Every finding on record at Transylvania Regional Hospital

Based on observations and staff interviews, the facility failed to discard expired food items, label and date food items, and remove food items with signs of spoilage in 1 of 1 walk-in cooler; label and date a food item in 1 of 1 walk-in freezer; and label, date, and cover food items in 1 of 1 reach-in freezer. These failures had the potential to affect food served to residents.Findings included:1. An initial observation of the walk-in cooler on 11/24/25 at 9:47 AM revealed the following:a. a 5-pound bag of peeled garlic with a use by date of 11/20/25 sitting on a shelfb. Seven pints of grape tomatoes that contained scattered shriveled tomatoes and tomatoes with a white fuzzy substance sitting on a shelfc. an opened and undated bag of spinach that was wilted and contained a small amount of liquid sitting on a shelfd. a 5-pound bag of jalapeno peppers containing scattered shriveled peppers sitting on a shelfe. a bunch of fresh cilantro wrapped in plastic wrap with a use by date of 11/22/25 sitting on a shelf. The cilantro leaves had yellow and brown discoloration. f. Four bags of unopened and undated romaine lettuce containing scattered brown and watery leaves sitting on a shelfg. a bag of coleslaw mix with a use by date of 11/23/25 sitting on a shelfh. a box of limes with scattered brown spots sitting on a shelfi. an opened and undated 5-pound container of sour cream sitting on a shelf A telephone interview with the Dietary Manager on 11/25/25 at 12:47 PM revealed she expected all opened food to be labeled and dated, expired food to be discarded, and food with signs of spoilage to be discarded. She stated the supervisor who worked on 11/23/25 was responsible for checking the cooler to ensure all items were labeled and dated, no food items were expired, and all food items with signs of spoilage were discarded. The Dietary Manager stated she also checked for expired food items, unlabeled or undated food items, and signs of spoilage each time she worked, and she had been out sick 11/24/25 and 11/25/25. An interview with the Administrator on 11/25/25 1:56 PM revealed she expected food to be labeled and dated when opened, expired food to be used or discarded on or before the expiration date, and food with signs of spoilage to be discarded. 2. An observation of the walk-in freezer on 11/24/25 at 10:12 AM revealed an opened and undated bag of butternut squash sitting on a shelf. A telephone interview with the Dietary Manager on 11/25/25 at 12:47 PM revealed she expected all opened food to be labeled and dated. She stated the supervisor who worked on 11/23/25 was responsible for checking the freezer to ensure all items were labeled and dated. The Dietary Manager stated she also checked for unlabeled and undated food items each time she worked, and she had been out sick 11/24/25 and 11/25/25. An interview with the Administrator on 11/25/25 1:56 PM revealed she expected food to be labeled and dated when opened. 3. An observation of the reach-in freezer on 11/24/25 at 10:17 AM revealed an opened and undated box of turkey breakfast patties partially open to air sitting on a shelf. A telephone interview with the Dietary Manager on 11/25/25 at 12:47 PM revealed she expected staff to cover food, so it was not left open to air. An interview with the Administrator on 11/25/25 1:56 PM revealed she expected food to be covered and stored appropriately.

Based on observations, record review, and resident and staff interviews, the facility failed to assess a resident to keep over-the-counter hydrogen peroxide and lubricating eye drops in the resident's room for 1 of 1 resident reviewed for self-administration (Resident #8).The findings included:Resident #8 was admitted to the facility on [DATE].The Physician Assistant admission history and physical progress note dated 11/14/25 noted Resident #8 was alert and oriented with intact functional cognition.Review of Resident #8's medical record revealed he had not been assessed for self-administration of medication.An observation of Resident #8's room on 11/24/25 at 3:09 PM revealed one 32 fluid (fl.) ounce (oz) brown bottle of 3% hydrogen peroxide (over-the-counter antiseptic) on the overbed table and one 0.5 fl. oz bottle of lubricating eye drops (over-the-counter eye drops used to relieve eye dryness and irritation) on the counter by the sink.An observation of Resident #8's room during medication administration with Nurse #1 on 11/25/25 at 8:36 AM revealed one 32 fl. oz brown bottle of 3% hydrogen peroxide on the overbed table and one 0.5 fl. oz bottle of lubricating eye drops on the counter by the sink.During an interview on 11/25/25 at 11:06 AM, Nurse #1 revealed when he administered Resident #8's medications this morning, he did not notice the bottle of hydrogen peroxide on the overbed table, or the bottle of lubricating eye drops on the counter by the sink, or he would have removed them at that time. Nurse #1 stated residents were not allowed to keep medications or medicated liquids in their room.During an observation and interview on 11/25/25 at 9:45 AM, on Resident #8's overbed table was one 32 fl. oz brown bottle of 3% hydrogen peroxide and one 0.5 fl. oz bottle of lubricating eye drops on the counter by the sink. Resident #8 explained at times, he used the hydrogen peroxide to gargle and rinse his mouth when his mouth was sore which was what he did at home. Resident #8 also stated he kept lubricating eye drops on hand to use when his eyes were red and/or itching but had not had to use the eye drops since being at the facility. Resident #8 could not recall if he had brought the bottle of hydrogen peroxide and lubricating eye drops with him from home or if his family brought them to him at the facility.During an interview on 11/25/25 at 10:03 AM, the Director of Nursing (DON) confirmed Resident #8 had not been assessed for self-administration of medications. The DON stated residents were not allowed to keep medications or medicated liquids, such as hydrogen peroxide and lubricating eye drops, at bedside. The DON stated the items should have been removed by nursing staff and not left in Resident #8's room.During an interview on 11/24/25 at 1:54 PM, the Administrator stated nurses kept and administered all resident medications and residents were not allowed to keep medications or medicated liquids in their rooms.

