for closing the screen when leaving it. She stated that leaving a computer without minimizing the computer screen can lead to exposing residents' private medical information to other residents or family members. During an interview on 12/09/2025 at 10:47 a.m. with CNA L, she stated that she was responsible for shutting down the charting kiosk's screen when she was called by a resident for assistance. She stated that she received HIPAA training several months ago, but she could not remember exact day. CNA L stated that leaving a charting kiosk without locking the screen can lead to exposing residents' private medical information to unauthorized people and residents' privacy would be violated. During an interview on 12/09/2025 at 4:21 p.m. with DON B, she said that the facility's policy was to minimize the charting kiosk' screen on hallways when stepping away from it. She stated that if the screen was not minimized someone could have unauthorized access to private clinical information displayed on the screen. She said that all these charting kiosks were new to CNAs as new company just bought them and nursing staff members were still learning the process. She stated that HIPAA policy in-service was provided to all employees at hire and annually through computer modules educating them on locking the computer screens. She said that the person who works with residents' private clinical information should lock the screen before walking away. The potential negative effect would be sharing private residents' information with unauthorized personnel. During an interview on 12/09/2025 at 4:39 p.m. with ADM A, he stated that all staff including him were trained on HIPAA at the time of hire and annually through computer modules and at least annually after that. He stated that it was the responsibility of whoever works at the charting kiosk to make sure it was closed before leaving. ADM A stated that leaving the charting kiosk open would make the private clinical information about residents (specific stuff about care, date of birth , social security numbers, and diagnosis) visible for visitors or other residents to see. It could possibly have negative psychosocial effects on those residents whose information was displayed. ADM A stated that all staff take HIPAA in-services through computer modules at hire and annually. He stated that CNA L completed her annual training on the computer per his understanding but could not provide the record.Record review of Resident #1's face sheet, dated 12/09/2025, revealed, a 90-years-old female admitted on [DATE]. Resident's #1's diagnoses included dementia (severe mental function loss (memory, thinking, language, problem-solving) impacting daily life), major depressive disorder (a serious mood illness causing persistent sadness, loss of interest, fatigue, and impaired daily functioning), schizophrenia (a serious brain disorder causing a breakdown in the connection between thoughts, emotions, and reality). Record review of Resident #2 's face sheet, dated 12/09/2025, revealed, a 91-years-old female admitted on [DATE]. Resident's #2's diagnoses included Type 2 diabetes mellitus (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively, leading to high blood sugar levels, as the body can't get glucose into cells for energy), chronic cough, and urinary tract infection. Record review of Resident #3's face sheet, dated 12/09/2025, revealed, an 89-years-old female admitted on [DATE]. Resident's #3's diagnoses included dementia (severe mental function loss (memory, thinking, language, problem-solving) impacting daily life), insomnia (a common sleep disorder making it hard to fall or stay asleep, causing daytime fatigue, concentration issues, and irritability), and atopic dermatitis (a chronic skin condition causing severe itching, redness, dryness, and inflammation). Record review of Resident #4's face sheet, dated 12/09/2025, revealed, an 81-years-old male admitted on [DATE]. Resident's #4's diagnoses included cerebrovascular disease (involves problems with blood flow to the brain, caused by narrowing, clots, or ruptures in blood vessels), squamous cell carcinoma (a common type of skin cancer that appearing as red, scaly patches), and actinic keratosis (a common, rough, scaly skin patch caused by long-term sun exposure, considered a precancerous growth that can develop into squamous cell carcinoma (skin cancer)). Record review of Resident 5's face sheet, dated 12/09/2025, revealed, a 91-years-old female admitted on [DATE]. Resident's 5's diagnoses included chronic systolic congestive heart failure (the heart's main pumping chamber (left ventricle) is weakened and can't squeeze effectively, leading to reduced blood flow and fluid backup, causing symptoms like breathlessness, swelling, fatigue), bronchitis (inflammation of the airways (bronchial tubes) in your lungs, causing a persistent cough that brings up mucus, chest tightness, wheezing, and shortness of breath), and urinary tract infection. Record review of Resident 6's face sheet, dated 12/09/2025, revealed, a 69-years-old female admitted on [DATE]. Resident's #6's diagnoses included dementia (severe mental function loss (memory, thinking, language, problem-solving) impacting daily life), dysuria (painful or uncomfortable urination), and candidiasis (a common fungal infection caused by an overgrowth of Candida yeast). Record review of Resident #7's face sheet, dated 12/09/2025, revealed, a 103-years-old female admitted on [DATE]. Resident's #7's diagnoses included hypertensive heart disease with heart failure ( heart conditions that result from chronic high blood pressure), candidiasis (a common fungal infection caused by an overgrowth of Candida yeast), and type 2 diabetes mellitus (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively, leading to high blood sugar levels, as the body can't get glucose into cells for energy). Record review of Resident #8's face sheet, dated 12/09/2025, revealed, an 86-years-old female admitted on [DATE]. Resident's #8's diagnoses included dementia (severe mental function loss (memory, thinking, language, problem-solving) impacting daily life), urinary tract infection, and constipation (common gastrointestinal problem where bowel movements are tough or occur less often than normal). Record review of Resident #9's face sheet, dated 12/09/2025, revealed, a 96-years-old female admitted on [DATE]. Resident's #9's diagnoses included Alzheimer's disease (a progressive brain disorder, the most common cause of dementia, characterized by memory loss, impaired thinking, and behavioral changes), dermatitis (skin condition that causes inflammation and irritation of the skin), and Type 2 Diabetes Mellitus (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively, leading to high blood sugar levels, as the body can't get glucose into cells for energy). Record review of Resident #10's face sheet, dated 12/09/2025, revealed, a 101-years-old female admitted on [DATE]. Resident's #10's diagnoses cerebral infarction (death of brain tissue caused by a lack of blood supply), hypokalemia (lower than normal concentration of potassium in the blood, and anxiety disorder (persistent and excessive worry about various things that is out of proportion to the actual situation). Record review of Resident #11's face sheet, dated 12/09/2025, revealed, a 77-years-old female admitted on [DATE]. Resident's #11's diagnoses included Alzheimer's disease (a progressive brain disorder, the most common cause of dementia, characterized by memory loss, impaired thinking, and behavioral changes), candidiasis (a common fungal infection caused by an overgrowth of Candida yeast), and dysuria (painful or uncomfortable urination). Record review of Resident #12's face sheet, dated 12/09/2025, revealed, a 76-years-old female admitted on [DATE]. Resident's #12's diagnoses displaced trimalleolar fracture of right lower leg (broken three parts (malleoli) of your ankle joint-the inner (medial), outer (lateral), and back (posterior)-with the pieces shifted out of place, a serious injury requiring surgery), dementia (severe mental function loss (memory, thinking, language, problem-solving) impacting daily life), and insomnia (a common sleep disorder making it hard to fall or stay asleep, causing daytime fatigue, concentration issues, and irritability). Record review of Resident #13's face sheet, dated 12/09/2025, revealed, a 72-years-old male admitted on [DATE]. Resident's #13's diagnoses acute posthemorragic anemia (a serious condition from rapid, significant blood loss), unspecified protein-calorie malnutrition (a person isn't getting enough protein and calories causing fatigue, weight loss, muscle wasting, and increased illness risk), and cerebral infarction (when a blood clot blocks an artery in the brain, cutting off oxygen and nutrients, leading to brain tissue death). Record review of Resident #14's face sheet, dated 12/09/2025, revealed, an 84-years-old male admitted on [DATE]. Resident's #14's diagnoses paraplegia (inability to voluntarily move the lower parts of the body), seizures a temporary disruption of the brain's electrical activity, causing sudden, uncontrolled changes in behavior or/and movement), and Parkinson's disease a progressive neurological disorder caused by dopamine-producing brain cells dying, leading to movement issues like tremors, stiffness, and slow movement). Record review of Resident #15's face sheet, dated 12/09/2025, revealed, a 94-years-old female admitted on [DATE]. Resident's #15's diagnoses included dementia (severe mental function loss (memory, thinking, language, problem-solving) impacting daily life), urinary tract infection and hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing down the body's functions). Record review of staff in-service dated 12/09/2025 and titled Kiosk revealed, Turn off the Kiosk when you walk away, do not leave the screen on. Could be a HIPAA violation if seen by a family member or others. Check before leaving that it goes off. This training was provided by DON B and completed by 11 nursing staff members including CNA L. Record reviews did not reveal in-services on HIPAA completed by CNA L and documented before this incident.Record review of Residents Rights policy, undated, revealed, The resident has a right to secure and confidential personal and medical records.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 4 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was within reach on 03/22/2025. