Every finding on record at University Health and Rehabilitation Center

Based on observations, records reviewed and interviews it was determined that the facility did not adequately maintain a safe environment to prevent potential hazards that could have resulted in accidents or injuries in two of five soiled utility rooms. Staff failed to secure two soiled utility room doors on the facility's second floor because paper towels had been placed in the locks, which prevented proper locking. At the time of the survey 140 residents resided in the facility. The findings include:On 04/01/2026 at 1:40 PM, the Wound Care Registered Nurse (RN) completed wound care disposed of a biohazard bag in the soiled utility room, and exited, leaving the soiled utility room door unlocked.On 04/01/2026 at 1:45 PM Staff A, Certified Nursing Assistant (CNA) exited the soiled utility room and the door remained unlocked.On 04/01/2026 at 1:46 PM Staff B, [NAME] exited the soiled utility room and the door remained unlocked.Observation on 04/01/2026 at 1:47 PM revealed someone placed a piece of paper towel in the lock of the soiled utility room door, which stopped the door from locking properly.On 04/01/2026 at 1:48 PM, the Assistant Director of Nursing (ADON), Staff A, CNA, the Wound Care RN, and Staff B, [NAME] looked at the lock together and saw the issue. None of the staff members knew who put the paper towel in the lock.On 04/01/2026 at 2:09 PM, the Wound Care RN left the second soiled utility room on the second floor and did not lock the door. The surveyor checked the lock and saw that a piece of paper towel blocked the lock, which prevented the door from locking (photo). On 04/01/2026 at 3:12 PM, the Wound Care RN was interviewed and stated: The Soiled utility room is to be kept locked. I did not check to make sure it was locked when I left the room because I never thought that the paper towels would be in the lock. I am surprised. During an interview on 04/01/2026 at 4:44 PM, the Director of Nursing (DON) stated: There is a lock on the soiled utility room door that requires a code to enter. The soiled utility room door should be kept locked to prevent residents from entering. There are sharps in containers and biohazard materials in bins inside the soiled utility room. The potential exists for a resident to enter the room and touch the sharps container and open the bins if the door if kept open. Record review of the facility's policy titled, Safety - Prevention of Accidents dated 2001 MED-PASS, Inc. (Revised July 2026) indicated:Policy Statement.Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation Facility-Oriented Approach to SafetyOur facility-oriented approach to safety addresses risks for groups of residents.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the causes) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.Individualized, Resident-Centered Approach to Safety.Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staff.b. Assigning responsibility for carrying out interventions.c. Providing training, as necessary.d. Ensuring that interventions are implemented, and documenting interventions.4. Monitoring the effectiveness of interventions shall include the following:Ensuring that interventions are implemented correctly and consistently evaluating the effectiveness of interventions.

Based on observation, interview and record review, the facility failed to store food under sanitary conditions as evidenced by the walk-in refrigerator contained flower bouquets on the shelves among the fruits and vegetables. This has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Food Storage Policy and Procedure (review date November 2024); Policy-Food storage areas are maintained in a clean, safe and sanitary manner and maximize nutrient retention and food quality; Procedure-1) Perishable foods are stored immediately after delivery. Observation of the initial kitchen tour on 5/19/25 at 6:47 AM with the Dietary Supervisor and Corporate CDM (Certified Dietary Manager) revealed the walk-in refrigerator with four bouquets of flowers lying on the shelf with vegetables and fruits. Photographic evidence submitted. Interview with the Corporate CDM on 5/19/25 at 6:48 AM. He revealed that the bouquets of flowers were for Nurses' week. He confirmed that the bouquets of flowers should not be in the walk-in refrigerator. Interview with the Dietary Supervisor on 5/19/25 at 6:50 AM. She revealed that the flowers were not to be in the walk-in refrigerator.

Based on observation, interview and record review, the facility failed to secure confidential information for the residents on the fourth floor as evidenced by an observation of an unattended paperwork with residents' pictures, names and rooms left visible on top of the fourth floor's south medication cart. There were 24 residents residing on the fourth floor. The findings included: Observation on 5/19/25 at 6:40 AM revealed confidential paperwork with residents' names, corresponding pictures and room numbers were observed on top of the unattended fourth floor's south medication cart. During an interview on 5/19/25 at 6:55 AM, Staff A, Registered Nurse (RN) stated: Sorry, I left the paperwork on top of the medication cart; I know all information should be kept private. Interview on 5/21/25 at 1:17 PM, the Director of Nursing (DON) stated: All resident information should be kept confidential. Record review of a policy titled Protected Health Information (PHI), Safeguarding Electronic revised January 2024, Reviewed January 2025 revealed Policy: Electronic protected health information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information. Policy Interpretation and Implementation: 1. This facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained, received, or transmitted by our information system.

Based on observations, record reviews and interviews, the facility failed to update a respiratory care plan for one (Resident #79) out of one sampled resident as evidenced by a respiratory care plan with interventions for a Bilevel Positive Airway Pressure (BiPAP) machine, despite physician orders for the discontinuation of the BiPAP machine since 10/15/24. There were three residents with BiPAP machines in the facility at the time of survey. The findings included: On 5/19/25 at 6:52 AM Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer (photographic evidence). On 5/20/25 at 9:26 Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer. On 5/22/25 at 7:26 AM Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer. Record review of Resident #79's demographic sheet revealed an admitted [DATE] with diagnosis that included: Heart Failure and Insomnia. Record review of a Quarterly Minimum Data Set (MDS) reference dated 4/8/2025 revealed Resident #79's was severely impaired cognitively, was independent with eating. Further review revealed Resident #79 had no shortness of breath and did not receive oxygen or respiratory therapy. Record review of the electronic health record revealed Resident #79 had a Respiratory care plan that was updated on 11/21/23 for sleep Apnea BiPAP to be applied at bedtime. Record review of Resident #79's Physician's Order Sheet revealed no active orders for a BiPAP machine. Further review revealed orders dated 8/30/23 for BiPAP to be applied at bedtime (HS) and may wear as needed (PRN) and may remove at liberty every night shift related to Obstructive Sleep Apnea. Review of the October 2024 physician orders revealed an order dated 10/15/24 for the BiPAP to be discontinued. On 5/22/25 at 7:10 AM, during a side-by-side observation with the night supervisor in Resident # 79's room; the night supervisor was asked if Resident # 79 uses the BiPAP machine; the night shift Supervisor stated: It is put on at nighttime and removed when the resident first wakes up. The surveyor requested to view the mask. The night shift supervisor opened the drawer, and a mask was observed inside a plastic bag (photographic evidence). Interview on 5/22/25 at 7:35 AM, the night shift supervisor stated, I checked and there are no active physician orders for this resident to receive the BiPAP machine, so the nurse did not administer it. On 5/22/25 at 8:40 AM, the MDS coordinator was asked about the interventions for the BiPAP machine mentioned in the care. The MDS coordinator stated: I will check. On 5/22/25 at 9:05 AM, the MDS coordinator returned with a care plan that documented the BiPAP interventions were resolved on 5/20/25. The MDS coordinator was asked about the time frame for resolving care plans once the orders have been discontinued. The MDS Coordinator stated, I think someone was trying to update the information. Interview on 5/22/25 at 9:38 AM, the Director of Nursing (DON) when asked about care plan interventions the DON stated: This resident (Resident # 79) had a physician order for use of BiPAP that were discontinued for a while, the machine is still in the room because the son lives out of the country and left it and staff should not be administering the BiPAP machine without an order. Record review of a policy titled Care Plans, Comprehensive Person-Centered revised January 2025 revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes.