Based on observations, record review and staff interviews, the facility failed to develop and implement Enhanced Barrier Precautions policy and procedures that included the use of Personal Protective Equipment (PPE) during high-contact care activities for residents with indwelling medical devices and chronic wounds. In addition, nursing staff did not don a gown while providing high-contact care for residents with indwelling medical devices for 2 of 2 nursing staff observed for infection control practices (Nurse #1 and Nurse Aide #1). Findings included: Review of the facility's infection control policy and procedures revealed no policy and procedure for Enhanced Barrier Precautions (EBP). a. An observation on 09/25/24 at 10:51 AM revealed Nurse #1 sanitized his hands and put on clean gloves but did not put on a gown. Nurse #1 proceeded to flush Resident #4's Peripherally Inserted Central Catheter line (abbreviated as PICC and refers to a long flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart). An interview with Nurse #1 on 09/25/24 at 10:55 AM revealed that he only wore gloves to flush the PICC line. He further stated that when the PICC line dressing or the PICC line itself needed changed, he wore a mask, gown and gloves. Nurse #1 stated that he had never heard of or received any education on EBP. 37538 b. During an observation on 09/25/24 at 10:06 AM Nurse Aide (NA) #1 provided urinary catheter care for Resident #57. NA #1 washed her hands with soap and water and donned a pair of gloves prior to the procedure. NA #1 did not don a gown. NA #1 held the catheter tubing approximately one inch away from the insertion site and wiped the tubing in the direction away from Resident #57. When finished with catheter care NA #1 discarded her gloves and washed her hands. During an interview on 09/25/24 at 10:15 AM, NA #1 revealed she did not wear a gown when she provided catheter care for Resident #57 because she did not receive instructions about EBP. She had not used EBP for residents with indwelling medical devices during high contact care activities and revealed the appropriate precautions were implemented if a resident had a specific organism that required it. A joint interview with the Director of Nursing (DON) and the Infection Preventionist (IP) was conducted on 09/25/24 at 11:07 AM. The IP revealed she had not informed staff to implement EBP during high-contact care activities. The IP stated she was not familiar with EBP and would need to update herself on the guidance for implementing EBP during high-contact care activities when a resident had an indwelling medical device. The DON revealed she had not informed nursing staff to implement EBP for residents with a PICC line or indwelling urinary catheter and was not familiar with the guidance for EBP related to indwelling medical devices. The DON revealed if a resident's lab identified the presence of a Multi Drug Resistant Organism (MDRO) an alert was sent to the nurse indicating the type of isolation precautions needed and it was the nurse's responsibility to implement the type of precautions by placing a sign on the resident's room door and bin of personal protective equipment by the door. An interview with the Administrator on 09/25/24 at 4:52 PM revealed she would expect staff had received education about EBP and were implementing the necessary precautions for indwelling medical devices.

Based on observations and staff interviews, the facility failed to store food items on a clean surface and maintain a clean floor in the dry food storage area and failed to discard thickened fluids as indicated by the expiration date. These deficiencies occurred in the kitchens dry food storage area and had the potential to affect food served to residents at the facility. Findings included: During initial tour of the kitchen on [DATE] at 9:01 AM with the Director of Dining Services revealed the following: a. Crumblike food debris on the plastic shelf covering in the dry food storage area where food items were being stored. b. Dark colored stains on the plastic shelf covering in the dry food storage area that appeared as if a liquid was spilled and left to dry where food items were being stored. c. The floor in the dry food storage area was noted to have food crumbs and other debris including unopened packets of condiments and other paper trash. d. Thirteen (13) four ounce containers of thickened water ready for use with an expiration date of February 2024. The expired water was removed by the Director of Dining Services. e. Six (6) 46 ounce containers of thickened sweet tea ready for use with an expiration date [DATE]. The expired sweet tea was removed by the Director of Dining Services. During an interview on [DATE] at 9:01 AM the Director of Dining Services revealed the cleaning schedule of the dry food storage area included to wipe clean the plastic shelf cover with soap and water every other month and the floor was swept and mopped twice a week and confirmed both the shelving and floor needed to be cleaned. The Director of Dining Services revealed the thickened liquids were available for use for the residents at the facility and it was an oversight those were not discarded as indicated by the expiration date on the container. During an interview on [DATE] at 4:42 PM the Administrator revealed the shelving and floor in the dry food storage area should be cleaned more often as needed and kept clean. She revealed expired items should not be stored and available for use and expected they were discarded based on the expiration date on the container.

