Every finding on record at Trinity Ridge

Based on observations, record review, staff and resident interviews, the facility failed to keep a urinary catheter collection bag from lying on the floor for 1 of 1 resident reviewed for indwelling urinary catheters (Resident #5). The findings included:Resident #5 was admitted to the facility on [DATE] with diagnoses that included overactive bladder, hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine), and bladder-neck (the base of the bladder) obstruction.Resident #5's physician orders revealed a physician order dated 03/26/26 for a urethral catheter, due to urinary retention related to hydronephrosis, ensure tubing is patent and catheter is in a privacy bag. Resident #5's annual Minimum Data Set assessment dated [DATE] revealed Resident #5 to be cognitively intact. Resident #5 was coded as having an indwelling catheter.Review of Resident #5's care plan last reviewed on 04/21/26 revealed a care plan for an indwelling urinary catheter for hydronephrosis. Interventions included to position catheter bag and tubing below the level of the bladderAn observation of Resident #5 completed on 06/17/26 at 11:24 AM revealed her to be in her room, in bed visiting with two outside visitors. An observation was made at this time of Resident #5's urinary catheter collection bag, the bag was lying flat on the floor beside her bed and approximately 1 1/2 feet from one of the standing visitor's feet. Observation of the catheter bag that was on the floor revealed it did have an undetermined amount of urine in the bag. An interview with Resident #5 on 06/17/26 at 11:25 AM revealed she had gotten up earlier in the day and went to the communal dining room for breakfast but requested to return to her bed after breakfast. She reported a nurse aide (whom she could not recall) assisted her to bed after breakfast. Resident #5 reported she could not transfer without assistance and had not touched her catheter bag while getting back into bed.An interview with Nurse Aide (NA) #1 who was assigned to Resident #5's hall on 06/17/26 at 11:28 AM revealed he was working on Resident #5's hall but that he did not assist Resident #5 back to bed after breakfast and stated it must have been NA #2 who was also working on Resident #5's hall.An interview with NA #2 on 06/17/26 at 11:32 AM revealed she was working on Resident #5's hall and verified that Resident #5 did get up earlier in the day but had requested to return to bed. She also verified that she assisted Resident #5 back to bed. NA #2 stated for residents who have catheters, when they were transferred back to bed, she would hang the catheter bag from the bed frame to ensure that it remained off the floor. An observation of Resident #5's catheter bag with NA #2 on 06/17/26 at 11:34 AM revealed the catheter bag to remain on the floor by Resident #5's bed. A continued interview with NA #2 revealed she must have forgotten to get Resident #5's catheter bag hung on the bed frame when she assisted Resident #5 back to bed after breakfast.An interview with the Director of Nursing on 06/17/26 at 11:47 AM revealed the facility's policy was to ensure that catheter bags and tubing remained off the floor. She also reported that when Resident #5 was assisted back to bed, the catheter bag should have been hung from her bed frame to ensure it did not touch or lie on the floor.An interview with the Administrator on 06/17/26 at 11:53 AM revealed she expected catheter bags to be kept off the floor. She reported that when a resident was in bed, the catheter bag should be hung from the bed frame.

Based on record review and staff interviews, the facility failed to accurately code a Medicare 5-day Minimum Data Set assessment for the use of antipsychotics for 1 of 5 residents reviewed for unnecessary medications (Resident #87). The findings included: Resident #87 was initially admitted to the facility on [DATE] with diagnoses that included dementia with behaviors and cognitive communication deficit. Resident #87 subsequently readmitted to the facility on [DATE] after a brief hospitalization . Review of Resident #87's Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed he was not receiving antipsychotic medications. Review of Resident #87's physician orders revealed an order dated 03/07/25 for Seroquel Oral tablet (antipsychotic medication) 25 milligrams (mg). The order was for Resident #87 to take 1/2 of a tablet, one time a day for mood disorder. Review of Resident #87's medication administration record revealed he received Seroquel 25mg starting on 03/07/25. During an interview with MDS Nurse #1 on 03/27/25 at 11:09 AM, she reported when she completed Minimum Data Set assessments, she reviewed residents' medication administration records and physician orders. She stated she was aware that Resident #87 was taking Seroquel at the time she completed the Minimum Data Set assessment and must have miscoded it in error. An interview with the Director of Nursing, on 03/27/25 at 11:22 AM, revealed Resident #87 had discharged from the facility and when he returned, he came back with a new physician order for Seroquel. She reported MDS nurses typically reviewed all of a resident's medications when they complete the Minimum Data Set assessments. She indicated that Resident #87's Minimum Data Set assessment dated [DATE] should have accurately represented his current use of an antipsychotic medication. During an interview with the Administrator on 03/27/25 at 12:03 PM, she indicated she expected resident Minimum Data Set assessments to accurately reflect the individual resident and their care needs and that included the medications that particular resident was currently taking.

Based on observations, record reviews, manufacturer's instructions, and staff and Consultant Pharmacist interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities, resulting in a medication error rate of 7.14% for 1 of 5 residents observed during the medication administration (Residents #25). The findings included: The manufacturer's instructions for prefilled Lantus insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary. Resident #28 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of Resident #28's physician orders revealed an order dated 06/24/25 for Lantus insulin Pen injector, inject 85 units subcutaneously one time a day for diabetes mellitus. On 03/26/25 at 9:08 AM an observation was made of Nurse #1 as she removed a Lantus prefilled insulin pen from the medication cart, placed a needle on the pen and turned the dose selector to 30 units in preparation for the injection. The Nurse removed another needle from the medication cart and explained that she would need to inject Resident #28 twice because her total dose of insulin was 85 units and that was too much to inject all 85 units at one time. The Surveyor accompanied Nurse #1 to Resident #28's room where the Nurse injected the Resident with the Lantus insulin without priming the insulin pen per the manufacturer's instructions. Nurse #1 then removed the needle from the prefilled insulin pen and applied the other needle then turned the dose selector to 55 units and proceeded to inject Resident #28 with the second dose of insulin again without priming the insulin pen. An interview was conducted with the Consultant Pharmacist on 03/27/25 at 12:08 PM. The Pharmacist explained that it was important to prime the insulin pen before every injection so that air bubbles were removed to ensure the total amount of insulin was delivered. The Pharmacist indicated that air bubbles can take up space that could prevent the correct dosage of insulin from being administered. Multiple attempts were made to interview Nurse #1, but the attempts were unsuccessful. Interviews were conducted with the Director of Nursing (DON) and the Administrator on 03/27/25 at 12:50 PM. The DON explained that Nurse #1 had attended the skills training which included how to utilize insulin pens therefore she could not address why Nurse #1 did not prime the insulin pen each time she gave the injection. The DON stated it was important that insulin pens be primed before injecting to remove the air bubbles and ensure all the ordered insulin dose was given to the resident.