Based on observations, interviews and record reviews, the facility failed to properly secure medications for residents residing on the fourth floor, as evidenced by a plastic bag with medications observed on top of the unattended fourth floor's south medication cart. There were 24 residents residing on the fourth floor at the time of survey. The findings included: Observation on 05/20/25 at 9:15 AM, revealed a plastic bag filled with medications left unattended on top of the south medication cart (photographic evidence). On 05/20/25 at 9:15 AM, Staff A, Registered Nurse (RN) who was seated at the nursing station was asked if medications were inside the plastic bag on top of the south medication cart. Staff A, RN walked with the surveyor to the medication cart, opened the plastic bag and revealed the contents which included loose pills and pills in containers. Staff A, RN stated:I found these medications in a resident's room, removed it and was going to notify the supervisor when I was called to help another nurse with an emergency situation. On 05/20/25 at 9:25 AM, Staff A, RN revealed: Any medications found in residents' rooms should be given to the supervisor .I should have taken the medication off the cart. On 05/21/25 at 1:15 PM, the Director of Nursing (DON) stated, Medications are to be kept in a locked cart. If a nurse discovers medication in a resident's room the medications are to be secured and labeled until the family can pick it up. Record review of a Policy titled, Storage of Medications Revised April 2019, Reviewed January 2025 Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.

Based on observations, interviews and record review, the facility failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F812- Food Procurement, Store/Prepare/Serve - Sanitary and F867- Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA). These repeated deficient practices have the potential to affect all residents residing in the facility. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 01/11/ 2024, F812 Food Procurement, Store/Prepare/Serve/ Sanitary was cited related the facility's failure to store food under sanitary conditions related to a buildup of ice in the ice cream freezer with the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of that survey. During this survey with an exit dated 05/22/2025, repeated deficient practice was identified for F812-Food Procurement, Store/Prepare/Serve/Sanitary, related to the walk-in refrigerator containing flower bouquets on the shelves among the fruits and vegetables which has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of this survey. F867-Quality Assurance and Performance Improvement was cited due to the QAPI/QAA committee's failure to monitor previous problem areas identified with existing need for improvement based on the committee's continued evaluation of their performance improvement projects. Interview with the Administrator, and Director of Nursing (DON) on 05/22/2025 at 12:10 PM, revealed The QAPI committee meets monthly on the fourth Thursday of each month. The most recent meeting was held on April 24, 2025. The committee includes: the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Registered Dietitian, Maintenance Director, Activities Director, Social Services Director, and other department heads. Each department is assigned specific objectives or focus areas to monitor and report on monthly. During QAPI meetings, department representatives-such as those from nursing, social services, and environmental services. These meetings serve as a collaborative forum for identifying trends, discussing concerns, and exploring opportunities for improvement.

Based on records reviewed and interviews the facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury which required medical attention for one resident (Resident #1) out of four sampled residents, as evidenced by during assisted transfer Resident#1 hit her head on the wheelchair and the incident went unreported after bruising was identified and reported the family member to staff. There were 143 residents residing in the facility at the time of the survey. The findings included: On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a small scratch on the left leg. Record review of a demographic sheet for Resident#1 revealed an initial admitted [DATE] and readmitted [DATE] with diagnosis that included: Dementia and Unspecified fall. Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and had no falls since admission/entry or reentry or the prior assessment. Further review of a care plan initiated on 12/15/21 and revised on 10/15/24 revealed Resident#1 is at risk for falls related to muscle weakness, impaired mobility and had a fall that occurred on 4/1/24, had goals to have no episodes of falls and suffer no injuries from falls. The interventions included: Encourage resident to ask for assistance when attempting to transfer. Review of a physician's order sheet revealed orders dated 11/24/24 for fall precaution every shift and order dated 8/8/24 for bed in lowest position every day and night shift. Review of progress notes revealed no documentation related to the incident that occurred during the resident's transfer. Record review of a Fall Risk assessment dated [DATE] revealed Resident#1 was at a low risk for falls. Review of a skin check dated 2/1/25 revealed Resident #1's skin was intact with no redness or bruising noted. On 2/17/25 at 11:35 AM, the Director of Nursing (DON) stated, After witnessing or discovering that a resident had a fall or injury of unknown origin, the protocol is for the staff to report to the doctor and family, we do an incident report and staff should document. Staff monitor residents to prevent fall depending on their risk for example by taking residents to activities. [Resident#1] hit her head on the arm rest of the wheelchair during transfer because the Certified Nursing Assistant was not looking or holding the resident for a moment. [Resident #1] was listed on the Incident Log for 2/1/25 after The CNA reported to us on 2/3/25 that the resident hit her head on the wheelchair during transfer. When an incident report is completed, it triggers for other assessments. The Skin check is dated 2/1/25 because the incident happened on that date, but I completed the Skin check for the Resident on 2/3/25. 31581 Interview with the Director of Nursing/Abuse Coordinator/Risk Manager on 2/17/25 at 11:25 AM. He stated, She did not have a fall. She hit her head with the wheelchair. The CNA was trying to transfer her from the bed to the wheelchair. She pulled the wheelchair closer to the bed and she let the resident go while she was sitting on the edge of the bed. The bruises did not come right away. At the moment, she didn't have a bruise. The incident was on 2/01/25, the bruises were noticed on 2/03/25. When the incident happened, she didn't have any bruises, the bruises were noted on 2/03/25. The family came and saw the patient and asked the nurse and she hadn't noticed the bruises. The CNA did not notify the facility about the incident on 2/01/25 and she was supposed to. She was reprimanded for not telling anyone about the incident. She did not have a fall. She hit her head on the handrest of the wheelchair. We did an incident report. The doctor was notified, an order was given for x-rays of the sacrum and coccyx. There were no fractures. Interview with Staff A, CNA on 2/17/25 at 12:52 PM via Spanish translator. She revealed on 2/01/25, she bathed the resident, dressed her and she was going to transfer her to the wheelchair. She had her on the edge of the bed, she held her with one hand and held the wheelchair with the other. The resident lost control of her body and leaned forward, and she bumped her head on the wheelchair handrest. The correct way to transfer a resident from the bed to the wheelchair is that you grab the resident, have them stand and then turn them. She confirmed that the wheelchair was not positioned before transferring the resident. She checked her and she didn't see anything and didn't think she had to report it. She was supposed to report the incident to the nurse but did not. Interview with Staff B, Registered Nurse (RN) on 2/17/25 at 1:19 PM. She stated, I work from 7:00 AM to 7:00 PM and during the day skilled nursing was done. The resident had no complaints of pain. After dinner, the daughter visited and asked me about something on her head. Throughout the day I never saw anything on her head. When I looked on the left side of her head under the hair, I saw the bruising. I did not see any bruise on her hand. I made an assessment head to toe. Her vital signs were stable and no complaint of pain. I called the DON/Abuse Coordinator and reported the bruise on 2/03/25. I called the doctor, and he gave an order for an x-ray. The x-ray was negative. I endorsed it to the night shift for neuro checks. The CNA is supposed to tell the nurse when something happens and if they hit their head. Record review of the Accidents and Incidents-Investigating and Reporting Policy and Procedure (revision date July 2017, reviewed January 2025); Policy Statement-All accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator; Policy Interpretation and Interpretation -2h) The date/time the injured person's family was notified and by whom.