Based on record review and staff interview, the facility failed to ensure the Medical Director (MD) was present for one (1) of the one (1) quarterly Quality Assurance (QA) meetings reviewed. This deficient practice had the potential to impact facility residents as the Medical Director was not involved in identifying and responding to quality deficiencies within the facility. The findings include: Review of the last quarterly QA committee meeting dated 05/18/2023 revealed the MD was not present for the QA committee meeting. On 06/20/2023 at 1:45 PM, the Administrator Director Quality and Safety reported that she was responsible for inviting the MD or his/her designee and she had never invited the MD or his/her designee to attend any of the quarterly QA committee meetings. She indicated the MD had no involvement in QA or by alternate means. She indicated that she was not aware that the MD or his/her designee was required to attend the QA committee meetings. Administrator Director Quality and Safety indicated moving forward she will make sure the MD or his/her designee was invited in all the QA committee meeting.

Based on observations, record review, and staff interview the facility failed to remove food ready for use with signs of spoilage and after the use by date for 1 of 1 walk-in cooler and the facility failed to remove foods ready for use by the use by date for 1 of 1 dry food storage area. This practice had the potential to affect food served to residents. The findings included: Initial tour of the kitchen was completed on 11/22/21 at 10:22 AM with the Executive Chef (EC). Observations of the walk-in refrigerator revealed a half full zip lock gallon size bag of sliced pepperoni with a use by date of 9/8/21 with several slices turning gray in color. Observation of the of the dry storage area revealed a large bag of dry peanuts labeled with an expiration date of 8/18/21, an opened 5-pound bag of quinoa with a use by date 11/15/21. During an interview on 11/22/21 at 10:22 AM the EC revealed foods should not be stored after the use by date and should be thrown away. The EC stated it was the responsibility of kitchen staff to label foods when opened and remove when out of date. The EC revealed kitchen staff were expected to use the labels generated by an automated system that printed the date food items were opened and the date it should be used by.

Based on record review and interviews with staff and the Division Director of Infection Prevention the facility failed to test unvaccinated staff based on the Center for Disease Control and Prevention (CDC) community transmission levels per the guidelines of the Centers for Medicare and Medicaid Services (CMS) before allowing to work for 3 of 3 staff reviewed for Covid-19. This failure occurred during a global pandemic. The findings included: A review of the facility's Infection Prevention Plan (IPP) with a revision date of 3/12/21 stated the facility would comply with the current CDC guidelines to reduce the transmission of infectious agents. The IPP will be based on the level of risk related to the community environment. The responsibility for implementing and overseeing all regulation and/or recommendations which involve infection prevention issues including recommendations from the CDC and regulations for healthcare facilities both local, state, and federal. A review of the CDC website titled, Covid-19 Integrated County View revealed community transmission levels for the location of the facility from 9/1/21 to 10/19/21 were high and from 10/20/21 to 11/24/21 were substantial. A review of the CMS guidelines for routine testing intervals of unvaccinated staff revealed when the community transmission levels were substantial or high staff were tested for Covid-19 twice a week. A review of unvaccinated staff test records revealed Nurse Aide (NA) #1 was scheduled to work on and tested for Covid-19 on 9/23, 9/28, 9/30, 10/6, 10/12, 10/20, 11/1, 11/4, 11/11 and 11/15 and received all negative results. A review of unvaccinated staff test records revealed NA #2 was scheduled to work on and tested for Covid-19 on 9/30, 10/6, 10/13, 10/19, 10/25, 11/3, 11/8 and received all negative results. A review of unvaccinated staff test records revealed Nurse #1 was scheduled to work on and tested for Covid-19 on 9/22, 9/28, 10/1, 10/5, 10/13, 10/15, 10/27, 11/1, 11/3, 11/5, 11/10, 11/15, and 11/19 and received all negative results. During an interview on 11/23/21 at 1:03 PM the Division Director of Infection Prevention (DDIP) revealed testing of unvaccinated staff was done weekly based on the state recommendations. The DDIP revealed the Director of Nursing (DON) kept the staff vaccination records. During an interview on 11/23/21 at 2:50 PM the DON revealed the plan for testing unvaccinated staff was based on their work schedule. The DON explained unvaccinated staff were tested on the day they worked using the polymerase chain reaction (PCR) test for COVID-19 and results were obtained within 48 hours. The DON revealed unvaccinated staff were not required to test twice a week if they didn't work on the unit. The DON revealed the DDIP checked the community transmission levels for the county and provided guidance on testing unvaccinated employees. The DON revealed none of the staff who worked on the unit and none of the residents had tested positive for Covid-19 since the unit reopened in 09/2021. A second interview was conducted with the DON on 11/23/21 at 4:34 PM. The DON revealed she didn't feel it was necessary to ask employees to come in on off days to be tested a second time and wasn't aware it was mandatory to test unvaccinated staff twice a week based on the community transmission levels. A second interview was conducted with DDIP on 11/24/21 at 11:59 AM. The DDIP stated the facility policy was to follow the CMS guidelines for routine testing of unvaccinated staff.