Based on observations, record reviews and staff interviews, the facility failed to follow their Hand Hygiene policy and procedure when the Director of Nursing did not perform hand hygiene after removing gloves and donning a clean pair of gloves while providing wound care to Resident #71 and Nurse #2 did not perform hand hygiene after removing gloves and donning a clean pair of gloves while providing wound care to Resident #62 for 2 of 3 staff members observed for infection control practices (Director of Nursing and Nurse #2). The findings included: A review of the facility's Hand Hygiene policy and procedure last revised 10/12/23 revealed in part: Hand Hygiene: Policy: Practicing hand hygiene is a simple yet effective way to prevent infections. Performing hand hygiene can prevent the spread of germs, including those that are resistant to antibiotics. All teammates are trained and regularly inserviced on the importance of hand hygiene in preventing the transmission of infections. Teammates are expected to follow hand hygiene procedures to help prevent the spread of infections to other staff members, residents, and visitors. Note: Hand Hygiene means cleaning hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer including foaming or gel), or surgical hand antisepsis. Procedures: 4. Before donning gloves and after removing gloves. 1. On 03/25/25 at 11:25 AM an observation was made of the Director of Nursing (DON) providing wound care to Resident #71 who had a stage 3 pressure ulcer on his coccyx. The Resident was positioned on his right side in preparation for the treatment and the previous wound dressing had been removed. The DON washed her hands and donned clean gloves and gown. The DON cleansed the pressure ulcer with wound cleanser-soaked gauze from the inside of the wound outward, then doffed her gloves and without sanitizing her hands donned a clean pair of gloves. The DON then applied and sealed the ordered dressing with an island dressing and doffed her gloves and gown, washed her hands with soap and water, gathered her supplies and trash and left the room. Interviews were conducted with the Director of Nursing (DON) and the Administrator simultaneously on 03/27/25 at 1:42 PM. The DON explained she did not realize that she did not sanitize her hands between glove changes and stated she should have sanitized her hands after doffing her gloves and prior to donning clean gloves. 2. On 03/26/25 at 11:40 AM an observation was made of Nurse #2 providing wound care to Resident #62 with the Director of Nursing (DON) assisting. Resident #62 had a stage 4 pressure ulcer on her right foot. Nurse #2 sanitized her hands and donned a clean gown and gloves and removed the dressing from the right foot ulcer and threw the old dressing in the trash can. Nurse #2 then proceeded to doff her gloves and without sanitizing her hands donned clean gloves and cleansed the pressure ulcer with wound cleanser-soaked gauze from the inside outward and applied the ordered dressing followed by an island dressing. Nurse #2 then covered the right foot with an ABD pad and wrapped it with gauze. Nurse #2 then doffed her gloves and washed her hands before donning clean gloves. The Director of Nursing removed the dressing from Resident #62's (2) stage 3 sacral pressure ulcers then doffed her gloves and washed her hands with soap and water after the end of the treatment. Nurse #2 cleansed the pressure ulcers with wound cleanser-soaked gauze from the inside outward and then doffed her gloves and without sanitizing her hands, donned clean gloves. Nurse #2 then applied the ordered dressing and an island dressing then doffed her gown and gloves and washed her hands with soap and water, gathered her supplies and trash and left the room. Multiple attempts were made to interview Nurse #2 but the attempts were not successful. Interviews were conducted with the Director of Nursing (DON) and the Administrator simultaneously on 03/27/25 at 1:42 PM. The DON explained she did not realize that Nurse #2 did not sanitize her hands between glove changes and stated she should have sanitized her hands after doffing her gloves and prior to donning clean gloves.

Based on observations, record review, and staff interview the facility failed to maintain the dignity of a cognitively impaired resident (Resident #43) when a Nurse Aide made an inappropriate sexual comment about the resident's son. A reasonable person would not want another person making inappropriate sexual comments about their family members. This was for 1 of 1 resident reviewed for dignity and respect. The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behaviors, depression, and insomnia. A review of Resident #43's annual Minimum Data Set assessment dated [DATE] revealed resident was severely impaired with no psychosis, behaviors, rejection of care, or instances of wandering. A review of Resident #43's care plan, last updated on 11/10/23 revealed a care plan for I have cognitive deficits and do not consistently recognize my needs. Interventions included to use Resident #43's name, identify yourself at each interaction, face Resident #43 when speaking, and to make eye contact when speaking to her. Interventions also included to provide Resident #43 with necessary cues and to stop and return if agitated. Review of a facility provided allegations of abuse, neglect, or misappropriation revealed Resident #43 was involved in an altercation with a nurse aide (Nurse Aide #1) in which Resident #43 used a racial slur directed towards NA #1 and in return, NA #1 got into Resident #43's face and told her she would have sex with Resident #43's son so Resident #43 would have interracial grandbabies. This interaction was reported to the facility by Resident #43's sitter (Sitter #1) several days after the interaction. An interview with Sitter #1 on 11/29/23 at 1:38 PM revealed she was not the sitter who was present with Resident #43 at the time of the incident. She reported Sitter #2 was there and notified her of the interaction between NA #1 and Resident #43. Sitter #1 reported Resident #43 was really bad about using derogatory racial slurs towards persons of color and that it was her understanding that Resident #43 used a racial slur towards NA #1 and that NA #1 moved close to Resident #43's face and asked Resident #43 if she would like it if NA #1 had intercourse with Resident #43's son and had an interracial child. Sitter #1 reported Sitter #2 contacted her after the incident and asked her to come in early because Resident #43 was upset. Sitter #1 reported when she arrived at the facility, Resident #43 was still upset but Sitter #1 was able to get her to take a nap and when she awoke, Resident #43 had no recollection of the interaction with NA #1. During an interview with Sitter #2 on 11/29/23 at 3:19 PM, she reported she had sat with Resident #43 for almost 4 years and that she remembered the incident well. Sitter #2 reported Resident #43 had been a little aggressive and disruptive that afternoon. She reported she and the staff decided to remove Resident #43 from the dining room as she was disrupting other residents and she, NA #1, and Restorative Aide #1 took Resident #43 back to her room. She reported once they got Resident #43 to her room, Resident #43 uttered a racial slur directed towards NA #1. She stated NA #1 retorted that she would have intercourse with Resident #43's son and have an interracial child. Sitter #2 reported she felt the interaction was inappropriate and it upset Resident #43. She also reported she ended up reporting the incident to Sitter #1 when she came to the facility. Sitter #2 verified she did not report the incident to any staff members. During an interview with Restorative Aide #1 on 11/29/23 at 1:55 PM, he reported he remembered very little about the incident. He stated he believed that Resident #43 had been irritated and aggressive that day and he, NA #1, and Sitter #2 had removed Resident #43 from the dining room because she was disturbing other residents. Restorative Aide #1 reported when they got Resident #43 to her room, she directed a racial slur towards NA #1 who responded that she would go and try to date Resident #43's son and have an interracial child. Restorative Aide #1 stated Resident #43 became more agitated and upset after the interaction. He stated he reported the incident to the Assistant Director of Nursing (ADON). An interview with the ADON on 11/29/23 at 3:42 PM, she reported she was made aware several days after the incident occurred when Sitter #1 informed her of the incident between Resident #43 and NA #1. She stated as soon as she was informed, she notified the Administrator. She reported NA #1 was also immediately suspended pending the results of the facility's investigation. She stated the facility investigated the incident as possible verbal abuse. She reported when she interviewed NA #1, she denied doing anything inappropriate even after being confronted with the statements from the other staff and visitors that were present at the time of the incident that verified the incident occurred. The ADON reported NA #1 was subsequently terminated and they completed education on the importance of ensuring interactions were respectful and appropriate. She also reported the incident was placed in the quality assurance plan and had been monitored. During an interview with the DON on 11/29/23 at 4:50 PM, she reported she was made aware of the incident between Resident #43 and NA #1 after it occurred as she was out of the facility at the time. She stated it was her understanding that Resident #43 directed a racial slur towards NA #1 and NA #1 retorted, telling Resident #43 that she would have intercourse with Resident #43's son and have an interracial child. She reported she knew there was an investigation into the incident and that NA #1 was ultimately terminated. She also reported the administration provided education to all staff on the importance of ensuring all interactions with residents were appropriate, interviewed alert and oriented residents, and included the incident in the facility quality assurance process. The DON also stated the facility had been randomly monitoring interactions between staff and residents in the middle of provided care and would continue to randomly monitor the interactions for 3 months. The DON reported the interaction was completely unacceptable and she expected her staff to treat all residents with respect and dignity. During an interview with the Administrator on 11/29/23 at 4:57 PM, she reported she was aware of an incident between NA #1 and Resident #43, where NA #1 told Resident #43 that she would have intercourse with her son and have an interracial child after Resident #43 directed a racial slur towards NA #1. The Administrator reported the facility investigated the incident and ultimately terminated NA #1. She also reported the incident was placed into the facility's quality assurance program and random interactions between staff and residents during care were being monitored. She also reported the facility administration completed education to the staff regarding appropriate interactions with residents and what to do if a resident is belligerent or aggressive in the facility and reported the incident to the state agency. She reported while the facility continued to monitor interactions between staff and residents, she felt the facility was back in compliance effective 08/21/23. Multiple attempts to reach NA #1 via telephone were unsuccessful. Review of facility provided monitoring tools revealed the facility had completed a 24 hour and 5 working day report upon notification of the incident and completion of their investigation. The investigation revealed written statements from all parties involved, a termination notification for NA #1, education with sign-in sheets for all staff in the facility regarding appropriate interactions towards residents and what to do when a resident is agitated, interviews with alert and oriented residents, and finally monitoring tools for ongoing monitoring to ensure the issue was resolved with random observations of interactions between staff and residents during care. The facility indicated they were back in compliance on 08/21/23. While onsite during the recertification survey the plan of correction submitted by the facility was validated by interviews with staff who confirmed that they had received education regarding what to do when a resident is agitated and expectations of appropriate interactions towards residents at all times, review of skin checks and interviews, and monitoring tools. The facility date of compliance of 08/21/23 was validated.