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 03/22/2025 documented an [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: hypertensive heart disease with heart failure(high blood pressure damage the heart and blood vessels), hyperlipidemia(high levels of fat particles in the blood),hypokalemia(blood level that s below normal that result in fatigue, muscle cramps, and abnormal heart rhythms),parkinsonism(cause tremors and slow movements, and depression(sadness). Record review of Resident #1's Quarterly MDS assessment, dated 02/05/2025, revealed the resident had a BIMS score of 12 indicating the resident had moderate cognitive impairment. The MDS also revealed Resident #1 required partial/moderate assistance in the areas of Toileting hygiene, shower/bathe self, lower body dressing, and putting on /taking off footwear. Record review of Resident #1's care plan, dated 03/22/2025, revealed Resident #1 was care planned for ADL self-care performance deficit r/t impaired balance, stroke, and PD. Resident # 1 had an intervention of: Encourage Resident #1 to use call light for assistance. Observation on 03/22/2025 at 12:50 PM., revealed Resident #1's call light was under her bed, in the middle, not in reach. During an interview on 03/22/2025 at 12:50 PM, Resident #1 stated it had been out of reach since early morning. Resident # 1 was not able to recall how long the call light was not in reach or the last time staff had come in to assist her. Resident # 1 stated she needed to be changed and was waiting on staff to pass by her room to call out for staff to assist her. Resident # 1 stated when the call light was not in reach, she would just wait for staff to come to her room. Resident # 1 stated she really didn't want to say too much because she had to stay there and did not want the facility to retaliate against her During an interview on 03/22/2025 at 2:29 PM, CNA A stated CNAs should make rounds at least every two hours or as needed. CNA A stated that CNAs should be checking to see if call lights were in reach. CNA A stated she had left Resident # 1's room around 12:30 PM, and the call light was in place when she had entered the room (time entered not recalled). CNA A stated the call light may have fell of when she made Resident #1's bed. CNA A stated she could not recall if the call light was tied to the bed rail when she had left Resident #1's room. CNA A stated if a resident's call light was not within reach, then the resident needs would not have been met. During an interview on 03/22/2025 at 3:10 PM, the DON stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The DON stated the purpose of a call light was for resident to notify staff when they needed assistance. The DON stated if a resident's call light was not in reach, then the resident could have an unmet need. The DON stated her expectation was that all resident's call lights were always within reach so the resident could notify staff they need assistance. During an interview on 03/23/2025 at 1:45 PM, the ADM stated the purpose of call light was for the residents to alert staff when they needed assistance. The ADM stated it was everyone's responsibility to ensure call lights were always within reach. The ADM stated that if a call light was not within reach, then a resident desired need would not be met. The ADM stated that she expected for call lights to be always within reach and answered timely. Review of the facility's Call Lights: Accessibility and Timely Response policy, implemented 05/01/2024 and revised 05/01/2024, reflected, Purpose: The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance. Policy Explanation and Compliance Guidelines 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 5.Staff will ensure the call light is within reach of the resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for hall 300, 400 and room [ROOM NUMBER]. The facility failed to ensure the carpet in the hallway between room [ROOM NUMBER] and 304, was in good repair. The facility failed to ensure the carpet in the doorway to room [ROOM NUMBER] was in good repair. The facility failed to ensure the flooring in the doorway into room [ROOM NUMBER] was in good repair. The facility failed to ensure the flooring on 400 hallway was kept in good repair. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 09/16/24 at 10:30 a.m., revealed snags in the carpet near room [ROOM NUMBER], a snag in the carpet in the entry way to room [ROOM NUMBER]. An observation on 09/16/24 at 10:33 a.m., revealed worn and stained carpet in the 300 halls. The stained carpet was visible in the remaining carpeted rooms on the 300 halls. An observation on 09/16/2024 at 10:45 am, on the 400-hall revealed deep staining in several areas throughout the entire hallway. An observation on 09/17/24 at 10:00 a.m., revealed the flooring on room [ROOM NUMBER] did not reach the threshold molding and was slightly curled at the end. Interview on 09/17/24 at 9:40 a.m., with a housekeeping aide revealed that they clean the floors as best they can, they sweep and vacuum every day. She stated that they are unable to get all of the stains from the carpet. They can get some stains up, but they are unable to get the deep stains out. She stated recently started working here but they stains were here when she came to work here. Interview on 09/18/24 at 10:23 a.m., with the Maintenance Supervisor revealed he was aware of the issues with the carpet on 300 and 400 halls. He stated that facility has put in an RFP for new flooring. He stated that RFP had an estimate for the replacement of the flooring. He stated that they have not heard anything back from corporate at this time. He stated he was not exactly sure when this request was sent in, and he was not able to provide a specific date. Interview on 09/18/ 24 at 10:27 a.m., with the Maintenance tech stated that they have been using tape in bad places in the carpet. He stated he just does what he is told to do and does not know what goes on above him. He stated he has not noticed the areas of snagged carpet shown to him. He stated that he would cover the areas with tape. He stated that they try to keep the carpet as clean as possible but at this point there is little they can do to help the appearance as this may be original to the building. He stated that the threshold in room [ROOM NUMBER] may need to be replaced, but he could put tape there to secure the flooring until it can be fixed permanently. He stated that he understands it could pose as a tripping hazard to residents, who live or walk thru those areas. Interview on 09/18/24 at 1:25 p.m., with the DON revealed that she was aware the carpet was stained and faded but was unaware of the snags in the carpet. She was also unaware of the issue with the flooring in room [ROOM NUMBER]. She stated she understood a resident could suffer a break, tear or death from a fall from for the snags in the carpet and loose flooring. Interview on 09/18/24 at 2:15 p.m., with the Administrator revealed that the facility is leased, and they have requested repairs to the carpet but are waiting on the landlord to approve the decision. She stated that she is aware of the condition of the carpet as far as wear and the staining in different areas of the carpet. She stated that she understands a resident or staff member may injured if they were to catch something on the carpet or flooring.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for four of four halls (Halls 100, 200, 300, and 400) and the nurse's station, conference room, lobby, and main dining room reviewed for pest control program. The facility had live flies and gnats in areas of the facility including the nurse's station, Halls 100, 200, 300, 400, nurse's station, conference room, lobby, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: An observation on 09/16/24 at 9:00 a.m., revealed in the front lobby there were three gnats flying around the front door. The food service carts were sitting outside of the kitchen door. There were three flies flying around the closed food carts. The flies landed and started crawling on the closed food carts. An observation on 09/16/24 at 9:15 a.m., revealed a live fly and a gnat flying in the conference room. An observation on 09/16/24 at 9:20 a.m., revealed a gnat crawling on top of the nurse's station. An observation on 09/16/24 at 9:20 a.m., revealed as the surveyor entered Hall 400 a live fly flew past down the hallway. An observation on 09/16/24 at 9:30 a.m., revealed three live flies flying down Hall 300 and a group of five gnats at the end of Hall 300. An observation on 09/16/24 at 10:00 a.m., revealed a live fly flying down Hall 100 and at the end of the hallway a live fly was crawling on the exit door. An observation on 09/16/24 at 10:45 a.m., revealed a live mosquito flying in the Administrators office. An observation and interview on 09/16/24 at 12:15 p.m., revealed a live fly crawling on a table in the dining room with a glass of juice on it. The fly lit on the lip of the glass. The resident returned to the table. The surveyor informed the staff in the dining room there had been a fly on the lip of the glass, the staff got a new glass of juice. Interview with MA A revealed it was the time of the year for the flies to be bad, the MA stated they come in the door that is in the dining room that goes outside and the front door. MA A stated there was a book at the nurses' station to write the fly sightings in, but she had not written anything in it lately. An observation on 09/16/2024 at 12:25 p.m., revealed a live fly flew out the main door of the dining room. An observation on 09/17/24 at 8:20 a.m., revealed a live fly crawling on the linen cart on Hall 100. In a confidential group meeting on 09/17/24 at 10:10 a.m., revealed a resident stated there were mosquitoes in the facility. An interview on 09/17/24 at 2:40 p.m., CNA B revealed there was a pest control book at the nurse's station, as she took the surveyor and showed her the book. CNA B stated if we see any pest we are to write in here. CNA B stated she had not seen any pest, but she had seen the pest control man here. An interview on 09/17/24 at 3:15 p.m., CNA C revealed there was a pest control log at the nurse's station. CNA C stated she would write in that book if she saw pest. CNA C stated she had not seen any flies. Record review of the pest control book reflected a log with no notations of flies, gnats, or mosquitoes. An observation on 09/17/24 at 4:00 p.m., in the men's bathroom located near the nurse's station revealed a large cloud of gnats swarmed in and out of the drain located in the middle of the bathroom. An interview on 09/17/24 at 7:45 a.m., LVN D revealed there was a pest control book at the nurse's station. LVN D stated she had seen some bugs recently and had documented in the pest control book and the pest control man had come. The pest was not flies, they were roaches, she stated she had not seen any more of them lately. LVN D stated the residents will also tell us and we will document in the pest control logs. An interview on 09/18/2024 at 1:21 p.m., Resident #47 revealed she had seen a mosquito in her room, she could not recall when that was, but she knew it was a mosquito, buzzing around her face. Resident #47 stated she did not think to tell anyone, it went away, and she did not see it anymore. An interview on 09/18/24 at 1:27 p.m., the Administrator revealed the pest control services was just here on the past Monday. The Administrator stated the pest control company would be contacted to come. The staff is supposed to document in the pest control log at the nurse's station. The Administrator stated if the pest were not controlled, they could spread germs. Record review of facility provided pest control visits revealed, in part, dates and treatments as follows: Treatment dates and services performed: -09-04-2024-after inspection . verified active fruit fly and gnat activity in kitchen, drains need to be cleaned better, built up food . treated the kitchen drains. -8-23-2024- after inspection . treated hallways, in kitchen . dish sink area drains flies . -06-28-2023- after inspection . targeted pest throughout the facility treated . drain flies, flies, gnats, fruit flies, and mosquitoes . treated hallways, reception, office areas, laundry, kitchen storage sink area, restrooms, recreation storage area for small and large flies, serviced fly light station. Record review of the facility's policy revised, April 2024 and titled Pest control Program reflected it is the policy of this facility to maintain an effective Pest control program that eradicates and contains common household pest and rodents .definition . effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats).