Based on record review and interviews with staff, the facility failed to complete an Admission Minimum Data Set (MDS) within the first 14 days of admission for 1 of 5 residents reviewed for accuracy (Resident #1). The findings included: Resident #1 was admitted from the hospital on 11/4/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's medical record was reviewed and revealed an Admission MDS assessment with an Assessment Reference Date (ARD, the last day of the observation period that the assessment covers) of 11/10/2021 had not been completed as of 11/24/2021. This was 21 days after Resident #1's admission to the facility. During an interview on 11/24/21 at 9:09 AM the MDS Coordinator explained the Admission MDS assessment with an ARD of 11/10/2021 was due to be signed as completed on 11/24/21. During an interview on 11/24/21 at 11:15 AM the Director of Nursing (DON) explained the floor nurses do the required assessments and documentation needed to complete the MDS. The DON then gathers this information and sends it to the MDS Coordinator who is expected to input the data and submit the information for each resident.

Based on record review, observations and interviews with staff and family, the facility failed to secure and date an opened medication that was available for use for 1 of 4 Residents reviewed for medication storage. (Resident #155) Findings included: A review of the manufacturer's recommendation for [MEDICATION(S)] ophthalmic solution indicated that an unopened bottle must be stored under refrigeration at 36° to 46° Fahrenheit (F). Once a bottle of [MEDICATION(S)] ophthalmic solution was opened for use, it could be stored at room temperature up to 77° F for 6 weeks. Resident #155 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) was not completed at the time of this survey. On 11/22/21 at 12:24 PM, 1 bottle of opened and undated [MEDICATION(S)] ophthalmic solution was observed next to the sink in Resident #155's room. The eye drop did not have a date to indicate when it was opened and was available for use. In an interview with the family member of Resident #155 on 11/22/21 at 12:25 PM, she stated Resident #155 received [MEDICATION(S)] once daily at night and had never been assessed for self-administration of medication. She did not know how long the eye drop had been left unattended in the room so far. She added Resident #155 had mild confusion at night most of the times. During an interview with Nurse #1 on 11/22/21 at 12:34 PM she did not know why [MEDICATION(S)] ophthalmic solution was left unattended by the second shift nurse in Resident #155's room. She acknowledged that the eye drop should be stored in the Pixel in medication storage room and dated when it was opened. She never administered [MEDICATION(S)] to Resident #155 as she only worked in the first shift. She did not know which nurse had initially opened this eye drop. In an interview conducted on 11/23/21 at 10:51 AM, the Director of Pharmacy stated it was her expectation for the nurse to date the [MEDICATION(S)] eye solution when it was opened and store it in the Pixel after it had been used. During a phone interview with Nurse #2 on 11/23/21 at 4:18 PM she confirmed she was working second shift on 11/21/21 and had administered [MEDICATION(S)] to Resident #155 during the shift. She indicated that the eye drop had been in Resident #155's room before she used it on 11/21/21. After she had administered the eye drop, she put it back to the same spot and did not do anything to secure it. She did not notice the opened eye drop was not dated after it was opened. Nurse #2 acknowledged that it was unsafe and inappropriate to leave any medication unattended in the facility. In an interview conducted on 11/23/21 at 4:27 PM, the Director of Nursing (DON) explained the second shift nurse had forgotten to date and return [MEDICATION(S)] to the Pixel after it was administered. It was her expectation for the nurse to date [MEDICATION(S)] when it was opened and store it in the Pixel after each administration.