Based on interviews and record reviews, the facility failed to ensure one resident (Resident #1) out of four sampled residents received adequate supervision to prevent accidents as evidenced by during transfer, Resident #1 sustained injuries that were not reported immediately by staff and were discovered by a family member. The findings included: On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a small scratch on the left leg. Record review of a demographic sheet for Resident#1 revealed an initial admitted [DATE] and readmitted [DATE] with diagnosis that included: Dementia and Unspecified fall. Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and had no falls since admission/entry or reentry or the prior assessment. Further review of a care plan initiated on 12/15/21 and revised on 10/15/24 revealed Resident#1 is at risk for falls related to muscle weakness, impaired mobility and had a fall that occurred on 4/1/24, had goals to have no episodes of falls and suffer no injuries from falls. The interventions included: Encourage resident to ask for assistance when attempting to transfer. Review of a physician's order sheet revealed orders dated 11/24/24 for fall precaution every shift and order dated 8/8/24 for bed in lowest position every day and night shift. Review of progress notes revealed no documentation related to the incident that occurred during the resident's transfer. Record review of a Fall Risk assessment dated [DATE] revealed Resident#1 was at a low risk for falls. Review of a skin check dated 2/1/25 revealed Resident #1's skin was intact with no redness or bruising noted. On 2/17/25 at 11:35 AM, the Director of Nursing (DON) stated, After witnessing or discovering that a resident had a fall or injury of unknown origin, the protocol is for the staff to report to the doctor and family, we do an incident report and staff should document. Staff monitor residents to prevent fall depending on their risk for example by taking residents to activities. [Resident#1] hit her head on the arm rest of the wheelchair during transfer because the Certified Nursing Assistant was not looking or holding the resident for a moment. [Resident #1] was listed on the Incident Log for 2/1/25 after The CNA reported to us on 2/3/25 that the resident hit her head on the wheelchair during transfer. When an incident report is completed, it triggers for other assessments. The Skin check is dated 2/1/25 because the incident happened on that date, but I completed the Skin check for the Resident on 2/3/25. 31581 Interview with the Director of Nursing/Abuse Coordinator/Risk Manager on 2/17/25 at 11:25 AM. He stated, She did not have a fall. She hit her head with the wheelchair. The CNA was trying to transfer her from the bed to the wheelchair. She pulled the wheelchair closer to the bed and she let the resident go while she was sitting on the edge of the bed. The bruises did not come right away. At the moment, she didn't have a bruise. The incident was on 2/01/25, the bruises were noticed on 2/03/25. When the incident happened, she didn't have any bruises, the bruises were noted on 2/03/25. The family came and saw the patient and asked the nurse and she hadn't noticed the bruises. The CNA did not notify the facility about the incident on 2/01/25 and she was supposed to. She was reprimanded for not telling anyone about the incident. She did not have a fall. She hit her head on the handrest of the wheelchair. We did an incident report. The doctor was notified, an order was given for x-rays of the sacrum and coccyx. There were no fractures. Interview with Staff A, CNA on 2/17/25 at 12:52 PM via Spanish translator. She revealed on 2/01/25, she bathed the resident, dressed her and she was going to transfer her to the wheelchair. She had her on the edge of the bed, she held her with one hand and held the wheelchair with the other. The resident lost control of her body and leaned forward, and she bumped her head on the wheelchair handrest. The correct way to transfer a resident from the bed to the wheelchair is that you grab the resident, have them stand and then turn them. She confirmed that the wheelchair was not positioned before transferring the resident. She checked her and she didn't see anything and didn't think she had to report it. She was supposed to report the incident to the nurse but did not. Interview with Staff B, Registered Nurse (RN) on 2/17/25 at 1:19 PM. She stated, I work from 7:00 AM to 7:00 PM and during the day skilled nursing was done. The resident had no complaints of pain. After dinner, the daughter visited and asked me about something on her head. Throughout the day I never saw anything on her head. When I looked on the left side of her head under the hair, I saw the bruising. I did not see any bruise on her hand. I made an assessment head to toe. Her vital signs were stable and no complaint of pain. I called the DON/Abuse Coordinator and reported the bruise on 2/03/25. I called the doctor, and he gave an order for an x-ray. The x-ray was negative. I endorsed it to the night shift for neuro checks. The CNA is supposed to tell the nurse when something happens and if they hit their head. Record review of the Accidents and Incidents-Investigating and Reporting Policy and Procedure (revision date July 2017, reviewed January 2025); Policy Statement-All accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator; Policy Interpretation -2h) The date/time the injured person's family was notified and by whom.