Based on interview and record review, the facility failed to ensure that the facility's Medical Director attended the QAA/QAPI Committee meetings, for 3 of 3 quarterly meetings ( July, August, September 2022, October, November, December 2022 and January,February, March 2023), reviewed for QAA/QAPI. The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of July 2022 through March 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of July 2022 through May 2023, revealed the Medical Director had not attended any of the meetings for the QAA/QAPI Committee, during those months. There were no notation indicating the Medical Director had attended any of the meetings by telephone or zoom. During an interview on 07/25/2023 at 11:35 AM, the Administrator said the QAA/QAPI met monthly, but no less than once per quarter. She said she realized the Medical Director was not in attendance for the QAA/QAPI meetings for the months of July 2022 through May 2023, but she could not say why he was not in attendance. She said she was not the Administrator at that time, she became the Administrator in September 2022 and could not speak to anything prior to that. She said there was no indication the Medical Director had attended any of the meetings between July 2022 and May 2023, nor by telephone or zoom, nor did he have a designee assigned to attend in his place. During an interview on 07/25/2023 at 12:15 PM, the medical director said he thought he had attended at lease two QAA/QAPI meetings. He was shown the sign in sheets and agreed that if he had not signed in there was no proof that he was there, he said if it wasn't signed it wasn't done. He also said he did not attend via telephone and did not have a designee assigned to attend in his place. Review of the facility's Quality Assurance and Performance Improvement (QAPI Plan Revised April 2014) revealed, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide, QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Authority: 1. The owner and/or governing board(body) of our facility shall be ultimately responsible for the QAPI Program. 2. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal,state and local regulatory agency requirements. Implementation: 2. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees .S483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection preventionist.

Based on observation, interview and record review, the facility failed to ensure that the resident was free from any significant medication errors for (Resident #1) of 5 residents reviewed. This facility failed to administer insulin medication for (Resident #1) according to the doctor's order. Resident #1 was administered a long- acting insulin (released over time), the resident should have been administered short acting insulin (taken daily before meals). This failure could place residents at risk of jeopardizing their health by not receiving medications as ordered. The noncompliance was identified as PNC (Past non-compliance). The non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. Findings Include: Review of Resident #1 face sheet undated reflected, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 quarterly MDS assessment dated [DATE] revealed, he has a BIMS score of 12 indicating mild cognitive impairment. Review of Resident #1 care plan dated [DATE], reflected the following: The resident will be free from any symptoms or signs of [CONDITION(S)] (Low blood glucose level) and the resident will have no complications related to diabetes. Interventions reflected Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of LVN A, progress note dated [DATE], reflected the following: This nurse was getting supplies to check blood sugar and checked insulin pens. Resident has 2 insulin pens. This nurse set both pens on top of cart. I checked order and resident's name to be on the pens. When grabbing supplies to take to resident's room this nurse grabbed the wrong insulin pen and administered [MEDICATION(S)] instead of [MEDICATION(S)] which is a routine medication he receives in the morning. When this nurse noticed she gave the wrong insulin pen this nurse immediately notified charge nurse of what had happened and charge nurse gave orange juice while this nurse called Doctor [NAME]. Doctor [NAME] ordered this nurse to check blood sugar every 15 minutes for 2 hours. This nurse checked blood sugar before giving insulin and blood sugar was 86. After giving insulin, eating cookies, drinking orange juice with sugar, and milk resident blood sugar was checked and blood sugar reading was 88. Doctor [NAME] was notified of blood sugar and ordered dextrose 5% via IV and resident refused. Doctor [NAME] also ordered this nurse to give resident Glucogon shot. Doctor [NAME] also ordered for this nurse to send resident to the hospital. Review of the Facility investigation dated [DATE], reflected Resident # 1 was administered 34 units of [MEDICATION(S)] 100units/nL- sliding unit, but should have been administered [MEDICATION(S)] 100 unit /mL (34 units) which is given daily. The investigation reflected, Resident # 1 was given milk, cookies, orange juice, and a glugon shot. The report indicated that Resident # 1 was stable, and did not have symptoms of [CONDITION(S)] at the time of his discharge to the hospital. Resident # 1 was sent to the hospital for IV glucose and observation, the report reflected that Resident # 1 did not have any adverse- affects from the medication error. The investigation reflected, that LVN A was immediately removed from the floor, confirmed findings (that this was a significant medication error), the nursing staff were in-served on long acting and fast acting insulin and insulin administration. The report reflected that LVN A, would be doing vitals signs only under the supervision of the DON until further notice. Review of the MAR, revealed, Resident #1 had orders for the following diabetic medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Medication Order date- [DATE]- [MEDICATION(S)] Solution 100 UNIT/ML (Insulin Degludec) Inject 34 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus. Long- acting 2. Medication order date - [DATE]-[MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial)) Inject subcutaneously one time a day related to Type 2 Diabetes Mellitus. Short-acting Review of medical records dated [DATE], EMS (emergency medical service) arrived at 8:44 am - per hospital records Resident #1 arrived at the hospital at 8:52 am. Resident #1 was admitted to the hospital and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 remained in the hospital for IV of D5W (saline with glucose/sugar) treatment and monitoring. Resident #1 was discharged back to the facility at 12:48 pm on [DATE]. Per hospital records the residents blood glucose levels remained stable with the lowest reading at 79 (normal ,d+[DATE]). Interview on [DATE] at 3:45pm with Resident #1, revealed he is not able to recall any of the events that took place. He stated he was in this facility because in [DATE] he had a diabetic black -out. Resident # 1 stated that he did take insulin, however, was not able to recall the recent incident. During a phone interview on [DATE] at 10:00am with LVN A, stated she was scheduled to work the 6am to 2pm shift on [DATE]. She stated approximately 8:32am she was getting Resident #1 medication ready and took out both insulin pens. She stated as she was checking the MAR to ensure she had the correct medication; she turned and grabbed the wrong pen and administered the resident the wrong medication. She stated she gave Resident #1; 34 units of [MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial). Inject subcutaneously one time a day related to Type 2 Diabetes Mellitus. She stated she should have been given the [MEDICATION(S)] Solution 100 UNIT/ML (Insulin Degludec) Inject 34 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus. She stated that she immediately