Based on record review, and resident and staff interviews, the facility failed to provide a copy of the baseline care plan to 3 of 3 residents (Residents #54, #55 and #56) reviewed for baseline care plans. The facility also failed to individualize the baseline care plans to include physician orders. Findings included: 1. Resident #54 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a nursing assessment dated [DATE] indicated Resident #54 required staff assistance with bathing, dressing, toileting, transfers, and ambulation. Review of Resident #54's baseline care plan, initiated on 04/23/19, included interventions for fall risk, pain, [MEDICAL CONDITION] and bleeding risk. The baseline care plan did not include interventions that addressed Resident #54's need for staff assistance with Activities of Daily Living (ADL). An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 04/30/19 at 9:57 AM revealed standard baseline care plans were initiated upon a resident's admission that typically included pressure ulcers, pain, fall risk/prevention, bleeding risk, and [MEDICAL CONDITION]. She added the care plans were updated as the resident's needs were assessed and Care Area Assessments (CAA) were completed. During an interview on 04/30/19 at 12:05 PM, Resident #54 indicated she was not provided a copy of her baseline care plan. A follow-up telephone interview was conducted with the MDS RN on 05/01/19 at 3:08 PM. The MDS RN reiterated the standard baseline care plans initiated upon a resident's admission included interventions for pain, fall risk/prevention, bleeding risk, and [MEDICAL CONDITION]. She confirmed problem areas such as ADL, nutrition, behaviors and discharge planning, varied with each resident and were not added to the baseline care plans but were discussed during the weekly care plan meetings. The MDS RN was unaware of the regulation that residents or their representative receive a written summary or copy of the baseline care plan. She confirmed one was not provided to Resident #54. An interview with the Director of Nursing (DON) on 05/01/19 at 4:04 PM revealed he would expect for baseline care plans to be individualized based on the resident's needs. The DON added the facility was unaware of the regulation that residents or their representative receive a written summary or copy of the baseline care plan. 2. Resident #55 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a nursing assessment dated [DATE] indicated Resident #55 required staff assistance with bathing, dressing, toileting, transfers, and ambulation. Review of Resident #55's medical record revealed a physician's orders [REDACTED]. Review of Resident #55's Medication Administration Record [REDACTED]. Review of Resident #55's baseline care plan, initiated on 04/23/19, included interventions for fall risk, pain, [MEDICAL CONDITION] and bleeding risk. The baseline care plan did not include interventions to address Resident #55's needs related to staff assistance with Activities of Daily Living (ADL) or mood and behavior. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 04/30/19 at 9:57 AM revealed standard baseline care plans were initiated upon a resident's admission that typically included pressure ulcers, pain, fall risk/prevention, bleeding risk, and [MEDICAL CONDITION]. She added the care plans were updated as the resident's needs were assessed and Care Area Assessments (CAA) were completed. A follow-up telephone interview was conducted with the MDS RN on 05/01/19 at 3:08 PM. The MDS RN reiterated the standard baseline care plans initiated upon a resident's admission included interventions for pain, fall risk/prevention, bleeding risk, and [MEDICAL CONDITION]. She confirmed problem areas such as ADL, nutrition, behaviors and discharge planning, varied with each resident and were not added to the baseline care plans but were discussed during the weekly care plan meetings. The MDS RN was unaware of the regulation that residents or their representative receive a written summary or copy of the baseline care plan. She confirmed one was not provided to Resident #55. An interview with the Director of Nursing (DON) on 05/01/19 at 4:04 PM revealed he would expect for baseline care plans to be individualized based on the resident's needs. The DON added the facility was unaware of the regulation that residents or their representative receive a written summary or copy of the baseline care plan. 3. Resident #56 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a nursing assessment dated [DATE] indicated Resident #56 required staff assistance with bathing, dressing, toileting, transfers, and ambulation. Further review revealed Resident #56 used oxygen while at home via nasal cannula at 2 liters per minute. Review of Resident #56's medical record revealed the following physician orders: · 04/26/19: [MEDICATION NAME] (medication used to treat depression) 25 milligrams (mg) at bedtime. · 04/26/19: [MEDICATION NAME] (medication used to treat anxiety) 10mg three times a day. · 04/26/19: [MEDICATION NAME] (medication used to treat anxiety) 0.25 mg three times a day as needed for depression. Review of Resident #56's baseline care plan, initiated on 04/26/19, included interventions for fall risk, diabetes, pain, [MEDICAL CONDITION] and bleeding risk. The baseline care plan did not include interventions to address Resident #56's needs related to staff assistance with Activities of Daily Living (ADL), mood and behavior or oxygen use. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 04/30/19 at 9:57 AM revealed standard baseline care plans were initiated upon a resident's admission that typically included pressure ulcers, pain, fall risk/prevention, bleeding risk, and [MEDICAL CONDITION]. She added the care plans were updated as the resident's needs were assessed and Care Area Assessments (CAA) were completed. A telephone follow-up interview was conducted with the MDS RN on 05/01/19 at 3:08 PM. The MDS RN reiterated the standard baseline care plans initiated upon a resident's admission included interventions for pain, fall risk/prevention, bleeding risk, and [MEDICAL CONDITION]. She confirmed problem areas such as ADL, nutrition, behaviors and discharge planning, varied with each resident and were not added to the baseline care plans but were discussed during the weekly care plan meetings. The MDS RN was unaware of the regulation that residents or their representative receive a written summary or copy of the baseline care plan. She confirmed one was not provided to Resident #56. An interview with the Director of Nursing (DON) on 05/01/19 at 4:04 PM revealed he would expect for baseline care plans to be individualized based on the resident's needs. The DON added the facility was unaware of the regulation that residents or their representative receive a written summary or copy of the baseline care plan.