Based on observations, interviews, and record review the facility failed to provide reasonable accommodations for Resident #343 as evidenced by Resident #343 call light was out of reach and had difficulty using other devices. There were 143 residents residing in the facility at the time of the survey. Findings include: On 01/08/24 at 10:31 AM. In an interview with Resident #343. Resident #343 stated, I'm not able to use the call light to ask for help. I'm not able to move my fingers to touch the device. On 01/10/24 at 02:50 PM, during an observation and interview with Resident #343. It was observed that the thumb call light was tucked underneath Resident #343's pillow to the right side of the resident's head. The resident was holding the bed control keypad on his chest. The resident was asked: Are you able to use your call light, if not, how are you able to call staff for assistance? Resident #343 stated, I'm hard of hearing. The call light is too hard to push. It's very difficult. The bed control is hard to push the buttons. My fingers are weak. The resident further reported that he cannot raise the television volume nor turn the light on or off. On 01/10/24 at 2:58 PM, during an interview Staff C a Registered Nurse (RN) was asked, if Resident #343 able to use the call light and how does Resident #343 call for help from staff and where are staff required to place call lights for residents? Staff C reported that Resident #343 cannot move their hands. The left hand is more contracted, and the right hand is swollen. I placed the call light on his chest, but the resident was not able to use the bed control. He uses his voice too. When residents are alert and oriented, the call lights are to be on the bed and where the resident can reach it. On 01/10/24 at 03:11 PM; In an interview with Staff D an Occupational Therapist (OT) and Staff E a Physical Therapist (PT), was asked, how Resident #343 was doing in occupational therapy and based on the current assessment is Resident #343 able to use a thumb call light. Staff D stated, I performed this assessment. The last day of physical and occupational therapy was on December 1, 2023. On both arms there were some limitations and impairment. We did not test his right- and left-hand grip as we do not have the machine for that. The resident's strength can decrease over time. He won't be able to use a pancake call light and thumb call light. It would require more effort. One of my goals was to use the pancake call button but he didn't have the strength and the manual dexterity. Staff further reported that Resident #343 was placed across from the nursing station and is able to communicate his needs. Review of facility documentation titled Occupational evaluation and plan of treatment revealed. In the section titled Objective Progress and Short-Long term goals. The short-term goal for Resident #343 documented that the resident will exhibit improved right manual dexterity as evidenced by an increased ability to press the pancake nurse call button in three out of five trials. Target date 11/2/23. The long-term goal stated Resident #343 will exhibit improved right manual dexterity as evidenced by an increased ability to press the call button five out of five times. Target date 12/1/23. In the section titled Musculoskeletal System Assessment indicated: Out of a scale of five. Resident's right shoulder flexion and extension was a two plus. The left shoulder flexion and extension was a one. The right elbow and wrist strength were two plus. The left elbow and wrist strength was one. The left-hand and right-hand grip was not tested . On 01/11/24 at 9:24 AM. In an observation and interview with Resident #343. It was observed that the call light device was changed to a pancake call light. Resident # 343 was asked if he was able to press the call light and Resident #343 pressed the pancake call light, and the call light rang in the room. The resident was asked if it was better for him to use this type of call light to work better for him. Resident #343 stated This is much better. My luck because you are here. On 01/11/24 at 10:35 AM, the Director of Nursing (DON) was asked where staff are to place call lights for a resident and Resident #343's history with using the thumb call light. The DON was also asked if the facility has any other types of call lights available for ease of use. The DON stated, Call lights are to be within reach of the resident. I spoke to [Resident #343] yesterday. With the previous call light, he was able to hold the call light with one hand and use the other hand to press the button. We wondered if he had the strength to use the call light. With him, it's difficult to press it. Sometimes, he was able to use the thumb call light. We tried the pneumatic call light before. We will try the pancake call light and monitor that. We have pneumatic call lights, but we were concerned that they would create a fire. We placed the resident close to the nursing station. Staff are aware to check on [Resident #343] frequently. It is not uncommon for residents who are unable to use the call light. He could press the call light, but it was difficult. On 1/11/24 at 11:33 AM. In an interview the Director of Maintenance was asked what type of call lights are available in the facility and if any pancake call lights were available. The Director of Maintenance stated: We have thumb and pneumatic call lights. We do not have pancake call lights. If I need another type of call light, I can contact Central Supply. Review of Resident #343 clinical records revealed a medical diagnosis of muscle weakness and lack of coordination. Record review of Resident #343's physician orders dated 12/5/23 at 3:13 PM revealed passive range of motion exercises to bilateral lower extremities and upper extremities in all available planes with the patient supine in bed to maintain joint/skin integrity. Three times a week and as tolerated. Record review of Resident #343's Minimum Data Set, dated dated dated [DATE] revealed in section C: Cognitive Patterns a brief interview of mental status score was a six suggesting severe cognitive impairment. In section GG: Functional Abilities and Goals, Resident #343 needed partial assistance from another person to complete any activities. Upper extremities were impaired on both sides. Eating was dependent with partial/ moderate assistance. In section O: Special Treatments, Procedures, and Program. Occupation therapy and physical therapy started on 11/2/23 and had four days in the last seven days. Review of Resident #343's care plan with next review date of 3/20/2024 revealed: The resident had a history of arthritis and has a risk for injury or discomfort. The intervention was for the use of supportive devices such as splints, etc. as recommended by the occupational therapist. The resident is dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits, and physical limitation. Interventions were to assist/ escort to activity functions as needed. Focus stated resident is a risk for falls related to muscle weakness and other lack of coordination. The intervention was to keep the call light within reach. Focus stated the resident has impaired functional abilities due to weakness, pressure ulcers, and impaired mental status. Interventions were to assist with activities of daily living based on the resident's functionality to keep residents clean and well-groomed. Review of the facility's policies and procedures titled Accommodation of Needs last reviewed January 2024 Policy statement indicate: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. In the section titled, Policy Interpretation and Implementation. Part one, the resident individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or the residents would be endangered. Part two, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. Part 4. To accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes. For example, interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communications, and maintain dignity.