notified the charge nurse of her mistake. During an interview on [DATE] at 10:50am with the DON, she stated she a call from the charge nurse on duty that day [DATE] regarding the medication error and immediately came to the facility. DON stated the resident was administered the wrong medication and the wrong dosage of medication. She stated LVN A, gave the Resident # 1, 34 units via IV of [MEDICATION(S)] Solution 100 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial)) Inject subcutaneously one time a day related to Type 2 Diabetes mellitus, she stated the resident should have been given [MEDICATION(S)] Solution Pen/Injec 100 UNIT/ML (Insulin Degludec) Inject 34 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus. She further stated by giving the resident this medication the resident could have died due to low (BGL). The DON stated all new staff are trained with a tenured nurse before going out on the floor. She stated all nursing staff are trained on medication administration. During a phone interview on [DATE] at 3:30pm with Pharmacist, revealed that giving a resident the wrong dosage of the [MEDICATION(S)] 100 unit/nl sliding scale could have different effects. He stated it could cause nausea, dizziness, confusion, could cause the person blood sugar levels to drop and send the person into [CONDITION(S)]. He stated if the person was given the [MEDICATION(S)] shot (given if a person has had an over- dose of this medication) the resident must have been having an adverse effect. During a phone interview on [DATE] at 3:50pm with PCP, revealed the resident should have been given the long- acting insulin which is the [MEDICATION(S)] Solution 100 UNIT/ML (Insulin Degludec), instead of the short-acting [MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML 34 units. He stated when he received the call from the nurse (could not remember the name) he advised to give the resident orange juice, milk, cookies, and a [MEDICATION(S)] shot. He further stated after the snacks given and the [MEDICATION(S)] shot the residents blood sugar level was at an 88 and he advised that the resident be sent to out the hospital for further evaluation and treatment. He stated if the levels get too low the person could have a [CONDITION(S)], lower potassium that could cause heart arrythmia or heart failure (death). During an interview on [DATE] at 4:20pm with ADM, revealed once notified of the incident she and the DON immediately came to the facility and removed LVN A from the floor. She stated LVN A, administered the wrong medication to Resident #1. She further stated it was her expectation that any staff administering medications follow their policy and procedure when verifying and ensuring that they are giving the correct medication, to the correct person, and the correct dosage. She stated this medication error could have been much worse for the resident. She stated all nursing staff are trained and have regular in-services conducted by the DON. During an interview on [DATE] at 1:25pm with LVN B, stated she was working the day of the incident [DATE]. She stated LVN A came and got her stating she messed up and gave a resident the wrong medication. She stated they immediately contacted the PCP and was advised to give the resident orange juice, milk, cookies, and the [MEDICATION(S)] shot. She further stated they stay on the phone with the doctor after giving the snacks and Resident #1 BGL was at 88, he advised to send the resident to the hospital for further treatment. LVN B stated, if they wouldn't have caught the error in time the residents BGL could have dropped and could have caused him to become unresponsive and possibly die. During an interview on [DATE] at 4:50pm with LVN C and LVN D, stated they were trained on the 10 steps of medication administration, insulin administration, the difference in long acting and Fast acting insulin. LVN C and LVN D reported the long acting and short acting pens and vials have been marked for visual queuing to help them ensure that they have the correct medication. The stated when giving any medications the MAR should be checked at least three times before any medication is administered. Record review of Resident #1 BGL readings dated [DATE], reflected BGL initial reading at 86, after wrong medication administered and snacks provided the reading reflected 88. Record review of Resident #1 BGL readings prior to [DATE] before the medication error occurred and after Resident #1 returned from the hospital on [DATE], the BGL's are as follows: [DATE]- 11:22 96mg/dL [DATE]- 07:40 102 mg/dL [DATE]- 07:14 101 mg/dL [DATE]- 07:29 94mg/dL [DATE]- 07:21 92mg/dL [DATE]- 12:33 86mg/dL Once resident returned from the hospital the readings were as follows: discharged from Hospital on [DATE]: [DATE]- 08:14 117mg/dL [DATE]- 07:55 102mg/dL [DATE] -07:22 123mg/dL [DATE]- 08:19 113mg/dL [DATE]- 07:28 107mg/dL [DATE]- 07:33 173mg/dL Records review of facility in-services and safety measures revealed the facility took the following steps prior to surveyor entering the building for past non-compliance: 1. The LVN was immediately removed from the floor suspended for 6 days, given a written warning. LVN is not able to administer medications currently. LVN is only able to do vital signs while under the supervision of DON. 2. Staff trained on [DATE] - 10 step medication administration training. Signed by nursing staff 3. Nursing staff training on [DATE]- long-acting vs fast acting insulin the difference. Signed by nursing staff 4. All insulin medications labeled long/ short acting with different colors to allow for a visual queuing 5. Facility followed their own internal policy on medication administration 6. LVN A was trained on insulin by the facility prior to the incident. Record review of employee personnel file and disciplinary document revealed LVN A received a written warning. Review of LVN A time sheets, revealed the time reported by DON of suspension for 6 days [DATE]-[DATE]. Observation of LVN A clinical skills trainings which included the following: Administering a subcutaneous injection Glucose testing and Proficiency Nutrition, hydration, and medication administration Observation at 4:46pm, on [DATE] of insulin administration, by LVN C. Per MAR in the PCC (Point Click Care) system the order for this observation stated. Hum along solution 100 unit/ML(Insulin [MEDICATION(S)]) vial sliding scale before meals and at bedtime. LVN C verified residents name on the MAR and medication vial, verified date [DATE] of medication on MAR and vial, cleaned glucometer allow to dry for 2min before using / to check the blood glucose level, observed wearing gloves / sanitized hands before putting on gloves, explained to resident what she was preparing to do, explained what medication she was preparing to give the resident, cleaned table to set up medication, got out first test strip (for glucometer machine), used alcohol pad clean resident finger before taking reading, BGL reading 195, LVN C sanitized her hands after taking the reading to prepare the insulin, set out lancet gauze, LVN C administered the insulin medication in residents lower abdomen, cleaned machine with anti- bacterial wipes let dry for 2min. LVN C cleaned in between each resident, changed gloves at the end clicked button in PCC (Point Click Care) system that the medication had been administered. Observation at 5:45pm on [DATE], of medication labeling of long acting/short acting insulin medications, labeled in red for visual queuing. Policy Reviewed regarding Administration Medications dated, [DATE] indicated the following: Policy: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and / or have related functions 3. Medications must be administered in accordance with the orders, including any required time frames 26. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 27. The charge nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned.