Based on record review and staff interviews the facility failed to develop comprehensive care plans for activities of daily living (ADL) for 3 of 3 residents reviewed for care plan development (#3, #104, and #1). Findings included: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #3 was cognitively intact. He was coded as requiring 2 person extensive assistance with transfers, dressing, toileting, and bathing and 1 person extensive assistance with hygiene. A review of Resident #3's care plan revealed no care plan was initiated for assistance with ADL. There were no ADL interventions in any other care plan areas. An interview with Nurse Aide (NA) #1 on 4/29/19 at 4:00 PM revealed she received ADL care report information for the residents verbally from the other NAs and nurses during the shift change report at the beginning of each shift. She further stated that she provided extensive assistance for transfer to wheelchair, toilet and bed as well as dressing and bathing for Resident #3. An interview with NA #2 on 4/30/19 at 8:40 AM revealed she received ADL care report information for the residents verbally from the other NAs and nurses during the shift change report at the beginning of each shift. She further revealed that she provided extensive assistance for Resident #3 for all transfers and dressing but he was independent for eating. An interview with NA #3 on 5/1/19 at 2:32 PM revealed she received ADL care information for the residents by observation of the color magnet signs on the doors which indicate the level of assistance the resident needs. She further revealed she did review the progress notes in the computer if she had time and Resident #3 had a red magnet which indicated he they required ADL assistance. An interview with Nurse #1 on 4/29/19 at 4:23 PM revealed he received ADL care information for the residents by shift report and the daily team meetings and he was unaware of any ADL care plans for the residents. An interview with the MDS Coordinator on 5/1/19 at 3:07 PM revealed she had not created an ADL care plan for Resident #3. She further stated it should have been created and she did not know why it had not been done. She confirmed she was responsible for this MDS and the care plan. An interview with the Director of Nursing (DON) on 5/1/19 at 4:06 PM revealed there was a daily team meeting with disciplines that included Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, and the MDS Coordinator. The DON explained during this team meeting each resident's goals and progress were discussed and this included ADL care. He further stated each resident should have an individualized care plan which included resident specific ADL care. He was not aware that Resident #3 did not have an ADL care plan. 2. Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #104 was cognitively impaired. She was coded as requiring 2 person extensive assistance with bed mobility, transfers, dressing, and toileting, and limited assistance with hygiene. A review of Resident #104's care plan revealed no care plan was initiated for assistance with ADL. There were no ADL interventions in any other care plan areas. An interview with Nurse Aide (NA) #1 on 4/29/19 at 4:00 PM revealed she received ADL care report information for the resident verbally from the other NAs and nurses during the shift change report at the beginning of each shift. She further stated that for Resident #104 she provided extensive assistance for transfer to wheelchair, toilet and bed. An interview with NA #2 on 4/30/19 at 8:40 AM revealed she received ADL care report information for the residents verbally from the other NAs and nurses during the shift change report at the beginning of each shift. She further revealed that she provided extensive assistance for Resident #104 for all transfers and dressing. An interview with NA #3 on 5/1/19 at 2:32 PM revealed she received ADL care information for the residents by observation of the color magnet signs on the doors which indicate the level of assistance the resident needs. She further revealed she did review the progress notes in the computer if she had time and Resident #104 had a red magnet which indicated she required assistance with ADL. An interview with Nurse #1 on 4/29/19 at 4:23 PM revealed he received ADL care information for the residents by shift report and the daily team meetings and he was unaware of any ADL care plans for the residents. An interview with the MDS Coordinator on 5/1/19 at 3:07 PM revealed she had not created an ADL care plan for Resident #104. She further stated it should have been created and she did not know why it had not been done. She confirmed she was responsible for this MDS and the care plan. An interview with the Director of Nursing (DON) on 5/1/19 at 4:06 PM revealed there was a daily team meeting with disciplines that included Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, and the MDS Coordinator. The DON explained during this team meeting each resident's goals and progress were discussed and this included ADL care. He further stated each resident should have an individualized care plan which included resident specific ADL care. He was not aware that Resident #3 did not have an ADL care plan. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was cognitively impaired. She was coded as requiring 2 person extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. A review of Resident #1's care plan revealed no care plan was initiated for assistance with ADL. There were no ADL interventions in any other care plan areas. An interview with Nurse Aide (NA) #1 on 4/29/19 at 4:00 PM revealed she received ADL care report information for the resident verbally from the other NAs and nurses during the shift change report at the beginning of each shift. She further stated that for Resident #1 she provided extensive assistance for transfer to wheelchair, toilet and bed. An interview with NA #2 on 4/30/19 at 8:40 AM revealed she received ADL care report information for the residents verbally from the other NAs and nurses during the shift change report at the beginning of each shift. She further revealed that she provided extensive assistance for Resident #1 for all transfers, toileting, and dressing. An interview with NA #3 on 5/1/19 at 2:32 PM revealed she received ADL care information for the residents by observation of the color magnet signs on the doors which indicate the level of assistance the resident needs. She further revealed she did review the progress notes in the computer if she had time and Resident #1 had a red magnet which indicated she required assistance with ADL. An interview with Nurse #1 on 4/29/19 at 4:23 PM revealed he received ADL care information for the residents by shift report and the daily team meetings and he was unaware of any ADL care plans for the residents. An interview with the MDS Coordinator on 5/1/19 at 3:07 PM revealed she had not created an ADL care plan for Resident #1. She further stated it should have been created and she did not know why it had not been done. She confirmed she was responsible for this MDS and the care plan. An interview with the Director of Nursing (DON) on 5/1/19 at 4:06 PM revealed there was a daily team meeting with disciplines that included Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, and the MDS Coordinator. The DON explained during this team meeting each resident's goals and progress were discussed and this included ADL care. He further stated each resident should have an individualized care plan which included resident specific ADL care. He was not aware that Resident #3 did not have an ADL care plan.