Based on observation and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, homelike environment and comfortable interior for 1 out of 3 residential floors (Resident rooms on 300 floor North Unit). The Findings Included: During the initial observations on 01/08/2024 beginning at 08:41AM of residents and residents' rooms revealed: room [ROOM NUMBER]B was noted with water stains on the wall and roof by the window (B Bed), (Photo Available). Rooms 307A, 308, 311B, 314B-Garbage on the floors-Straw wrapping, empty condiment packets, tissues, alcohol pad packets, and paper of different kinds (photo available). room [ROOM NUMBER] B-Privacy curtain observed with dark red stains (Photo available) During an interview on 01/08/24 at 09:22 Resident #92 reported that when it rains, water leaks through the wall in her room (Photo available). The resident stated she has respiratory issues, every time it rains the situation gets worse, you can see more water spots on the wall when it rains. The people here know all about the problem and it has been going on for some time, a long time now. In an interview on 01/10/24 at 09:02 AM, the Maintenance Director/Housekeeping/Laundry stated: Last time we had a problem with the air conditioning (AC), the AC had a leak, and it goes through the wall, the AC was fixed last week, and now we will prepare the wall. We saw the problem with the wall, but we were working on finding out where the leak was coming from before, we did any repairs to the wall. We finally figured out that the leak was coming from the AC. We removed the AC and saw there was a hole, and we fixed the hole. So now we are waiting for the drywall to dry, and then we will plaster and paint the wall in room [ROOM NUMBER]. The whole process of finding out where the leak was coming from took about 2 to 3 weeks. I personally spoke to the resident in 305B to let her know what was going on with the wall in the room. I do not have any invoices for the repairs because I fixed the hole myself. Regarding cleaning the residents' rooms, Housekeeping cannot go into the rooms to clean during breakfast, lunch, or dinner. Once the resident starts being served their food, we stop cleaning the rooms and wait until the residents are done eating. We have one porter/housekeeper that works 12:00 PM to 8:30 PM at night for cleaning. The morning shift Porters starts at 6:00 AM and Housekeeping starts at 7:00 AM. Interview with Resident #92 on 01/11/24 at 08:49 AM revealed the first time she noticed the leak to the wall was a more than a few months ago, she had her son talk to someone at the facility, they came and looked at the wall and said they fixed the problem, the problem was never fixed, and no one has given her an update about what is going on. Review of the facility's policy titled Cleaning and Disinfecting Resident's Rooms revision date January 2023 indicated: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 4. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.

Based on Interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 139) out of one resident whose MDS assessments reviewed at the time of survey. This deficiency has the potential to affect 143 residents residing in the facility at the time of survey. The findings included: Record Review of Admission Record revealed Resident # 139 was admitted to the facility on [DATE] and discharged on [DATE]. Record review of the clinical records revealed the resident's diagnosis included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified focal traumatic brain injury without loss of consciousness, subsequent encounter, other lack of coordination, difficulty in walking, not elsewhere classified, dysphagia, oropharyngeal phase, muscle weakness (generalized), generalized anxiety disorder, gastro-esophageal reflux disease with esophagitis, without bleeding, anemia, unspecified, unspecified psychosis not due to a substance or known, physiological condition, primary open-angle glaucoma, right eye, stage unspecified, essential (primary) hypertension, constipation, unspecified, benign prostatic hyperplasia without lower urinary tract, symptoms, repeated falls, fall on same level from slipping, tripping and stumbling with subsequent striking against other object, subsequent encounter. Record review of Discharge - Return not Anticipated Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to short-term/general hospital. Record review of the Care Plan: Date Initiated: 09/22/2023, Revision on: 12/28/2023 revealed Focus: Resident is admitted as short-term placement and will go home with son upon Discharge. Goals: Resident will have discharge planning initiated. Interventions: Arrange for transportation. Discuss discharge plan with resident/responsible party. Involve family or significant others in all teaching, evaluate equipment needs and order accordingly. Nurse's note dated 10/13/2023 time stamped 13:15 documented resident discharged home today with home health care services Physical Therapy (PT), Occupational Therapy (OT) nurse aid and RN, and Durable Medical Equipment (DME) supplies necessary to promote and support Activities of Daily Living (ADLS). At this time the resident was hemodynamically stable within his baseline status, with no complaints of pain or discomfort, or any sign of distress. Skin dry and warm to touch, no rash no bruising, no redness or trauma, no open area noted. Instruction was given to the patient to follow up with Primary Care Physician (PCP) within a week for continuation of services including medical regimen and two schedule appointment . with Cardiology other with Neurology, The patient was educated on sign or symptoms of distress or complication of existing condition that that granted emergency medical attention before next PCP consult. I ordered and reported any sign or symptoms to avoid further complication, resident verbalized understood. All resident belongings are given to resident facility transportation in place. During an Interview on 01/11/24 at 10:53 AM the MDS Coordinator was asked about the MDS coding on Section A that indicated that the resident had gone to the hospital but documented in the progress notes that the resident was discharged from home. The MDS Coordinator stated: Let me check. When he checked he stated: You are correct I need to correct it, because resident actually went to the community/home and not to a hospital. Record review revealed the Nursing Home Transfer and Discharge Notice was completed on 10/13/2023 and indicated: Location to which resident is transferred or discharged to Home. Review of the facility's MDS Policy and Procedure documented: Policy Statement The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established process for completing, submitting, and making corrections to MDS. Completion of MDS Interdisciplinary Team will complete sections on MDS for a resident in the facility. Submission of MDS The assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Correction of Error If an error is discovered in a record that has already been accepted by QIES ASAP system, implement procedures for either Modification or Inactivation of the information in the system within 14 days of the discovery of the error.