Based on interviews and record review, the facility failed to ensure the Activity Program was directed by a qualified professional for one (Activity Director) of one activity-directing professional reviewed for quality of life. The facility failed to ensure Activity Director was qualified to direct the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. Findings included: Review of personnel records on 05/06/22 revealed no evidence that Activity Director had completed the required activity director course. Interview on 05/06/22 at 12:54 PM with Activity Director revealed she had not completed the required activity director course. She stated her anticipated completion date was in three weeks. She stated the Social Worker and herself provide activities to the residents daily. She stated there was a May 2022 activity calendar posted on a wall near the nurse's station. She stated the purpose of an activity director was to keep residents entertained and to give them something to do every day. Interview on 05/06/22 at 1:53 PM with Social worker revealed she had been assisting the Activity Director with activities for three weeks. She stated the facility did not have a certified activity director. She stated the residents participate in activities every day. She stated the importance of a qualified activity director was to improve a resident's quality of life. Interview on 05/06/22 at 1:51 PM with Administrator revealed the facility did not have a qualified activity director. She stated the facility has not had an activity director since 04/15/22. She stated she had given the Activity Director until 05/16/2022 to complete required activity director courses. She stated the Activity Director and Social Worker have been assisting residents with activities. She stated the importance of an activity director was to assist residents with their psycho-social needs. She stated the facility did not have a policy for regarding a qualified activity director.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored in the facility's refrigerator, freezer, and dry storage. 2. The facility failed to ensure expired/spoiled foods were discarded. 3. The facility failed to ensure the floor in the freezer was free from spills and unpackaged food. 4. The facility failed to ensure food on the steam table reached the appropriate temperature before plating food for resident consumption. These failures could place residents at risk for food-borne illness. Findings included: Observation of the facility's refrigerator on [DATE] at 10:44 AM revealed: - 1 plastic bag of meat open and exposed to air. Observation of the facility's walk-in freezer on [DATE] at 10:50 AM revealed: - A red spill on the floor - 3 individually packaged containers of butter on the floor - 2 sausage links on the floor Observation of the facility's smaller freezer on [DATE] at 10:55 AM revealed: - 1 box of Salisbury patties open and exposed to air. Observation of the facility's dry storage on [DATE] at 11:00 AM revealed: - 1 bag of Japanese style breadcrumbs open and exposed to air - 1 bag and box of thickener open and exposed to air Observation of the main area in the kitchen under a prep table on [DATE] at 11:10 AM revealed: - 1 white onion with black and fuzzy white spots Observation of milk storage in the main area in the kitchen on [DATE] at 11:15 AM revealed: - Spilt milk on the top of three boxes containing gallons of milk. Observation of Dietary Cook D checking food temperatures on the steam table on [DATE] at 11:45 AM revealed: - Ground beef with peppers were temped at 132F and again at 121F. - Puree ground beef with peppers were temped at 125F; and - Chicken strips were tempted at 150F Interview with substitute Dietary Manager on [DATE] at 12:20 PM revealed the ground beef with peppers and chicken strips were safe for residents to consume. She stated residents' trays would not be pulled and they will eat the food that has been temped and plated. Interview with DON and Administrator on [DATE] at 12:30 PM revealed the food temperatures were safe for residents to consume. They stated their facility policy revealed food could be served at a temperature of 115F. They stated there would be no adverse reaction to residents consuming chicken strips at 150F and ground beef with peppers at 132F, 125F, and 121F. Interview with Dietary Cook D on [DATE] at 3:06 PM revealed the ground beef with peppers should not have been served to residents because the temperature was too low and not safe to consume. She stated the temperature of the chicken strips were safe to serve residents. She stated beef and chicken must reach a temperature of 135F on the steam table before they are served to residents. She stated the substitute Dietary Manager was responsible for determining the accurate temperature for food to be served to residents. She stated the the substitute Dietary manager monitors temperatures for breakfast, lunch, and dinner. She stated the substitute Dietary Manager informed her the ground beef with peppers and chicken strips were at an appropriate temperature to serve to residents. She stated she received an in-serviced regarding food temperatures in [DATE]. She stated residents could become sick if food was consumed at the wrong temperature. In an interview with the substitute Dietary Manager on [DATE] at 12:43 PM revealed she had been the substitute dietary manager for one month. She stated she has ten years of experience as a cook, possesses her food handler's certificate, and educated regarding food temperatures and kitchen sanitation. She stated she was not classified as a qualified dietary manager because she had not completed her dietary manager courses. She stated she was responsible for overseeing the kitchen. She stated she completes walk throughs of the kitchen upon arrival to work, in between meals, and Thursdays on food truck arrival. She stated dietary staff have a cleaning chore list in the kitchen. She stated she ensured the dietary staff were educated and reeducated regarding the kitchen. She stated proper food storage and cleanliness of floors was important. She stated residents could be at risk of food borne illnesses. Review of the facility policy titled Food Receiving and Storage, dated [DATE], revealed, Foods shall be received and stored in a manner that complies with safe food handling practices.(5) The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: (a) poultry and stuffed foods - 165F. Ground meat, ground fish and eggs held for service - at least 115F. Review of facility policy titled Food Handling and Service, dated [DATE], revealed, To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. (1) Serve all hot foods at a temperature of 135F or greater and all cold food at 41F or less. (2) If hot foods drop below 135F, reheat to 165F for a minimum of 15 seconds. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, ,d+[DATE].15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Review of the Food and Drug Administration Food Code, dated 2017, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Review of the Texas Food Establishment Rules, dated 2015, reflected, Time/temperature controlled for safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius(165 degrees Fahrenheit) for 15 seconds.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #25) of four residents reviewed for environment. 1. The facility failed to ensure Resident #25's personal items were unpacked in her new room. 2. The facility failed to ensure Resident #25's recliner was moved into her new room. This failure could place residents at risk for diminished quality of life due to the lack of a homelike environment. Findings included: Review of Resident #25's MDS dated [DATE] revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were anemia, peripheral vascular disease, seizure disorder, anxiety disorder, and insomnia. Observation and interview in Resident #25's room on 05/04/22 at 11:15 AM revealed she had two boxes filled with personal items. She stated she had been in her new room for two weeks. She stated she returned from the hospital and was moved to a new room. She stated she did not remember why she was moved from her previous room. She stated she has asked staff to assist with unpacking her personal items and moving her recliner in her new room. She stated she does not feel like her room has a homelike experience because she does not have access to her personal items. Observation of Resident #25's previous room on 05/04/22 at 11:30 AM revealed there was an unused blue recliner. Review of Resident #25's electronic medical record on 05/05/22 revealed she had previously resided in a different room. Interview with CNA C and CNA D on 05/06/22 at 11:02 AM revealed they assist residents with room changes by moving their personal items. They stated Resident #25 has been in her new room for two weeks. They stated some of her personal items were in boxes and her recliner was not in her room. They stated she did not have enough space in her new room for all her items. They stated the resident had not asked them to assist with unpacking her items but requested her recliner be moved into her new room. They stated Resident #25 was moving into a new room with more space on 05/06/22. They stated Resident #25's room was not homelike because her items were not unpacked, and she did not have her recliner. They stated a homelike environment was important because the nursing facility was Resident #25's home. Interview with LVN B on 05/06/22 at 9:25 AM revealed Resident #25's recliner was moved into her new room on 05/04/22. She stated Resident #25 had personal items in boxes because there was not enough space to unpack her items. She stated CNAs assist with moving the resident's items and maintenance assists with moving resident's furniture. She stated Resident #25's recliner and personal items unpacked would help her have a home like environment. She stated residents need a home like environment to feel safe and enjoy living in the facility. Interview with DON on 05/06/22 at 1:09 PM revealed the Resident #25's requested a new room upon arrival from hospital and did not want to return to old room. She stated Resident #25 had a lot of personal items and her current room does not have enough space for the items. She stated Resident #25 was being moved from her current room to her previous room on 05/06/22. She stated Resident #25's items would be unboxed and her recliner would be in the new room. She stated Resident #25's items personal items boxed and not having her recliner did not affect her homelike environment. She stated a homelike environment was important for residents to feel at home and comfortable at the facility. Review of the facility policy titled Quality of Life - Homelike Environment, dated 04/2014, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised as appropriate for one (Resident #20) of four residents reviewed for care plans. The facility failed to revise Resident #20's care plan to reflect she slept in a recliner. This failure could place residents at risk of not receiving needed services and care. Findings Included: Review of Resident #20's MDS dated [DATE] revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were hypertension, renal insufficiency, diabetes, hyperlipidemia, non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, psychotic disorder, and hyperthyroidism. Review of Resident #20's most recent care plan, undated, revealed her care plan had not been revised to include she preferred to sleep in a recliner and not a bed. Observation on 05/04/22 at 11:35 AM revealed Resident #20 did not have a bed in her room. Interview with Resident #20 on 05/04/22 at 12:00 PM revealed she slept in a recliner instead of a bed. She stated she did not have a bed in her room and could not remember if she ever had a bed in her room. She stated her preference was to sleep in her recliner because is was more comfortable. Interview with LVN B on 05/06/22 at 9:25 AM revealed Resident #20 prefers to sleep in a recliner because her bed was uncomfortable. She stated Resident #20's bed was removed because she refused to sleep in the bed. She stated Resident #20 should be care planned to sleep in her recliner. She stated the MDS coordinator was responsible for revising resident care plans. Interview with MDS Coordinator on 05/06/22 at 11:22 AM revealed she was responsible for updating care plans. She stated Resident #20's care plan should have been updated once her plan of care changed. Resident #20 was sleeping in a bed upon admission to the facility then requested to sleep in a recliner. She stated she did not know when Resident #20 requested to sleep in a recliner. She stated Resident #20 should have been care planned to sleep in a recliner. She stated the purpose of a care plan was to educate staff about a resident's disease process and intervention. She stated Resident #20's care plan not being revised did not pose any risks. Interview with ADON on 05/06/22 at 1:44 PM revealed she was responsible for overseeing the MDS coordinator's completion and revision of care plans. She stated care plans were audited every week. She stated she reviewed Resident #20's care plan a few months ago. She stated Resident #20 slept in a recliner. She stated Resident #20 should have been care planned for a recliner. She stated she was not aware Resident #20's care plan had not been revised to include her recliner. She stated the importance of revising Resident #20's care plan was to educate everyone that her preferred method of sleeping was in a recliner. Review of facility policy, Care plans, Comprehensive Person-Centered, dated 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.