Based on observations and staff interviews, the facility failed to include the ongoing monitoring of bed side rails as part of their routine maintenance program for 6 of 6 beds observed with side rails in 6 of 6 sampled resident rooms (Rooms 52, 53, 55, 56, 57, and 59). Findings included: During the initial tour on 04/29/19 at 9:30 AM, observations of rooms 52, 53, 55, 56, 57, and 59 revealed the beds all had half side rails in use on both sides of the bed. Observations conducted throughout the remainder of the survey revealed the side rails remained in use. An interview with the Facility Manager of Plant Operations (FMPO) on 05/01/19 at 2:17 PM revealed weekly, routine maintenance rounds were conducted on the unit which included checking the water temperature and functioning of call bells in each resident room. The FMPO confirmed the residents' bed side rails were not inspected or monitored as part of the facility's weekly or monthly routine maintenance program. The FMPO explained side rails came preassembled on the bed frames and were monitored as needed. The FMPO added they relied on staff to notify them when there was an issue that needed to be addressed with a bed side rail. An interview on 05/01/19 at 4:04 PM with the Director of Nursing (DON) revealed bed side rails were used on all residents for safety and fall prevention. The DON confirmed there was no plan currently in place for the ongoing maintenance of bed side rails and he would be working on a solution for compliance.

Based on observations, record review, and resident and staff interviews, the facility failed to assess the need for side rails for 1 of 1 resident who was using half side rails on both sides of the bed (Resident #54). Findings included: Resident #54 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a nursing assessment dated [DATE] indicated Resident #54 required staff assistance with transfers. Review of Resident #54's fall prevention care plan, initiated on 04/23/19, included the following interventions: bed locked and in low position, both bed side rails in up position and call light within reach. Review of Resident #54's medical record revealed there was no side rail assessment. Observations conducted on 04/29/19 at 9:33 AM and 04/30/19 at 8:08 AM revealed Resident #54 was lying in bed with half side rails in the upright position on both sides of the bed. An interview on 04/30/19 at 9:57 AM with the Minimum Data Set (MDS) Registered Nurse (RN) revealed side rails were used on all residents for bed mobility and safety. The MDS RN confirmed there was no formal side rail assessment completed for any resident and explained fall risk assessments were completed instead that included patient education on the use of side rails. She added different components for the need for side rail use, such as cognition and medical diagnosis, were included in the fall risk, patient education and safety risk assessments that were completed for each resident. The MDS RN was unaware if the benefits or potential risks, such as entrapment, associated with side rail use were assessed or discussed with Resident #54. During an interview on 04/30/19 at 12:05 PM, Resident #54 confirmed both side rails were raised any time she was lying in bed. Resident #54 added the bed side rails were for safety and me to use when I need to move around in bed. An interview on 05/01/19 at 1:32 PM with the RN assigned to provide care to Resident #54 revealed half side rails were routinely used for all residents on the unit for bed mobility and safety. The RN stated he reviewed with Resident #54 how to use the buttons located on the side rails to raise or lower the head of the bed but did not discuss the benefits or potential risks to using side rails or assess for entrapment risk. An interview on 05/01/19 at 4:04 PM with the Director of Nursing (DON) revealed bed side rails were used on all residents for safety and fall prevention. He confirmed there was no formalized assessment completed on any resident, including Resident #54, for the use of side rails. The DON explained components that assessed the need for side rail use were addressed under other assessments such as fall risk and patient education but there was nothing currently on any of the assessments that addressed assessing for the risk of entrapment or discussing the potential risks and benefits of side rail use with residents.

Based on observation and staff interview the facility failed to post the Complaint Intake Unit information and telephone number for residents to access. Findings included: On 09/14/15 an initial tour of the Transitional Care Unit had been conducted at 8:30 AM. The Complaint Intake Unit information and telephone number had not been observed anywhere in the Transitional Care Unit. An interview with the Nurse Manager on 09/14/15 at 9:30 AM revealed all State information was posted on the bulletin board located on the front hall of the Transitional Care Unit. An observation of the Transitional Care Unit on 09/15/15 at 9:00 AM revealed no postings related to the Complaint Intake Unit information or telephone number anywhere in the Transitional Care Unit. An interview with the Nurse Manager on 09/15/15 at 5:15 PM revealed she thought the Ombudsman telephone number posted on the bulletin board and the Medicare/Medicaid telephone numbers in the Admission Handbook were the contact for the Complaint Intake Unit. She verified the Complaint Intake Unit telephone number had not been posted anywhere in the Transitional Care Unit, and had not been accessible to residents.