Based on record review and staff interviews, the facility failed to develop and implement care plan interventions for 5 of 5 insulin dependent residents (Resident #38, Resident #21, Resident #97, Resident #90 and Resident #15) reviewed for unnecessary medication review. The findings included: 1.a. Resident #38 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired. The MDS further revealed the resident was diabetic and received injections. Review of Resident #38 physician order [REDACTED]. Review of Resident # 38 physician order [REDACTED]. Review of Resident #38 medical record revealed no care plan or interventions for the use of insulin for the [DIAGNOSES REDACTED]. b. Resident # 21 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] revealed Resident #21 was moderately cognitively impaired, had a [DIAGNOSES REDACTED]. Review of Resident #21 physician order [REDACTED]. Review of Resident #21 physician order [REDACTED]. Review of Resident #21 physician order [REDACTED]. Review of Resident #21 medical record revealed no care plan or interventions for the use of insulin for the [DIAGNOSES REDACTED]. c. Resident #97 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] revealed Resident #97 was cognitively impaired, had a [DIAGNOSES REDACTED]. Review of Resident #97 physician order [REDACTED]. Review of Resident #97 medical record revealed no care plan or interventions for the use of insulin for the [DIAGNOSES REDACTED]. d. Resident #90 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] revealed Resident #90 was cognitively impaired, had a [DIAGNOSES REDACTED]. Review of Resident #90 physician order [REDACTED]. Review of Resident #90 medical record revealed no care plan or interventions for the use of insulin for the [DIAGNOSES REDACTED]. e. Resident # 15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] revealed Resident #15 was cognitively impaired, had a [DIAGNOSES REDACTED]. Review of Resident #15 physician order [REDACTED]. Review of Resident #15 medical record revealed no care plan or interventions for the use of insulin for the [DIAGNOSES REDACTED]. In an interview with MDS Coordinator #1 on 9/19/19 at 1:28 PM reveled she had not care planned the use of insulin due to the resident having a [DIAGNOSES REDACTED]. An interview with the Director of Nursing (DON) on 9/19/19 at 4:00 PM revealed insulin did required monitoring and was a nursing standard of practice. Due to insulin requiring monitoring it should have been care planned to include interventions. An interview with the Administrator on 09/19/19 at 4:00 PM revealed that there should have been a care plan in place for a resident that is diabetic and requires insulin.

Based on observation, record review and staff interview the facility failed to assess 1 of 3 sampled residents positioning device (Resident #62). Findings included: Resident #62 was admitted to facility 10/05/18 with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #62 was cognitively intact. The MDS further revealed Resident #62 required extensive assistance for mobility which included sit to stand and movement about the facility. A review of Resident #62's incident report dated 7/26/19 revealed she had a fall from her wheelchair while in the TV room. The note further revealed she had a lap tray attached to her wheelchair at the time of her fall. The review of resident #62 care plan 7/30/19 revealed Resident #62 had the potential to fall, get hurt and had impaired physical mobility. The goal stated Resident #62 would avoid major injury from a fall. The care plan further indicated Resident #62 had a hard time moving, frequently fell , got tired quickly and would lose her balance. Review of Resident #62 medical record revealed no physician order for [REDACTED].>Review of Resident #62 occupational therapy assessments revealed no indication of use of a lap tray. An observation of Resident #62 on 9/16/19 at 11:54 am revealed her to be in the common area seated in her wheelchair. Resident #62's left arm was observed to be resting on a lap tray attached to her wheelchair. An interview was attempted with Resident #62 on 9/18/19 at 1:19pm. Resident #62 was unable to answer questions as asked. Nurse #6 was interviewed on 9/18/19 at 1:51 PM revealed that Resident #62 used the lap tray to keep resident upright in her wheelchair. Interview with Occupational Therapy Assistant #1 on 9/18/19 at 2:53 PM revealed that Resident #62's lap tray had not been assessed by the therapy department. Nurse #5 was interviewed on 9/18/19 at 2:54PM. During this interview, the Resident #62's incident report dated 7/26/19 was reviewed with Nurse #5. She indicated that she had provided Resident #62 with the lap tray as a nursing intervention due the resident leaning forward in her chair. Nurse #5 further stated she had intended to use the lap tray for a 2-week trial period and she had not documented the use of the lap tray and did not have documentation indicating the day the trial for the lap tray began. She further stated she the tray was removed on 9/16/19 because Resident #62 was unable to lift the tray independently. Nurse #5 also stated that a physician order and care plan should have been initiated in the instance the trial period extended beyond the 2 weeks. An interview with Nurse #3 on 9/18/19 at 3:05 PM revealed the nursing assistant worksheet and electronic medical record showed no indications for use of the lap tray. Interview with Nursing Assistant (NA) #1 on 9/19/19 at 9:55 AM revealed Resident #62 had used a lap tray to prevent falls. NA #1 was unable to recall how long the lap tray was used but indicated it was used at times Resident #62 was up in her wheelchair. On 9/19/19 4:00 PM an interview with Director of Nursing (DON) revealed an assessment was not needed if the tray was to be used as a trial period. However, if the device was to be continued, it would need to be assessed. The DON stated the use of the lap tray should have been addressed in the staff meetings to determine its appropriateness and need for a formal assessment. An interview with the Administrator on 9/19/19 at 4:00 PM revealed that the use of the lap tray should have been assessed at the end of the 2-week trial period.