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Resident #41) of three residents reviewed for feeding tubes. LVN A failed to follow the facility's policy regarding administering medications via g-tube (gastrostomy tube). LVN A crushed seven medications together and administered them all at once to Resident #41. The failure placed residents at risk of obstruction of the g-tube and adverse drug interactions. Findings included: Record review of Resident #41's Admission Record, dated 07/07/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #41's diagnoses included dysphagia, cerebral infarction, muscle weakness, unspecified dementia and anxiety disorder. Record review of Resident #41's Annual MDS assessment, dated 04/08/22, revealed that Resident #41 had a feeding tube. Review of the Resident #41's May 2022 Medication Administration Record revealed the following medications were scheduled to be administered at 12:00 PM every day: Norco 5-325mg tablet, Amlodipine 500mg tablet, Aspirin 81mg tablet, Gabapentin 100mg Capsule, Lisinopril 20mg tablet, Carvedilol 12.5mg tablet and Miralax Powder 17gm. Review of the Resident #41's May 2022 Medication Administration Record revealed a doctor's order dated 05/04/22 may crush and mix all meds and dissolve in 4-6oz of water to administer via g-tube unless contraindicated. Observation on 05/05/22 at 12:00 PM revealed LVN A crushed Resident #41's medications and placed them in a medication cup. LVN A entered Resident #41's room and positioned the resident. LVN A checked the Resident #41's g-tube (gastrostomy tube) placement and residual and flushed the g-tube with 30 cc of water. LVN A mixed the medications in the cup with 30 cc of water and placed a syringe in the cup and pulled the plunger, pulling all of the crushed medications in the cup along with the water into the syringe. LVN A attached the syringe to the g-tube port and pushed the plunger, pushing the medications in via the syringe. LVN A then flushed the g-tube with 30 cc of water. In an interview on 05/05/22 at 12:30PM LVN A stated she crushes and mixes all of the medications together because that is the way she was trained, and she has an order from the doctor to cocktail the medications together. LVN A stated that she feels administering the medications one by one is best practice and mixing medications together may cause an adverse reaction. LVN A also stated that medications should be administered via gravity to prevent stomach pain or discomfort. In an interview with the DON on 05/05/22 at 1:14 PM revealed that nursing staff have been trained to administer medications upon hire. The DON stated that the facility policy stated to follow the doctor's order. The DON stated she felt best practice was to administer medications via g-tube separately and via gravity to avoid adverse reactions. Further interview revealed that the DON is responisble for ensuring proper medication administration is practiced within the facility. The DON was unable to provide a policy that stated to follow the doctor's orders over the facility policy. Review of LVN A's g-tube medication administration training dated 11/01/21 revealed she was trained to administer medications one at a time. Review of facility policy, revised March 2015 titled Administering Medications through an Enteral Tube, revealed, General Guidelines 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately. Steps in the Procedure, 26. If administering more than one medication, flush with 15ml warm sterile or purified water between medications.

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for one of three meals reviewed for meal accuracy: The facility failed to follow the menu or the meal ticket that was based off the lunch menu for 05/04/22. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss. The findings included: Review of the daily lunch menu for 05/04/22 reflected the date of Tuesday, sliced turkey with gravy, sweet potato, veggies, dinner roll, and salted caramel apples. Review of the residents' meal tickets, dated 05/04/22, revealed chicken pot pie, mixed green salad, saltine crackers, dressing of choice, and pumpkin pie. Observation on 05/04/22 at 12:30 PM revealed there were 15 residents eating lunch in the dining room. All 15 of the resident's meal tickets did not match the food they received or the daily menu. The residents were served pork loin, sliced steamed carrots, beans, and pie. Interview with substitute dietary manager on 05/06/22 at 12:43 PM revealed she had been the substitute dietary manager for one month. She stated the residents' meal tickets and daily menu on 05/04/22 were not updated because the system took a while to update to the current menu. She stated the meal tickets, and the daily menu were supposed to reflect the food the residents were served. She stated she was responsible for updating meal tickets and menus. She stated accurate meal tickets and daily menus were important because residents need to know what they will be eating. Interview with Administrator on 05/06/22 at 1:51 PM reflected the facility did not have a policy regarding meal tickets and menus.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for Resident #5. The facility failed to ensure Resident #5's catheter bag and tubing did not drag/lie on the floor. These failures placed residents at risk for cross-contamination and spread of infection. Findings included: Review of Resident #5's Face Sheet, printed date 12/14/2020 revealed he was a [AGE] year old male readmitted on [DATE] with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's initial Minimum Data Set ((MDS) dated [DATE] revealed he had a Brief Interview of Metal Status was score a 12 indicating cognitively intact. Review of Resident #5's most recent interim plan of Care, dated 12/07/2020, revealed Resident #5 was continent -Catheter; at risk for Ulcer- incontinent bowel; encourage fluids and wears briefs. Resident #5 had a Foley catheter with an order size 16 French:10 cc, assesses for continued use, encourage fluids, Diagnosis: [REDACTED]. In an observation on 12/14/2020 from 3:50 PM through 4:20 PM revealed Resident #5 was in his wheelchair in his room completely nude with his door open. Resident #5's catheter bag and tubing were lying flat on the floor and the resident was rolling over the bag and tubing with the wheels of his wheelchair. In an observation on 12/14/2020 at 4:10 PM, Resident #5 was in his wheelchair in his room completely nude with his door remaining open. His urine bag and tubing were observed to be lying flat on the floor in a manner the resident was rolling over the bag and tubing with the wheels of his wheelchair. The urine bag was not in a privacy bag and there was a plastic bin in his lap. In an observation on 12/14/2020 at 4:20 PM, Resident #5 was in his wheelchair in his room completely nude with his door remaining open. His urine bag and tubing were observed to be lying flat on the floor in a manner the resident was rolling over the bag and tubing with the wheels of his wheelchair. The urine bag was not in a privacy bag and there was a plastic bin that was now under his chair. Interview on 12/14/2020 at 4:23 PM LVN C had an aide close Resident #5's door and stated she expected a cover over his catheter bag, to be below the bladder and be attached to the wheelchair in a manner so it is not left on the floor and did not drag on the floor. Interview on 12/14/2020 at 7:15 PM the DON stated she expected catheter bags and tubing to not touch the floor or drag on the floor. She stated catheter bags should be gravity draining and off the floor with no kinks. Interview on 12/14/2020 at 7:52 PM DON stated catheter bags should be gravity draining, off the floor with no kinks and placed in a privacy bag. Interview on 12/14/2020 at 7:52 PM the Administrator stated her expectation was catheter bags should be gravity draining and off the floor with no kinks and placed in a privacy bag. Review of Nursing Services Policy and Procedure Manual for Long-Term Care Review of Urinary and Renal Conditions-Emptying a Urinary Drainage Bag-Level II revision dated October 2010 included the following: Purpose: The purposes of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain a sterile specimen. 9. Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage.