Based on observations and staff interview the facility failed to remove expired foods and dented canned goods from storage, completely cover stored foods and ensure the kitchen's slicer was cleaned for use. The findings included: 1. Observations of the facility's kitchen on 09/30/14 from 9:30 AM to 10:00 AM revealed the following problems with food storage: a. Observations on 09/30/14 at 9:30 AM of foods stored in the kitchen's walk-in refrigerator revealed six (6) 32 ounce containers of yogurt that had expired, expiration dates of 09/12/14. Further observations of foods stored in this refrigerator revealed an opened turkey breast that was not completely covered. Interview with the facility's Food Service Director (FSD), at the time of the observation, revealed staff should check the expiration dates of stored foods daily and discard any foods found with an expired expiration date. The FSD further stated that all foods should be completely covered when stored by staff. b. Observations on 09/30/14 at 9:35 AM of foods stored in the kitchen's walk-in freezer revealed a bag of cookie dough that was opened and not completely covered. Interview with the facility's FSD, at the time of the observation, revealed all foods should be completely covered when stored by staff. c. Observations on 09/30/14 at 9:40 AM of foods stored in the kitchen's dry good storage area revealed four (4) 14 ounce cans of condensed milk that were dented. Interview with the facility's FSD, at the time of the observation, revealed any dented cans should be removed from possible use by staff by placing them in the store room's designated "dented can" area for return to the product's vendor. d. Observations on 09/30/14 at 9:50 AM of the kitchen's milk refrigerator revealed four (4) half pint cartons of chocolate milk that had expired expiration dates of 09/27/14. Interview with the facility's FSD, at the time of the observation, revealed staff should check the expiration dates of the milks store in the refrigerator every day to ensure they do not have expired expiration dates. 2. Observations on 09/30/14 at 9:55 AM of the kitchen's electric slicer revealed the slicer was stored and ready for use. Observations of the slicer's cutting blade revealed the back of the blade was unclean with an accumulation of a dried white substance which appeared to be dried turkey. Interview with the facility's FSD, at the time of the observation, confirmed the slicer was ready for use and the slicer's blade was not clean. The FSD stated that staff is instructed to clean the entire slicer, including the slicer's blade, prior to storing it for use.

Based on observation and staff interviews, the facility failed to correctly disinfect a blood glucose meter after use on 1 of 1 resident during observation of obtaining a finger stick blood sugar. The findings included: A review of the instructions provided by the manufacturer of the germicidal disposable wipe utilized by the facility was conducted. The directions specified to accomplish disinfection on a hard surface, unfold a wipe and thoroughly wet the surface. Treated surface must remain visibly wet for a full 2 minutes. Use additional wipe(s) if needed to assure continuous 2 minute wet contact time. Let air dry. An observation of Nursing Assistant (NA) #1 obtaining a finger stick blood sugar was conducted on 09/04/13 at 11:05 AM. Following the procedure at 11:07 AM, NA #1 wiped the blood glucose meter with a germicidal disposable wipe. NA #1 ensured the entire surface of the meter was wiped. She then set the wipe aside, removed her gloves, and placed the meter in a docking station at 11:08 AM. An observation of the meter at this time revealed all areas of the meter were not visibly wet. During an interview with NA #1 at this time, she stated this was the facility practice and her normal practice of disinfecting a blood glucose meter after use. An interview was conducted with the Director of Nursing (DON) at 12:00 PM on 09/05/13. The DON disinfected the blood glucose meter following the same practice as NA #1. She stated the meter did not remain continuously wet all over for a full 2 minutes using this method of disinfection. The DON acknowledged the manufacturer's recommendations for disinfection were not followed to ensure disinfection of the blood glucose meter.

Based on observations, staff interview and documentation review the facility failed to store canned good items past the use by date. The findings are: An initial tour was made of the facility ' s kitchen on 4/12/11 at 11:15 a.m. The Food Service Director (FSD) was present during the observations of the kitchen. At 11:35 a.m. the dry goods storage was observed and revealed canned good items stored ready for use. Included on a shelf, ready for use were eight (8) twelve (12) ounce cans of evaporated milk stamped with the manufacturer ' s use by date of 3/1/11. The FSD was present for the observation and immediately removed the expired canned good items. The FSD was interviewed and reported a dietary aide was assigned to check stock weekly for outdated and expired food items. He specified he would expect all outdated items to be removed. The FSD also reported a second staff member, the kitchen supervisor, was assigned to do random audits of the dry goods storage to check for outdated and expired food items. The FSD provided a document that specified the kitchen supervisor last audited the dry goods storage on 3/28/11 and found no concerns with outdated food items in the dry goods storage area. The FSD offered no explanation why the outdated cans of evaporated milk were stored ready for use despite current audit systems.