Based on observations, staff interviews, and record review, the facility failed to maintain proper temperatures in 2 of 4 refrigerators reviewed for medication storage (One white refrigerator and one black refrigerator located in the medication storage room on 100/200 hall). The findings included: 09/19/19 09:58 AM Observation of refrigerator temperatures recorded on clipboard on top of each refrigerator. Instructions on bottom of refrigerator temperature log sheet recorded daily stated: Temperatures are taken daily on third shift Initial and record temp for each day. If temperature is not between 34-42 degrees, a work order should be filled out for maintenance to check. 1. The White medication storage refrigerator contained the following medications: [REDACTED] a) [MEDICATION NAME] 23 vaccine (container indicate storage temps should be between 36-46 degrees) b) [MEDICATION NAME] 15 mcg (container indicate storage temps should be between 36-46 degrees) c) Energix-B [MEDICAL CONDITION] vaccine has red label on container that states Do not freeze d) [MEDICATION NAME] HCl 25 mg (container indicate storage temps should be between 36-46 degrees) e) 12 Insulin Pens in bags f) [MEDICATION NAME] 5T (container indicate storage temps should be between 35-46 degrees) g) Prevnar 13 Pneumococcal vaccine (container indicate storage temp should be between 35-46 degrees) July 2019 temps for white refrigerator ranged between 30 and 38 degrees with temps out of range on the following dates: 7/2 - 32 degrees 7/3 - 32 degrees 7/5 - 32 degrees 7/6 - 31 degrees 7/7 - 32 degrees 7/8 - 31 degrees 7/9 - 32 degrees 7/10 - 32 degrees 7/13 - 30 degrees 7/16 - 32 degrees 7/17 - 30 degrees 7/18 - 32 degrees 7/19 - 30 degrees 7/24 - 32 degrees 7/11 and 7/12 Missing recorded temperatures 7/14 and 7/15 Missing recorded temperatures 7/20 and 7/21 Missing recorded temperatures 7/28 Missing recorded temperature August 2019 temps for white refrigerator ranged between 32 and 38 degrees with temps out of range on the following dates: 8/1 Missing recorded temperatures 8/8 - 32 degrees 8/4 Missing recorded temperatures 8/11 Missing recorded temperatures 8/17 Missing recorded temperatures 8/18 Missing recorded temperatures 8/19 Missing recorded temperatures 8/22 Missing recorded temperatures 8/23 Missing recorded temperatures 8/30 Missing recorded temperatures 8/31 Missing recorded temperatures September 2019 temps for white refrigerator ranged between 31 and 40 degrees with missing and out of range recorded temps on: 9/7 Missing recorded temperatures 9/10 Missing recorded temperatures 9/11 32 degrees 9/12 Missing recorded temperatures 9/16 Missing recorded temperatures 2. The Black medication storage refrigerator contained the following medication: Intravenous [MEDICATION NAME] labeled for resident #101 with freezing/below freezing temps recorded as follows: July 2019 Black refrigerator temps ranged between 30 and 36 degrees with missing recorded temps and temps out of range on: 7/5 - 32 degrees 7/6 - 32 degrees 7/7 - 30 degrees 7/8 - 31 degrees 7/9 - 30 degrees 7/10 - 32 degrees 7/11 and 7/12 Missing recorded temperatures 7/13 - 32 degrees 7/14 and 7/15 Missing recorded temperatures 7/19 - 32 degrees 7/20 and 7/21 Missing recorded temperatures 7/25- 32 degrees 7/26- 32 degrees 7/27- 32 degrees 7/28 and 7/29 Missing recorded temperatures 7/30 - 32 degrees August 2019 Black refrigerator temps ranged between 30 and 36 degrees with missing recorded temps on: 8/1 Missing recorded temperatures 8/3 and 8/4 Missing recorded temperatures 8/5 - 30 degrees 8/7- 32 degrees 8/8- 30 degrees 8/16 - 32 degrees 8/21 Missing recorded temperature 8/23 Missing recorded temperature 8/25- 32 degrees 8/30 - 32 degrees 8/31 Missing recorded temperature September 2019 Black refrigerator temps ranged between 30 and 40 degrees with missing recorded temps on: 9/2 - 30 degrees 9/3 - 32 degrees 9/5 - 32 degrees 9/7 Missing recorded temperature 9/10 Missing recorded temperature 9/12 and 9/13 Missing recorded temperature 9/16 Missing recorded temperature 09/19/19 09:58 AM Interview with nurse #2 stated that third shift nurses are responsible for recording temperature of refrigerator on temperature log. 09/19/19 01:28 PM Interview with maintenance manager: Asked him if he would expect a repair order if there was a problem with any of the medication refrigerators in the med rooms on each unit and he replied, yes Ma'am. He also stated that he has been doing maintenance at this facility for over [AGE] years. 09/19/19 03:47 PM Interviewed Nurse #1 in medication room on 100/200 wing. Asked if there were any reason medications would need to be moved from the refrigerators. She stated that would be reasonable in the event they needed to defrost the refrigerators. When asked if she had ever seen the medications moved for any reason, she stated she had not. She stated she has been employed at this facility since 2003. 09/19/19 03:35 PM Interview with DON regarding policy for medication storage in refrigerators in med rooms. DON stated night nurses check the refrigerators daily and documents temperatures on temperature logs. She stated when temps are out of range, medications are to be moved to another working refrigerator, and a repair order sent to maintenance to request repair.