Based on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for two Residents (#69 #46,) out of 28 sampled residents. As evidenced by several observations of Resident #46 revealed the oxygen was running at the incorrect rate. Resident #69's tracheostomy (trach) collar that provided oxygenation to the resident was dislodged from the trach opening and hanging to the right side of the resident's neck. There were 14 residents that required respiratory services out of the 148 residents residing in the facility at the time of the survey. The Findings Included: During observation on 01/08/24 at 09:43 AM Resident #69 was in bed Oxygen (02) running at 10 liters per Minute (LPM) via trach collar, the resident was not receiving oxygenation via trach collar because the trach collar for oxygenation was off of the resident and laying on the right side of resident's neck. On 01/08/24 09:49 AM Registered Nurse (Staff C) and the surveyor went to Resident #69's room, Staff C stated the resident removed the 02 tubing herself, Staff C donned gloves, placed the trach collar for oxygenation correctly on resident, and elevated the head of the bed. When asked by the surveyor how often does she checks on the resident, Staff C stated: I check on the resident every time I make my rounds, which is usually every hour. On 01/09/24 at 09:16 AM Resident #69 was not in the room. The bed was stripped of linen. The Assistant Director of Nursing (ADON) reported that the resident was sent to the hospice unit yesterday. Review of the medical records for Resident #69 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Respiratory Failure, unspecified, unspecified whether with hypoxia or hypercapnia and Encounter for attention to tracheostomy. Resident #69 was discharged on [DATE] to a hospice unit. Review of the Physician's Orders Sheet for January 2024 revealed Resident #69 had orders that included but not limited to: Trach: Encourage and assist Resident with use of humidified Oxygen 10 LPM via trach collar continuously. Trach: Obtain O2 saturations-every shift. Notify physician if saturations less than 90%. Trach: #6.5 millimeter (mm) for Diagnosis: encounter for tracheostomy care. Suction tracheostomy tube-every shift for patency or to keep the airway open related to respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia and as needed for patency or to keep the airway open. Record review of Resident #69's 02 (oxygen) saturation recordings on 1/8/23 ranged from 92% to 98% via oxygen by trach collar at 10 LPM. Record review of Resident #69 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed in Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is undetermined. Section GG for functional Abilities and Goals documented resident is dependent for care. Section J for Health Conditions documented no shortness of breath Section O for Special Treatments documented resident received oxygen therapy, tracheostomy care and suctioning. Record review of Resident #69 's Care Plans reference Date 01/17/2024 revealed: Resident requires Tracheostomy due to inability to maintain airway related to Respiratory failure. Interventions include Labs and x-rays as ordered and notify MD of any abnormalities. Maintain aspiration precaution. Monitor for congestion and suction as needed. Monitor for elevated temperature and notify MD as needed. Monitor for signs and symptoms of respiratory distress such as shortness of breath, cyanosis, and wheezing. Report to MD promptly. Monitor O2 sat as ordered and as needed. Provide Oral Care as needed to maintain oral cavity clean, and Provide Tracheostomy Care as indicated. Resident is at risk for shortness of breath, impaired breathing pattern secondary to diagnosis of respiratory failure. Interventions In room visits for social stimulation if resident cannot attend activities. Monitor for episodes of shortness of breath and implement interventions as ordered, notify Physician (MD) if ineffective and follow up as indicated. Oxygen per MD order. Provide reassurance and support to prevent anxiety during episode of shortness of breath and Provide rest periods in between activities as needed. Review of the nursing progress notes for Resident #69 dated 1/8/2024 timestamped 18:46 documented Resident is transfer at this time to Hospice unit. family member aware. During an interview on 01/10/24 at 09:32 AM the Assistant Director of Nursing (ADON) stated: The nurses are required to conduct their rounds hourly but for this resident moving forward when and if she comes back to the facility, we will be doing rounds more often for the resident. The nurse told me that the resident most likely had removed her oxygen, regarding if that is something the resident did regularly, I would have to follow up with my nurses. Review of the facility's Policy and procedure for Oxygen Administration Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. 3. Assemble the equipment and supplies as needed. Physician Orders Policy and procedure Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Nursing Staff must follow safe and effective transcription of physician orders and safe and effective medication/treatment administration. 34007 Resident # 46 Observation of Resident # 46 on 01/08/24 at 09:18 AM revealed the resident lying on his bed, awake watching television. Resident was receiving oxygen therapy. It was observed the oxygen concentrator level set at 4 LPM. (Photographic evidence). No distress or anxiety was noted. A sign Oxygen in use was observed at the room door. Observation of Resident # 46 on 01/09/24 at 07:57 AM. The resident was observed sleeping. No distress or anxiety was noted. The oxygen concentrator level was set at 4 LPM (Photographic evidence). Observation of Resident # 46 on 01/10/24 07:48 AM. The resident was sleeping. No distress or anxiety was noted. The oxygen concentrator level was set at 4 LPM. (Photographic evidence). Record review of Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Medical Diagnosis revealed the resident's diagnosis included, but were not limited to, Rheumatoid arthritis, unspecified, respiratory failure, unspecified with hypoxia, interstitial pulmonary disease, unspecified, disorder involving the immune mechanism, unspecified, chronic obstructive pulmonary disease, unspecified, cutaneous abscess, unspecified, other lack of coordination, difficulty in walking, not elsewhere classified, muscle weakness (generalized), unspecified protein-calorie malnutrition, chronic kidney disease, stage 3 unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified osteoarthritis, unspecified site, rash and other nonspecific skin eruption, hypo-osmolality and hyponatremia, pain, unspecified, encounter for screening for respiratory tuberculosis, generalized anxiety disorder, orthostatic hypotension, hypothyroidism, unspecified, other disorders of electrolyte and fluid balance, not elsewhere, classified, major depressive disorder, recurrent, unspecified, insomnia, unspecified, essential (primary) hypertension, chronic rhinitis, gastro-esophageal reflux disease without esophagitis, long term (current) use of antithrombotic/antiplatelets. Record review of orders dated 01/10/2024 revealed the resident had an order of Oxygen Therapy at 2 LPM via nasal cannula continuously. Record review of Quarterly Minimum Data Set (MDS) Section C dated 11/07/2023 revealed the resident Brief Interview for Mental Status (BIMS) Summary Score was 13. Record review of Quarterly MDS Section GG dated 11/07/2023 revealed the resident Functional Abilities and Goals - Walker-Yes, Upper extremity (shoulder, elbow, wrist, hand)- Impairment in both sides, Eating-Setup or clean up assistance, Toileting hygiene, Sit to stand, Toilet transfer-Substantial/maximal assistance. Record review of Quarterly MDS Section O dated 11/07/2023 revealed the resident was receiving oxygen therapy continuous. Record review of Care Plan initiated on 10/19/2023 and completed on 01/25/2024 revealed the Focus: Resident is using Oxygen therapy. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions: Administer oxygen as per MD orders. Monitor for signs/symptoms of respiratory distress and report to MD PRN (as needed) such as increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and/or skin color changes. (e.g., respiratory treatment and care, possible complications, communication, advance directives, equipment functioning and cleaning, procedures for emergencies). Interview with Staff A Registered Nurse (RN) on 01/10/24 at 08:37 AM stated I do not know about this resident, I just started working today and I have not checked her, we are very good following the doctors' orders. Let me check and if it says different, I will correct it immediately.