Based on interviews and record review the facility failed to consistently offer bedtime snacks to residents. Two identified Resident #43 and #51 as well as 6 confidential residents stated they were not consistently offered bedtime snacks. The facility's failure to offer nightly bedtime snacks to residents could cause residents to experience low blood sugar, hunger in the evening hours, have avoidable weight loss, and a diminished quality of life. Findings included: In an interview on 02/10/2020 at 11:16 AM resident #43 stated, sometimes there aren't any night time snacks. She said, she keeps some change in her room, so she can go to the vending machine to get something. She said she worries about her blood sugar getting too low and sometimes she gets hungry. During a confidential interview on 02/11/2020 at 1:30 PM 6 of 7 residents stated they were not offered or served a HS snack. They said snacks are delivered to the nurse's station, but there are not enough snacks for everyone. The residents stated often the snacks are gone before they can get to the nurse's station. The residents said not all residents are able to independently go to the nurse's station, those residents often go without a snack. In an interview with the DON on 02/11/2020 at 2:45 PM she stated she did not have a current procedure in place to be sure residents who are at risk for weight loss or have a [DIAGNOSES REDACTED]. She said currently the CNAs are tasked to take snacks to residents when requested. She stated she did not currently have a system in place to determine if HS snacks had actually been delivered. In an interview with the ADON on 02/12/2020 at 09:45 AM she said a tray of snacks is brought to the nurse's station each evening around 7:00 PM. Residents come to the nurse's station to get snacks as wanted. The CNAs are responsible to take snacks to anyone they know wants a snack if the resident is unable to get to the nurse's station. In an interview on 02/12/2020 at 10:05 AM with Resident # 51, he said he was offered a snack last evening, he said it was the first time ever. In an interview on 02/12/2020 at 11:00 AM with resident # 43 she stated she was served a peanut butter and jelly sandwich at approximately 10:00 PM last night, she stated that's never happened before. Review of Resident #51's face sheet dated 02/12/2020, reflected a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident # 51's Quarterly MDS assessment dated [DATE] reflected Resident #51 was assessed to have a BIMS score of 11 indicating intact cognition. Review of Resident #43's face sheet dated 02/12/2020, reflected a [AGE] year-old female with an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident # 43's Comprehensive MDS assessment dated [DATE] reflected Resident #43 was assessed to have a BIMS score of 12 indicating intact cognition. Review of CNA task documentation sheets dated [DATE]20 through 02/11/2020 revealed residents were not offered a HS snack during that time period. Review of a printed schedule of meal and snack times provided by the facility on 02/12/2020 reflected snack times listed as 10am, 2pm, and 8pm. Review of a facility policy titled Frequency of Meals, with a revised date of July 2017, reflected the following: 5. Nourishing snacks will be available for residents who need or desire additional food between meals. 6. Evening snacks will be offered routinely to all residents.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Multiple staff members were observed not washing or hand santizing their hands while passing lunch trays. Multiple sinks were also in need of repair and did not have hot water for handwashing. This deficient practice could place residents in the dining area of sickness and spreading of communicable diseases. Findings Included: An observation on 2/10/20 at 12:11 PM revealed 26 residents in the dining room waiting for lunch trays to be served. There were no hand sanitizer dispensers located in the dining room. An observation on 2/10/20 at 12:20PM revealed a closed door next to the food prep room. The surveyor stood by this door and noted that nobody entered or exited through this door to wash their hands. In an interview on 2/10/20 at 12:26 PM CNA-B stated kitchen staff prepared plates in the prep room and placed them on a tray. The trays were placed on a cart where the staff picked up the trays and delivered the plate to each resident. In an interview on 2/10/20 at 12:28 PM ADON was asked if there was a handwashing station available for staff, it was reported that staff were to wash their hands at the handwashing station next to the drink area, or in the utility room. She pointed out the utility room and pointed to the closed door, next to the food prep room. An observation on 2/10/20 at 12:29 PM the surveyor entered the utility room, that had been indicated by ADON. Surveyor noticed a small stainless-steel sink that was dry and had streaks of dry white residue in the sink. When the cold-water knob was turned, no water flowed from the faucet. When the hot-water knob was turned, cold water came from the faucet. The water remained cold after running for several minutes. The paper towel dispenser was empty. There was no trash receptacle located in the room for paper towel disposal. In an interview on 2/10/20 at 12:30 PM DA it was reported that she believed the housekeeping or maintenance department were responsible for stocking supplies for the hand washing sink in the utility room and providing a trash receptacle and for emptying the receptacle. An observationon 2/10/20 at 12:32 PM revealed the hand washing station next to the drink area, the hot water side never reached a warm temperature and remained as cold as the cold water after running for several minutes. In an interview ib 2/10/20 at 12:33 PM DON reported that a hand sanitizer dispenser is located in that hallway, outside the dining room. She stated her expectation is that staff will sanitize hands between serving trays. She stated the staff had hand sanitizer in their pockets. An observation on 2/10/20 at 12:36 PM revealed CNA-B scratch her head while walking back to retrieve a resident lunch tray from the cart. CNA-B then served food to the resident without washing or sanitizing hands. CNA-B touched the top surface of the plate of food with the same hand she had used to scratch her head. An observation on 2/10/20 at 12:38 PM revealed CNA-A as she returned an empty tray to a table, then repositioned the back of her shirt at the waist. She did not wash or sanitize hands before picking up a new tray to be delivered to a resident. An observation on 2/10/20 at 12:42 PM revealed LVN-A touched a wheelchair to move a resident to a different position. Then she picked up a new food tray to be delivered to a resident, without washing or sanitizing her hands. An observation on 2/10/20 at 12:43 PM revealed DON enter the dining room with several small bottles of hand sanitizer and began passing them out to CNAs standing by the food prep room. In an interview on 2/10/20 at 3:00 PM DON reported the hot water in the utility room had been corrected and that a hand sanitizer dispenser had been placed on the wall outside the food prep room in the dining room. She reported that they would instruct all staff wash their hands in the utility room prior to food service and before serving lunch. An observation on 2/11/20 at 12:27 PM revealed CNA approach the food cart outside the food prep room and asked the ADON Is this the room we are supposed to wash our hands in?, while she was pointing to the utility room. In an interview on 2/12/20 at 9:05 AM Administrator reported the hand washing sink next to the drink area did not have hot water, because a breaker had been flipped. She reported that the cold water in the utility room was discovered to have a kink in the line and plumbers were on the way to make repairs. She reported that it was her expectation that hand washing sinks would have hot water and her expectation was that staff would wash or sanitize their hands before serving food, and after touching unclean surfaces, wheelchairs, their clothing or their hair. Record Review of facility Handwashing/Hand Hygiene Policy Interpretation and Implementation revealed: All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; before and after eating or handling food; before and after assisting a resident with meals. Record Review of facility Handwashing/Hand Hygiene Policy Procedure revealed: The following equipment and supplies are necessary for hand hygiene; Alcohol-based hand rub containing at least 62% alcohol; paper towels; trash can. Washing Hands: Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash. Using Alcohol-Based Hand Rubs: Apply generous amount of product to palm of hand and rub hands together. Cover all surfaces of hands and fingers until hands are dry.

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for one (11/28/18 lunch meal) of two meal reviewed for meal accuracy. The facility failed to follow the menu or the meal ticket that was based off of the menu. This failure could contribute to dissatisfaction, poor intake, and weight loss. The findings included: Observation and interview on 11/28/18 at 8:30 a.m. revealed Resident #1's tray consisted of oatmeal, scrambled eggs, sausage, toast, and gravy poured all over her meal. She stated she liked gravy, but not all over her meat. She wanted gravy in a bowl. Resident #1 stated she mentioned it several times and keeps getting her tray that way and she gets tired of having the same food at breakfast all the time. She would like something different. Review of Resident #1 meal ticket dated 11/28/18 revealed 2 pieces of toast at breakfast with No gravy, Baked cheese omelet, Raisin toast, and grits. She stated was not aware of the Cheese Omelet and raisin toast and grits, but stated that it sounded good and she would have loved to eat it. Observation and interview on 11/28/18 at 8:45 a.m. revealed Resident #2 tray consisted of scrambled eggs, toast, oatmeal, and bacon. Review of Resident #2 meal ticket dated 11/28/18 revealed Baked Cheese Omelet, grits, raisin bread toast. Resident #2 stated she wished she had known she could have a cheese omelet, she would have liked that. Observation and interview on 11/28/18 at 9:00 a.m. revealed Resident #3 tray consisted of two fried eggs, one piece of toast, oatmeal, and bacon. Resident #3 stated the food tasted ok but, she got tired of the same two fried eggs every day. Review of the meal ticket dated 11/28/18 revealed Baked Cheese Omelet, over easy Eggs, Raisin toast, Toast, grits Resident #3 stated she did not know she could have a Cheese omelet and she would have like that. Review of Resident #3's meal ticket dated 11/28/18 revealed Baked Cheese Omelet, over easy Eggs, Raisin toast, Toast, and grits. In a confidential group