Based on observations, interviews, and facility policy review, the facility 1) failed to adequately disinfect 1 of 1 glucometers according to disinfecting wipe manufacturer instructions, and 2) failed to separate clean and uncleaned glucometers in its medication storage cart for 3 of 3 reviewed during medication administration. Findings include: Review of the Facility Policy Titled BLOOD SAMPLING - CAPILLARY (FINGER STICKS), Manual: LSC Infection Control, Section: General Infection Control Practices, Date Approved: 2/22/10 Date Revised: 1/26/16 Approved by THG Paragraph 6, Section 2 read in part as follows: If no visible organic material is present, disinfect the exterior surfaces after each use following the manufacturer's instructions using a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10 (one-part bleach to 9 parts water) to 1:100 concentration. The disinfecting wipe instructions from the manufacturer read in part as follows: Repeated use of the product may be required to ensure that the surface remains visibly wet for 2 minutes Disinfecting wipes product claims it is effective against TB [MEDICAL CONDITION] after 3 minutes of use, and HIV-1, HBV, and HCV within 2 minutes of use. 1. On 09/19/19 at 08:26 AM Observed nurse #3 perform Blood Glucose Check (BGC) on resident #46. Upon completion of the BGC, the nurse placed the glucometer into its old, unzipped plastic bag and returned it to the drawer in the medication cart where several other glucometers are also stored in open/unzipped plastic bags. There were no disinfecting wipes used to clean resident #46 glucometer prior to placing it back into the original used bag. An interview with nurse #3 conducted on 09/18/19 4:55 pm. stated she cleans the glucometers once a day at the end of the day. The nurse demonstrated her disinfecting technique and was observed cleaning a glucometer with a disinfecting wipe. She donned gloves, placed glucometer on paper towel on countertop, wiped glucometer with disinfecting wipe and waited for it to dry. Dry time of wiped glucometer was 47.9 seconds from start of wipe. The nurse then placed the glucometer back into its original used bag. When asked if she ever placed glucometers into new zip close bag, the nurse said she does this after cleaning them at the end of the day. On 09/19/19 at 08:14 an interview with nurse #4 revealed that all blood sugars are completed around 6:30 a.m. and she uses a disinfecting wipe to clean glucometers. She said that she cleans them between each use and that she wipes it for about 30 seconds, and then is done. On 09/19/19 at 08:26 AM, following BGC on resident #46, observed nurse placing used glucometer into open used bag in drawer with 4 glucometers in the front of the drawer, and 6 more in the back of the same drawer. Glucometers were in individual zip bags for each resident, and all bags were unzipped and open to air. All bags appeared older and used more than one time. The open bags were stacked on top of each other with both clean and unclean glucometers in same drawer and touching one another. On 09/19/19 at 08:32 AM Two other medication carts on 500/600 and 700/800 halls were observed to have open/unzipped glucometers in bags placed in the drawers in the same manner. On 09/19/19 at 09:04 AM an interview was conducted with Director of Nursing (DON) regarding the infection control policy for glucometers. She stated that she knows the glucometers are kept in individual bags and are to be cleaned between every resident use. The DON said they are wiped with disinfecting wipes until they dry and placed back in the resident's bag. The glucometers are kept in the medication carts. Instructions on the canister for disinfecting wipes were shown to the DON where the need to remain wet with disinfecting solution for 2-minute duration is located. Upon reviewing the instructions, the DON stated she was not aware the glucometers needed to be wet for two minutes.

Based on record review and staff interviews, the facility failed to develop a care plan to address antipsychotic medication use for 1 of 5 sampled residents reviewed for unnecessary medication. (Resident #23). The findings included: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Annual (Comprehensive) Minimum Data Set ((MDS) dated [DATE] specified the resident was severely impaired and the resident was receiving the antipsychotic medication, [MEDICATION NAME] on a routine basis. Review of Resident #23's Care Area Summary (CAA), dated 11/01/2017, revealed that the resident had the potential of having adverse reactions to the antipsychotic medication and that a care plan would be developed. Review of Resident #23's medical record revealed that her care plan was reviewed and updated on 08/22/2018 by the interdisciplinary team and stated that the resident may experience side effects from the [MEDICAL CONDITION] medication. Further review of Resident #23's care plan revealed the resident did not have a care plan in place to address the antipsychotic medication between the months of (MONTH) (YEAR) and (MONTH) (YEAR). During an interview with Administrator, Director of Nursing (DON), Social Worker Director, MDS nurse on 08/23/2018 at 5:25 PM, they stated did not have an updated antipsychotic care plan in place from 4/29/2018 to 8/22/2018. The MDS Nurse stated the last antipsychotic care plan was discontinued on 04/29/2018 and that there should have been one in place prior to 08/22/2018. The DON and the Administrator both revealed it was their expectation any resident, who had been prescribed an antipsychotic, should have a care plan in place.

Based on observations and resident and staff interviews, the facility failed to post the notice of location and availability of the facility's survey results. Findings included: During initial tour of building on 08/20/2018 at 10:00 am, the notebook of survey results was located in main lobby. No signage was observed posted regarding the availability and location of recent survey results. Resident Council interview was conducted on 08/22/2018 at 10:00 am. During the meeting, 10 of 10 Resident Council members stated they had no knowledge of the location of the survey results notebook. The resident council members stated they did not know where the survey results were located and had not seen any signage that directed residents to their location. An observation on 08/22/2018 at 10:45 am, revealed there were no notices posted in the facility regarding the availability and location of recent survey results, including the secured unit. An observation on 8/23/18 at 4:45PM, revealed there were no notices posted in the facility regarding the availability and location of recent survey results, including the secured unit. During an interview with the Administrator, Director of Nursing (DON) and Social Worker, on 8/23/18 at 5:00PM, they all stated they did not have signage posted for survey results. The Administrator and DON stated the survey results were located in the main lobby; however, the facility did not have signage posted that identified the location of the survey results notebook. The DON and Administrator said they were unaware that posting a notice of the location of survey results for the facility, including the secured unit, was part of the regulation, but that going forward they would expect signage to be posted that directed residents and families to the location of the survey results.