Based on observation, interview and record review, the facility failed to store food under sanitary condition by ensuring the ice cream freezer was properly defrosted and did not contain a buildup of ice. This has the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Refrigerators and Freezers Policy and Procedure (revision date May 2023); Policy Statement-This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation; Policy Interpretation and Implementation-7) Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, excess condensation and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance and or cleaning schedules will be monitored for compliance. Observation of the initial kitchen tour on 1/08/24 at 8:31 AM with the Certified Dietary Manager revealed the ice cream freezer noted with a thick buildup of ice within the inside parameter of the unit. Photographic evidence provided. The facility was cited in November 2022 for the ice buildup in the ice cream freezer. Interview with the Certified Dietary Manager on 1/08/24 at 8:32 AM. He stated, This should not be here and we will defrost it right now. Interview with the Certified Dietary Manager on 1/10/24 at 8:45 AM. He stated, The ice cream freezer is defrosted and cleaned every Monday. I had to defrost it again today. Review of the Dietary Weekly Cleaning Schedule dated 12/10/23-1/07/24 documented the ice cream freezer was defrosted and cleaned every Monday.

Based on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to resident rights, safe, clean, comfortable and homelike environment and food procurement, store, prepare and serve-sanitary resulting in repeated deficient practice. The facility was cited for Resident rights in 2022; Safe, clean, comfortable and homelike environment in 2022 and Food procurement, store, prepare and serve-Sanitary in 2022. These repeated deficiencies practice has the potential to affect any of the 143 residents residing in the facility. The findings included: Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure (implemented November 2017, reviewed March 2023) documented the following: Policy-It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) The QAA Committee shall be interdisciplinary and meet alongside Risk Management Committee: a) Consist at a minimum of: The Director of Nursing Services, The Medical Director and at least three other members of the facility's staff; b) Meet a least quarterly and as needed to coordinate and evaluate activities under the QAPI Program and c) Develop and implement appropriate plans of action to correct identified quality deficiencies. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 10/26/23 for September 2023, 11/30/23 for October 2023 and 12/21/23 for November: documented the facility had a QAA Committee meeting quarterly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. On 1/11/24 at 12:53 PM, interview with the Administrator/QAA. He stated, The QAA Committee meets quarterly and monthly. We meet the last Thursday of the month. Committee members are: Administrator, DON, Medical Director and Department Heads. The purpose of the QAA committee is to identify any trends regarding quality of care and any physical plant concerns.

Based on observation, interview and record review, the facility failed to promote dignity and respect for two residents (#41 and #93) out of 28 sampled residents. As evidenced by a Certified Nursing Assistant (CNA) was observed standing while feeding Resident #41 and Resident #93 not having any food while his roommate was being fed and eating food. There were 143 residents residing in the facility at the time of the survey. The findings included: On 01/08/24 at 12:15 PM Certified Nursing Assistant (CNA), (Staff B) was observed standing over the bed of Resident #41 and feeding him lunch from the lunch tray. On 01/08/24 at 12:15 PM Resident #93's roommate was eating lunch being fed by Staff B meanwhile, Resident # 93 was observed with no food. The surveyor asked Staff B where Resident #93's food was. Staff B reported it will be coming soon. During an interview on 01/08/24 at 12:17 PM Staff B was asked about standing while feeding the resident. Staff B stated, I am sorry but there is only one chair in the room, and it has stuff on it. Staff B acknowledged that she should not be standing and feeding the resident. On 01/08/24 at 12:23 PM Resident #93's lunch tray arrived in the room and Staff B set up the food tray and sat in a chair to feed the resident. On 01/10/24 at 09:37 AM, the Assistant Director of Nursing (ADON) stated I will be conducting an in-service for all nursing staff regarding dignity-making sure they sit when they are feeding the residents, and all other dignity concerns. Review of the facility's policy titled Assistance with Meals revision date January 2023 states: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example a. Not standing over residents while assisting them with meals.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety that include; maintenance of refrigeration units, holding of foods at regulatory temperatures, proper thawing of foods, and preparation of foods within clean areas. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 11/07/22 at 9 AM with the Certified Dietary Manager (CDM) , the following were noted: (a) Prior to entering the kitchen it was noted that 3 large uncovered carts full of used resident trays were located outside the kitchen. Specifically the trays were from the resident's breakfast meal of 11/7/22 and the garbage and trash was exposed to the area areas. The surveyor requested to the CDM that all garbage/trash inside of the facility must be covered as per regulation (b) The ice cream freezer was noted to have a thick build up of ice within the inside parameter of the unit. The surveyor requested that the unit was not being maintained properly and that removal of the ice was required. (c) Observation of the walk-in freezer noted a large tear tear (approximately 10 inches) to the door gasket. The CDM was unaware of the issue and the surveyor requested repair to ensure proper temperature maintenance. (d) Observation of the reach-in refrigerator ( #1 and #2) noted large tears to the door gaskets. The CDM was unaware of the issue and the surveyor requested repair to ensure proper temperature maintenance. (e) Observation of the food preparation skillets noted that the interior Teflon surface was being scraped off as a result of continued use. it was discussed with the CDM that each time the skillets were being used for food preparation that particles of the Teflon finish are being scrapped off resulting on potential food contamination . 2) During the observation of the breakfast tray line in the main kitchen on 11/08/22 at 7 AM, temperatures of foods were taken by the CDM with the facility's calibrated bayonet thermometer. The temperature testing noted that hot foods were not being held at the minimum regulatory requirement of 135 degrees F or above as evidenced by : Boiled Eggs (12 ) = 120 degrees F French Toast (40 portions) = 115 degrees F Sausage Links (30 ) = 110 degrees F Grits (24 portions ) = 120 degrees F Cafe Con Leche (24 portions) = 120 degrees F The surveyor requested that these hot foods not be served to the facility residents until heated to the regulatory requirement for holding of hot foods that included a minimum 135 degrees F. 3) During a third observation of the main kitchen on 11/14/22 at 11:30 AM, it was noted that approximately 50 pounds of packaged raw chicken was located in the preparation sink. Further observation noted that the chicken was resting in a full sink of hot water. NO cold water was noted to be running over the chicken. Interview with the CDM and cook (Staff L) noted that the chicken was being defrosted for the evening meal. The surveyor informed the CDM that required thawing of perishable food was not being conducted. Specifically it was reviewed that maximum cold water must be flowing onto the surface of all the chicken. The surveyor requested that the temperature of the raw chicken be taken with the facility's calibrated thermometer and was recorded at 70 degrees F. The cook (Staff L) also stated she was unaware of the regulations for safe thawing of perishable foods. The surveyor stated to the CDM that the chicken should not be used due to the potential of food borne illness, however the CDM had already made the decision to discard the raw chicken. 4) Observation conducted on 11/14/22 at 2 1:15 PM noted that the dinner trays (approximately 120) were being set up with silverware, napkins, condiments, clean drinking cups, etc. in the soiled service hallway that houses the Laundry Department, Central Supply department and entrance /exit for employees . It was noted that the service hallway contains containers of soiled linens, numerous cleaning chemicals, and soiled commercial cleaning equipment (vacuums and floor clearing equipment). It was further noted that a soiled commercial vacuum was resting directly against a clean tray set up cart. The CDM was asked to observe the issue and stated that he was unaware that the resident food trays were being set up in the dirty service hallway .