interview on 11/28/18 at 9:35 a.m. revealed 5 out 8 residents stated menu not followed. Interview with Cook E on 11/28/18 at 11:35 a.m. revealed she did not cook baked cheese omelets and she only provided one resident grits. Interview with Dietary Manger on 11/29/18 at 11:45 a.m. revealed she did not serve baked cheese omelets and grits because the residents did not like them. She did not serve raisin bread because the bread man did not deliver it. Interview with Dietitian on 11/29/18 at 10:35 a.m. revealed menus should be followed. Substitutions should be documented on the substitution list or the menus should be revised according to residents' preferences. Review of the Diet Spreadsheet (Menu) for Week 1 Wednesday Day 4 Menu date 11/28/18 Breakfast revealed baked cheese omelet, grits cereal, and raisin toast. Review of Menu Substitution Log did not reveal food items substituted for 11/28/18 breakfast. Review of the facility's policy, titled Menus, revised date (MONTH) (YEAR) reflected .6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #6) of 20 residents reviewed for dignity. CNA A and OT B failed to promote dignity while dining when they stood over Residents #6 to feed him. These failures could place residents at risk of feeling uncomfortable, disrespected, decreased self-esteem and a diminished quality of life. Findings included: Review of Resident #6's MDS assessment dated [DATE] reflected Resident #6 was an [AGE] year-old male admitted to the facility on [DATE] from acute care hospital. [DIAGNOSES REDACTED]. Resident #6 required one-person physical assistance while eating. His functional limitation in range of motion reflected impairment on both upper and lower extremities. Observation on 11/27/18 at 12:31 PM revealed CNA A was standing over Resident #6, who was in bed, while feeding the resident. There was a chair on the left-hand side of Resident 6's bed that CNA A could have used to sit and assist with the meal. Interview on 11/27/18 at 12:35 PM revealed CNA A left the room to let OT B evaluate Resident #6's eating ability. CNA A stated he stood over Resident #6 while feeding the resident the noon meal. Observation on 11/27/18 at 12:36 PM revealed OT B observed standing over Resident #6's while spooning food into his mouth. A chair was located on the left side of the bed. Interview on 11/27/18 at 01:05 PM revealed OT B acknowledged she stood over Resident #6 while feeding him. She also acknowledged there was a chair available for her to sit in at that time. Interview on 11/30/18 at 11:00 AM with ADON, revealed staff should be sitting when assisting residents to eat and facing them at eye level. Review of undated Facility policy regarding Assisting with meals reflected the following: .When feeding or assisting resident make sure you are facing the resident and at eye level

Based on interview and record review, the facility failed to use the services of an RN (Registered Nurse) for at least eight consecutive hours a day, seven days a week for three days (08/20/17, 08/27/17, and 09/30/17) out of a 12 week period. The facility failed to have an RN on duty for eight consecutive hours for 7 days a week. This failure could affect 63 residents by placing them at risk of not receiving having their nursing and medical needs met. Findings included: Review of the facility's Punch Detail, dated 06/17/17 through 10/17/17, revealed there was not eight consecutive hours of coverage by a Registered Nurse on the following dates: 08/20/17, 08/27/17, and 09/30/17. There was no punch detail for the following dates: 08/20/17, 08/27/17, and 09/30/17. Interview on 10/19/17 at 10:33 am with the DON revealed for two of those days (08/27/17, and 09/30/17) the facility had call-ins. She stated she and another nurse were on call, but she or an RN did not work that weekend. She stated on 08/20/17 the overnight nurse clocked out at 6:15 a.m. Interview on 10/19/17 at 2:32 pm with the ADM revealed on 08/20/17 the midnight nurse was at the facility for 6 hours and 13 minutes. She stated on 08/27/17 she did not know what happened. She stated on 09/30/17 two RN's traded out, but the nurse that agreed to come in did not show up. The facility was unable to provide a policy regarding coverage by a Registered Nurse. The Form CMS 672, Resident Census and Conditions of Residents, signed and dated by the Director of Nursing on 10/13/17, reflected a census of 63 residents.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. Dietary personnel failed to properly store dispensing utensils and food items in the dry storage and walk-in freezer; 2. Housekeeper D failed to wear an effective hair restraint while in the kitchen to prevent contamination of food; and 3. Dietary personnel failed to follow proper grooming procedures for kitchen service personnel as Dietary Aide B was wearing painted nail polish and a stoned ring while and Dietary Aide C was wearing a long dangling necklace with a cross while serving food. These failures could affect sixty one residents who received their meals from the facility's only kitchen by placing them at risk for food- borne illness and food contamination. Findings included: 1. Observation of the kitchen on 10/17/17 at 9:26 a.m. revealed a measuring cup in the storage bin of rice. Interview with the Dietary Manager on 10/17/17 at 9:26 a.m. revealed the measuring cup was not to be stored in the rice storage bin and she removed it. Observation of the kitchen walk in freezer on 10/17/17 at 9:34 a.m. revealed a case of okra stored on the floor. Interview with the Dietary Manager on 10/17/17 at 9:34 a.m. revealed there were not much freezer storage space and items were not to be stored on the floor. She picked up the box of okra from the floor. Review of the facility policy entitled, Sanitation, dated 02/18/16 reflected, 4. Foods are stored at least 6 inches off the floor The Health and Human Services US FDA Code 2013 reflected, Preventing Contamination from Equipment, Utensils, and Linens 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour, or cinnamon Preventing Contamination from the Premises, 3-305.11 Food Storage (A) Except as specified in (B) (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash or other contamination; and (3) At least 15 cm (6 inches) above the floor 2. Observation of the kitchen on 10/17/17 at 9:27 a.m. revealed Housekeeper D entered the kitchen without a hair covering to stock supplies at the hand sink. Interview with the Dietary Manager on 10/17/17 at 9:28 a.m. revealed everyone entering the kitchen must wear a hair covering. She told Housekeeper D she is to wear a hair restraint when entering the kitchen and to put one on. Housekeeper D then put a hair covering on. Interview with the Housekeeper D on 10/17/17 at 9:45 a.m. revealed she had been trained on wearing a hairnet when entering the kitchen. She forgot to put one on before entering the kitchen. Interview with the Housekeeping Supervisor on 10/19/17 at 10:15 a.m. revealed all housekeepers are trained to wear a hair covering/hair restraint before entering the kitchen. The Health and Human Services US FDA Code 2013 reflected, Hair Restraints 2-402.11 Effectiveness . FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . 3. Observation of the kitchen on 10/18/17 at 11:32 a.m. revealed Dietary Aide B wore nail polish with a ring which had a green stone in it and Dietary Aide C wore a long gold necklace with a cross while handling resident tray line food items. Interview with the Dietary Manager on 10/18/17 at 11:32 a.m. revealed nail polish was not allowed and she never noticed the gold necklace until it was mentioned. She told both Dietary Aides this was not allowed. Dietary Aide C tucked her necklace in her shirt and Dietary Aide B stated she would remove the nail polish. Interview with Dietary Aide C on 10/18/17 at 1:52 p.m. revealed she was trained when she was hired in June 2017 on grooming procedures requirements for the kitchen and forgot to tuck her necklace in her shirt. Interview with Dietary Aide B on 10/18/17 at 1:55 p.m. revealed she forgot to remove her nail polish, and she was trained on not to wear nail polish and the stoned ring when she was hired a month ago. Review of the facility policy entitled, Personnel Management, dated 08/02/16 reflected, Attire . Hair should be clean and in a style appropriate for food service. Hair must be fully covered with a hairnet, hair bonnet, or chef hat at all times within the department Attire Prohibited . Artificial nails or nail polish .All jewelry except a smooth wedding band Grooming guidelines Fingernails should be kept clean and at a short length. Artificial nails of any kind and/or nail polish may not be worn in the kitchen The Health and Human Services US FDA Code 2013 reflected, Fingernails 2-302.11 Maintenance. (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD 4. Form CMS 672, Resident Census and Condition of Residents, signed by the DON on 10/18/17 reflected a total census of 63 with two residents nourished by tube feeding.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents, staff and the public for four of four halls reviewed for environment. The facility failed to ensure the handrails were not cracked, chipped, had rough edges and were in disrepair. This failure could affect all 63 residents by placing them at risk for diminished quality of life due to the lack of well-kept environment. Findings included: Observation on 10/18/17 at 9:41 a.m. revealed on 400 Hall between rooms 406 to 404, the handrail was in disrepair due to jagged rough scrapes. Observation on 10/18/17 at 9:50 a.m. revealed on 300 Hall, the corner handrail located by room 307 and 312 was in disrepair due to rough corner edges. Observation on 10/18/17 at 9:52 a.m. revealed at the beginning of 200 Hall, on the left side handrail and on the right side of room 220, the handrail was in disrepair due to scrapes and rough edges. Observation on 10/18/17 at 9:55 a.m. revealed on the 100 Hall, between rooms 105 and 110, the corner handrail was in disrepair due to jagged rough edges. Interview with the Administrator on 10/19/17 at 10:40 a.m. maintenance conducts handrail checks weekly. There was no system in place to notify maintenance on handrail repairs. Interview with the Administrator on 10/19/17 at 1:45 p.m. revealed maintenance would have to focus on one hall at a time to repair the handrails. Interview with the Maintenance Director on 10/19/17 at 2:50 p.m. revealed maintenance did not have a policy regarding preventative maintenance for handrails. Environmental rounds are done monthly. Review of the Maintenance Request Log logs from August 2017 until October 2017 revealed no entries for any of the observed handrail problems. Form CMS 672, Resident Census and Condition of Residents, signed by the DON on 10/18/17 reflected a total census of 63.