Based on observations, record review and staff interviews, the facility failed to follow and serve the prescribed therapeutic diet of no added salt to 2 of 4 sampled residents residing in the facility (Residents 2 and #7). The findings included: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the May 2017 recapitulation physician orders, the original order of 01/29/17 was included for a limited concentrated sweet, no added salt diet. His most recent Minimum Data Set, a quarterly dated 03/09/17, coded him with moderately impaired cognition, requiring set up and supervision for eating, and receiving a therapeutic diet. The most recent dietary notes dated 05/15/17 stated he was on a limited concentrated sweet, no added salt diet. A care plan last updated 05/15/17 identified the problem of needing set up and if not eating provide encouragement. Interventions included to provide the ordered diet. On 05/24/17 at 12:33 PM Resident #7 was observed to have been served his meal by Nurse Aide #2 in the dining room. He was left with an unopened salt packet by his plate. The tray card indicated he was to receive a limited concentrated sweet, no added salt diet. He was observed able to cut up his roll and ham independently. At 12:36 PM, NA #2 was interviewed and she stated she gave him a salt packet by mistake. Upon follow up interview on 05/24/17 at 2:27 PM, NA #2 stated she was supposed to read the tray cards but was side tracked orienting a new staff member. Resident #7 stated during interview on 05/24/17 at 12:42 PM that he usually does not need salt as the food is fine without it. On 05/24/17 at 3:51 PM the Director of Nursing (DON) was interviewed. The DON stated the kitchen staff serve up the entree on the plates and the nurse aides were responsible for placing the condiments on the tray before service. The DON stated she expected the nurse aides to read and follow the tray card information. She further stated that they just had an all staff meeting specific to following the tray cards. On 05/24/17 at 4:03 PM the Administrator stated she expected staff to read and follow the tray cards. 2. Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED]. Her admission Minimum (MDS) data set [DATE] coded her with having intact cognition, being independent with set up only for eating, and receiving a therapeutic diet. The initial dietary assessment dated [DATE] revealed she was on a no added salt limited concentrated sweets diet. The note stated the resident was on daily weights due to fluid retention. A care plan was developed 05/11/17 due to her risk for dehydration and weight fluctuations. Interventions included providing the diet as ordered. Resident #2 stated during interview on 05/24/17 at 10:59 AM that her weights varied due to her fluid volume. On 05/24/17 at 1:05 PM she was observed eating in her room her noon meal tray. The tray card listed her diet as no added salt and limited concentrated sweet. She received the planned menu of ham, sweet potato and received a fruit cup per her personal choice. She also had a salt packet which was not opened. At this time she stated she usually received a salt packet but usually the food did not need additional salt. An interview with Nurse Aide (NA) #1 on 05/24/17 at 1:09 PM revealed NA #1 delivered Resident #2 her meal tray at noon. She stated she did not realize that she should not have received a salt packet. During follow up interview with NA #1 on 05/24/17 at 2:34 PM, NA #1 stated she was supposed to check the tray card and was rushing and failed to check the tray card indicating no added salt. On 05/24/17 at 3:51 PM the Director of Nursing (DON) was interviewed. The DON stated the kitchen staff serve up the entree on the plates and the nurse aides were responsible for placing the condiments on the tray before service. The DON stated she expected the nurse aides to read and follow the tray card information. She further stated that they just had an all staff meeting specific to following the tray cards. On 05/24/17 at 4:03 PM the Administrator stated she expected staff to read and follow the tray cards.

Based on observation and staff interview the facility failed to air dry kitchenware before stacking it in storage and using it to serve resident beverages, failed to dispose of kitchenware with abraded serving surfaces, failed to de-stain discolored kitchenware, and failed to monitor dish machine gauges which were not registering the manufacturer's minimally acceptable temperatures. Findings included: 1. During initial tour of the main kitchen on 06/13/16, beginning at 9:38 AM, 1 of 8 tray pans stacked on top of one another on a storage rack had moisture trapped inside it. At this time a dietary employee reported the tray pans had to have been stacked on the rack the night before because no tray pans had been washed from the current day's breakfast meal yet. During a follow-up main kitchen tour on 06/15/16, beginning at 8:47 AM, 1 of 8 tray pans stacked on top of one another on a storage rack had moisture trapped inside it. At this time the assistant dietary manager (ADM) reported the tray pans had to have been stacked on the rack the night before because no tray pans had been washed from the current day's breakfast meal yet. At 10:15 AM on 06/15/16 twelve cups with moisture trapped inside were stacked on top of one another in auxiliary pantry #3 (long term care back). At this time the dietary manager (DM) reported these cups were stacked last night because the dietary employee had not yet begun to wash the current day's breakfast dishes. At 10:20 AM on 06/15/16 two cups with moisture trapped inside were stacked on top of one another in auxiliary pantry #1 (rehab). Again, the DM reported these cups were washed and stacked the night before. At 10:53 AM on 06/15/16 3 of 6 tray pans, brought from the auxiliary pantries and placed in storage in the main kitchen, were stacked wet. At 12:30 PM on 06/15/16 24 of 24 cups used to serve beverages to residents in auxiliary kitchen #1 (rehab) were stacked wet. At 3:45 PM on 06/15/16 4 of 10 tray pans, brought from the auxiliary pantries and placed in storage in the main kitchen, were stacked wet. At 2:32 PM on 06/16/16 the DM stated all dietary staff were previously in-serviced to completely air dry kitchenware before stacking it in storage or using it for serving food and beverage. She reported when kitchenware sat for long periods of time with moisture trapped inside harmful bacteria could develop which could make residents sick. At 2:49 PM on 06/16/16 a dietary employee stated if kitchenware remained wet for long periods of time bacteria might grow on it which could make residents sick. He reported all dietary staff were previously in-serviced about the need to air dry kitchenware before stacking it in storage or using it to serve food and beverage. 2. At 3:50 PM on 06/15/16 the interior surfaces of 12 of 12 plastic soup/cereal bowls were abraded and 2 of 8 plastic coffee mugs were abraded inside. This kitchenware was found in auxiliary pantry and kitchen #4 (memory care). At 3:55 PM on 06/15/16 the interior surfaces of 6 of 7 plastic coffee mugs and 9 of 12 plastic soup/cereal bowls were abraded. This kitchenware was found in auxiliary pantry and kitchen #3 (long term back). At 4:02 PM on 06/15/16 the interior surfaces of 6 of 14 plastic coffee mugs and 6 of 6 plastic soup/cereal bowls were abraded. This kitchenware was found in auxiliary pantry and kitchen #1 (rehab). At 4:09 PM on 06/15/16 the interior surfaces of 5 of 13 plastic coffee mugs and 5 of 9 plastic soup/cereal bowls were abraded. This kitchenware was found in auxiliary pantry and kitchen #2 (long term front). At 2:32 PM on 06/16/16 the dietary manager (DM) stated compromised kitchenware that was chipped, cracked, and abraded was supposed to be returned to the main kitchen where it could be counted and replaced. She reported it was a risk to use kitchenware with abraded serving surfaces because the abraded particles could slough off and be ingested by residents. At 2:49 PM on 06/16/16 a dietary employee stated employees in the auxiliary kitchens/pantries were supposed to bring damaged kitchenware back to the main kitchen to be reviewed by the DM who usually disposed of compromised items and made sure they were replaced or re-ordered. 3. At 3:50 PM on 06/15/16 7 of 7 sectional plates were discolored (dark brown), and 3 of 8 plastic coffee mugs were discolored (tan to dark brown) inside. This kitchenware was found in auxiliary pantry and kitchen #4 (memory care). At 3:55 PM on 06/15/16 4 of 8 sectional plates were discolored (dark brown), and 4 of 7 plastic coffee mugs were discolored (tan to dark brown) inside. This kitchenware was found in auxiliary pantry and kitchen #3 (long term back). At 4:02 PM on 06/15/16 2 of 3 sectional plates were discolored (dark brown), and 8 of 14 plastic coffee mugs were discolored (tan to dark brown) inside. This kitchenware was found in auxiliary pantry and kitchen #1 (rehab). At 4:09 PM on 06/15/16 5 of 7 sectional plates were discolored (dark brown), and 7 of 13 plastic coffee mugs were discolored (tan to dark brown) inside. This kitchenware was found in auxiliary pantry and kitchen #2 (long term front). At 2:32 PM on 06/16/16 the dietary manager (DM) stated dietary employees should be de-staining discolored kitchenware in bleach water as they found it. She reported it had been at least over a week since kitchenware was last de-stained. At 2:49 PM on 06/16/16 a dietary employee stated he was not sure if a frequency had been set for the practice of de-staining discolored kitchenware, but he reported when unsightly brown stains were found, it was time to soak kitchenware in a solution of bleach and water. 4. Between 10:28 AM and 10:35 AM on 06/15/16 four racks of kitchenware were run through the dish machine in auxiliary pantry #2 (long term front). The employee operating the dish machine was not watching the temperature gauges, and the final rinse temperature ranged between 144 and 148 degrees Fahrenheit as these racks were run through. After surveyor intervention, the employee and the dietary manager (DM) stated the manufacturer recommended the final rinse temperature register at least 180 degrees Fahrenheit in order for kitchenware to be properly sanitized. At 2:32 PM on 06/16/16 the DM stated a repairman who examined the dish machine in auxiliary pantry #2 (long term front) found the final rinse temperatures to range between 180 and 185 degrees Fahrenheit when he ran kitchenware through. However, she reported the repairman found a problem with the digital display in the dish machine gauge system. According to the DM, all dietary employees were previously in-serviced about the need to watch the dish machine gauges continuously and about what the effective wash and final rinse temperatures should be. At 2:49 PM on 06/16/16 a dietary employee stated staff were supposed to watch the dish machine gauges the whole time kitchenware was being run through. He reported it was important that the final rinse temperature reach 180 degrees Fahrenheit or the kitchenware would not get sanitized since no sanitizing solution fed into the dish machine. He explained when the final rinse temperature did not reach 180 degrees Fahrenheit the racks of kitchenware were to be rerun, and if temperature parameters were still not me, the kitchenware was to be taken to another auxiliary kitchen or the main kitchen where the dish machines were functioning properly. He also commented at this point the DM and maintenance manager should be notified, and it was possible the service technician might night to assess the problem.

Based on observations, staff interviews and record reviews the facility failed to update the care plan for 1 of 2 sampled residents reviewed for pressure ulcer. (Resident #127) Findings included: Resident #127 was admitted to the facility 8/8/12 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with assessment reference date of 3/19/15 indicated that Resident #127 was totally dependent of staff for activity of daily living (ADL ' s) and had one unhealed stage 3 pressure ulcer. The care plan dated 1/13/15 indicated a problem at risk for skin breakdown with approaches to assess skin status, assess nutrition status, keep MD informed, administer [MEDICATION NAME] as ordered, initiate treatment per standing orders, foam boots in place when in bed and broad chair. The goal was to have no open areas or skin breakdown and the goal time was 3 months. There was no evaluation or update noted. Review of Resident #127's weekly skin assessment revealed an initial discovery of a stage 2 pressure ulcer on 2/25/15 to the left lower buttock. The treatment initiated was to clean left lower buttock with normal saline and apply protective cream and cover every day. During an interview with the MDS coordinator on 5/14/15 at 9:30 AM revealed that changes and updates to the care plans are done from information in morning meeting and the MDS. Each discipline updates their own section. Nursing is responsible for updating the skin care plan. The care plan was not updated, it should have been updated with the onset of the pressure ulcer and caught again when the quarterly MDS was done and it was missed. An interview with the director of nurses on 5/14/15 at 10:30 AM revealed that her expectations are that the care plans are to be updated with any resident changes that is noted in morning meetings, weekly meetings and with the MDS by the MDS coordinators.

Based on observation and staff interviews the facility failed to discard outdated, thawed nutritional supplement shakes intended for resident consumption. The findings are: During an inspection of the kitchen on 11/05/12 at 10:50 AM the following food storage issue was observed: The walk in cooler contained four (4) plastic crates with thawed nutritional supplement shakes. Crate #1 contained five (5) thawed shakes with "10-14" written on a piece of cardboard in the crate. Crate #2 contained thirty-six (36) thawed shakes with "10-13" written on a piece of cardboard in the crate. Crate #3 contained eleven (11) thawed shakes with "10-17" written on a piece of cardboard in the crate. Crate #4 contained thirteen (13) thawed shakes with "10-12" written on a piece of cardboard in the crate. Printed on each nutritional supplement shake was a label that read, "Store frozen, thaw at or below forty (40) degrees, use thawed product within fourteen (14) days, keep refrigerated". An interview was conducted on 11/05/12 at 11:00 AM with the Dietary Manager (DM). The DM stated that the nutritional supplement shakes were placed in plastic crates in the cooler to be thawed. The date the shakes were placed in the cooler to thaw was written on a piece of cardboard from the shipping box, after the product was transferred into the plastic crates. The DM stated that the nutritional supplement shakes located in the plastic crates were thawed and ready to be served. The DM reviewed the label on a shake carton and confirmed that all the shakes in the four (4) crates were expired. The DM stated that she and the Assistant Dietary Manager (ADM) were responsible to check and remove all out of date products from the kitchen and that these shakes got overlooked. An interview was conducted on 11/05/12 at 11:12 AM with the ADM. The ADM stated that the corporate dietician had recently had a meeting to discuss nutritional supplement shakes. The information presented in the meeting for dietary staff included the fact that the nutritional supplement shakes were to be used within fourteen (14) days of thawing and to thaw only a few shakes at a time, to reduce waste. The ADM stated that she checked to make sure shakes were thawed and available on 11/05/12, but did not check the date the shakes were thawed.

Based on observations, staff and resident interviews, and medical record review, the facility failed to ensure liquids were thickened to nectar consistency for one (1) of three (3) residents on thickened liquids (Resident #156). The findings are: Resident #156 was admitted to the facility with [DIAGNOSES REDACTED]. The facility provided a list of residents assessed to be reliable for interview which included Resident #156. Review of an initial evaluation by the facility Speech Therapist revealed the resident was at risk for choking due to his swallowing disorder and that the resident required nectar thick liquids for safe swallowing. Review of the physician orders [REDACTED]. Review of the resident's care plan revealed that fluid volume deficit was addressed as a problem with interventions which included liquids thickened to nectar consistency. On 10/25/11 at 10:45 AM Resident #156 was observed lying on his bed in his room. Nursing Assistant (NA) #6, who was pushing the snack cart down the hall from room to room, was observed to ask Resident #156 if he wanted some lemonade. He accepted and NA #6 set approximately 120 cc of lemonade on his bedside table and left the room. The lemonade appeared to be unthickened and of normal consistency. When this was pointed out to the resident, he stated that he needed nectar thick liquids and would have to ask the nurse to thicken the lemonade before he could safely drink it. He also stated that occasionally nurses had offered thin liquids to him with his meds and he had told them he needed the liquids nectar thick. On 10/25/11 at 12:15 PM Resident #156 was observed feeding himself lunch with the Speech Therapist monitoring and cueing the resident. She stated his diet had been upgraded from pureed to mechanical soft but he remained on nectar thick liquids. She stated she was trialing the resident today with small sips of thin liquids after each bite of food. The Speech Therapist stated, however, that the resident should only receive nectar thick liquids from other staff members. She stated Resident #156 should not have been given thin consistency lemonade by the NA. She stated she expected staff to check the list of residents who received thickened liquids before passing out thin liquids. She stated she expected this list to be available to NAs who were passing out snacks. On 10/25/11 at 12:25 PM NA #6 was interviewed. She stated the lemonade she gave to Resident #156 was not thickened. She stated residents on thickened liquids had coolers to hold thickened liquids in their rooms instead of water pitchers. She also stated there is a list of residents on thickened liquids available to NAs. She stated Resident #156 is fairly new to the facility and she was not aware he was on thickened liquids. She stated she should have checked the list before she gave him thin consistency lemonade. On 10/25/11 at 12:35 PM Licensed Nurse #2 was interviewed. She stated the fluid status of all residents is on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated if an NA saw a cooler in a room, they were supposed to inquire of the nurse about the resident's fluid status before serving liquids. She also stated she expected NAs on her hall to ask her about a resident's fluid status anytime they were unsure. She stated NA #6 should have inquired if she were unsure. On 10/25/11 at 1:10 PM The Director of Nursing (DON) was interviewed. She stated NAs knew residents were on thickened liquids if they saw a cooler in the room. She stated they could also check the list of residents on thickened liquids or ask the nurse. The DON stated that residents on thickened liquids should be designated on the NA assignment sheet. She stated she expected NA #6 or any NA to use one or more of these methods to determine whether a resident was on thickened liquids before passing out thin liquids.

Based on observations, record and facility policy review, and staff interviews, the facility failed to remove expired and unlabeled medication from the medication cart on one (1) of four (4) medication carts allowing one expired medication to be administered. The findings are: A facility policy related to medication administration and dated [DATE] specified check expiration date on package/container prior to drug administration. An observation of the medication cart on the 100 hall on [DATE] at 1:57 PM revealed a partially used vial of Insulin with an opened date of [DATE] and an expiration date of [DATE]. Another partially used vial of Insulin that was not designated for any resident contained no opened or expiration dates. Licensed Nurse (LN) #1 was present during this observation. She stated she administered a dose of Insulin from the expired vial today, [DATE], at 11:30 AM. LN #1 stated she did not notice the expiration date. She added she should not have administered expired medication. LN #1 stated she did not use the vial that was not designated for any resident. LN #1 continued she should have checked her cart for expired meds when she began her shift. An interview with the Director of Nursing on [DATE] at 2:32 PM revealed she expected nurses to note the expiration date of a medication before it was administered.

Based on observations and staff interviews, the facility failed to dispose of soiled briefs in an appropriate manner as observed in two (2) resident bathrooms on one (1) of four (4) halls. The findings are: A facility policy regarding personal care and dated 02/03/11 contained in part soiled disposable briefs should be handled and disposed of so as to prevent contamination of the environment. An observation in the bathroom between Rooms #203 and #204 on 10/24/11 at 3:46 PM revealed an unbagged soiled brief on the floor against the wall in front of the commode. A strong urine odor was noted at this time. An interview with Resident #25 on 10/24/11 at 3:46 PM revealed the brief had been on the bathroom floor since after lunch. She stated this was not a usual happening. An observation in the same bathroom on 10/24/11 at 4:01 PM revealed the soiled brief was not present, but the urine odor continued to be noted. An interview with Nursing Assistant (NA) #5 on 10/24/11 at 4:02 PM revealed she had removed the soiled brief from the bathroom floor. She stated she found it on the floor just before this interview. NA #5 stated it was not typical for the residents in the adjoining rooms to leave soiled briefs on the bathroom floor. She added the urine odor came from the brief and it should not have been left on the floor. On 10/26/11 at 2:25 PM an observation from room [ROOM NUMBER] into the bathroom that adjoins room [ROOM NUMBER] revealed an unbagged soiled brief on the floor between the commode and the wall. Two nursing assistants were observed entering room [ROOM NUMBER] to assist a resident. After they left the room, the bathroom door was observed closed and the brief was observed in the same position on the bathroom floor. An interview with NA #3 on 10/26/11 at 11:45 AM revealed the residents in the adjoining rooms were unable to toilet independently. A continued interview with NA #3 on 10/27/11 at 9:10 AM revealed her normal practice was to place soiled briefs in a plastic bag. She added she had not noticed soiled briefs on residents' bathroom floors. An interview with NA #4 on 10/27/11 at 9:16 AM revealed plastic bags are kept in holders mounted on the doors of the bathrooms. She added soiled briefs were supposed to be placed in the plastic bags and not directly on the floor. Observations of bathrooms between the first four (4) rooms on both sides of the 200 hall on 10/27/11 beginning at 9:31 AM revealed clear holders were mounted on the bathroom side of doors. The holders in the bathroom between Rooms #201 and #202 and the bathroom between Rooms #203 and #204 were empty. Plastic bags were observed in the holders on the other bathroom doors. An interview with the Director of Nursing on 10/27/11 at 10:13 AM revealed her expectation was soiled briefs should not be placed directly on any floor. They should be placed in plastic bags and disposed of promptly.

Based on observations, staff and resident interviews, and medical record review, the facility failed to provide a functioning call system in two (2) of two (2) public toilets available for use by residents. The findings are: Resident #93 was admitted to the facility with [DIAGNOSES REDACTED]. The facility provided a list of residents assessed to be reliable for interview which included Resident #93. On 10/24/11 at 12:30 PM an observation was made of two unlocked toilets, available for use to the public, both located on the hallways closest to the therapy gym. Neither toilet had a call bell system or an emergency alarm system available. Further observations were made of both toilets on 10/25/11 at 5:00 PM, on 10/26/11 at 6:00 PM, and on 10/27/11 at 12:15 PM. All observations revealed that the toilets remained unlocked and available for use by anyone and that neither toilet had a call bell system or emergency alarm system available. On 10/27/11 at 1:30 PM Resident #93 was interviewed. She stated she had occasionally used the bathrooms across from the therapy gym. She stated she normally used the bathroom in her room, but that if she were ambulating around the facility in her wheelchair, she sometimes had urgency and would use one of the bathrooms near the therapy gym. Resident #93 stated she would stand from her wheelchair, open the toilet door, and ambulate into the toilet. On 10/27/11 at 1:43 PM the Rehab Manager was interviewed. She stated that when a resident needed to use the toilet, a therapist accompanied them back to the bathroom in their room. She stated the toilets across from the therapy gym were meant for use by the public and visitors, not by residents. She also stated, however, that occasionally an ambulatory resident had left the therapy gym and used the public toilets across the hallway. On 10/27/11 at 2:00 PM the Maintenance Director was interviewed. He stated that a functioning call bell system should be in any common area used by residents including showers and toilets. He stated the toilets across from the therapy gym were not equipped with a call bell system. He stated he was aware that residents occasionally used those toilets, though staff redirected them when they observed this. On 10/27/11 at 3:10 PM the Administrator was interviewed. She stated she was not aware that residents used the two toilets across from the therapy gym. She stated she expected any toilet used by a resident should be equipped with a call bell system.