Based on record review,observation and interview, it was determined that the the facility failed to treat residents with respect and dignity as evidenced by; 5 out of 18 residents sampled residents (Resident #2, Resident #12, Resident #54, Resident #76, and Resident #158) who drank thickened liquids from condiment cups, 119 resident were not provide with proper drinking cup/glass to pour milk into of which 2 out of 19 were sampled residents who were required to drink milk from the carton, 2 (Resident's #57 and Resident #69) 2 sampled residents were fed by standing staff, and 1 (Resident #48) of 1 sampled resident who was referred to as a feeder. The findings include: Review of facility's policies and procedures for Resident Rights noted Policy Statement: * Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to be: (a) a dignified existence; (b) be treated with respect, kindness, and dignity; (c) exercise his or her rights as a resident of this facility and as a citizen of the United States; (d) be supported by the facility in exercising his or her rights; During the observation of the breakfast meal on 11/08/22 in the main kitchen it was noted that residents who required thickened liquids (Nectar and Honey) had a portion of thickened apple juice served in a disposable black condiment container (2 ounces) that are to be use for servings of condiments (dressings, ketchup, mustard, mayonnaise, etc.). It was noted that due to the black color of the disposable condiment contained they juice could not be identified by the surveyor. Kitchen staff stated that the disposable containers are used daily for residents receiving thickened liquids. The following were discussed with the Certified Dietary Manager (CDM) at the time of the observation; (1) the use of disposable cups should not be use and all residents should be served beverages in appropriate reusable cups, (2) the type of juice being served could not be determined due to the black color of the cup, (3) the wide mouth of the cup would make it difficult for residents to drink from, and (4) the approved menu documented that a 6 ounce servings of apple juice to be served. The CDM stated he was aware that disposable cups should not be used however was unaware that staff were utilizing disposable condiment cups for drinking. Observation of the breakfast meal conducted on 11/08/22 at 8 AM in the second floor assisted dining room it was noted that residents and staff could not determine the type of juice being served and due to the wide mouth of the disposable contained it was noted that staff would spill when attempting to assist residents with drinking. A review of the Diet Census for 11/08/22 noted that there were currently 18 residents with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further investigation noted that of the 18 residents, Resident #2,Resident #12, Resident #54,Resident #76, and Resident # 158 were included in the residents sampled. During the observation of the breakfast meal on 11/14/22 at 8 AM it was noted that all residents residing on the second, third, and fourth floor received a portion of of in the original 8 ounce container. Further observations noted that residents were required to drink the portion of milk directly from the milk container and that no residents received a proper drinking cup to pour the milk into from the container. Residents were noted to have difficulty and noted to spill when attempting to drink form the milk container. Interview with the CDM at the time of the above observation on 11/14/2022 noted that he was aware that drinking cups should be provided when milk is served via the carton, but was unaware that dietary staff were not including a drinking cup on the food trays. Interview with the facility's Registered Dietitian on 11/14/22 revealed that 119 resident failed to receive a drinking cup for the breakfast meal on 11/14/22. Of the 119 residents it was noted that 19 residents were included in the final sample. During the observation of the breakfast meal conducted on 11/14/22 at 8 AM on the second floor, it was noted that the food trays were served in room for Resident's #57 and Resident #69. Further observation of the meal noted that Staff E stood over Resident #57 while feeding the resident in bed and Staff F also stood over the Resident #69 while feeding the resident in bed. Interviews conducted with Staff E and F at the time of the observation noted to state that they were aware that they were required to sit while feeding and assisting residents with meals. The staff stated no reason why the were standing and feeding the residents Review of the clinical records of Resident's #57 and Resident #69 noted the following: Resident #57 - Minimum Data Set ( MDS) dated [DATE] documented in Section G for functional status that the resident was Total Dependence with eating. Resident #69 - MDS dated [DATE] documented in Section G for functional status indicated that the resident required extensive assistance with eating. Record review revealed Resident #48 was admitted to the facility on [DATE]. According to a Quarterly Minimum Data Set (MDS) dated [DATE], Resident #48 had a Brief Interview for Mental Status score of 02, indicating severe cognitive impairment. The MDS documented that Resident #48 required 'extensive assistance' and 'one person physical assist' for eating. According to the Director of Therapy, 'extensive assistance' would mean that the resident would require anywhere from minimal assistance from staff up to staff physically feeding the resident with the resident not participating at all in the task. During an observation of lunch being served to the residents in their rooms, on 11/14/22 at 1:52 PM, Staff were preparing to serve Resident #48 lunch in her room. Staff G, a Registered Nurse (RN) removed the lid from the meal and compared the meal to the slip that accompanied the meal which documented the dietary order and the resident's preferences. After placing the lid back on the meal, Staff G instructed staff that Resident #48 was a 'feeder'. When this surveyor inquired about the resident and her ability to feed herself, Staff G stated, she is a feeder, we have to feed her.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary , orderly, and comfortable interior for 3 of 3 resident floors (second, third, and fourth floors). The findings included: During the environment tour conducted on 11/8/22 at 1 PM accompanied with the Administrator and Director of Maintenance, the following were noted: Room #204 - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. Room #205 - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. Room #206 - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), numerous large black scuff room marks walls, toilet seat not secure, and Geri chair exterior cushions were torn. Room #208 - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. Room #209 - Numerous large black scuff marks to walls, exterior of over-bed tables were rusted, and cushions to Geri chair were torn. Room #210 - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls, and toilet seat was not secure. Room #212 - bathroom emergency call cord was wrapped around handrail, Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. Room #214 - The electrical cord of the wall mounted a/c unit was not secured to the wall and was a tripping hazard. Room #215 - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. Room #217 - Landing mats (2) noted to be soiled and torn, exterior of over-bed tables 92) were in disrepair and sharp edges, and room walls required repainting due to numerous black scuff marks. Room #220 - Broken night stand, room walls were heavily scuffed with large black marks, and full urinal on resident's bedside table. Room #225 - Window blinds broken and unable to close, toilet requires recaulking to the floor, room base boards falling off from wall, and over-bed tables exteriors were in disrepair. Second Floor Dining Room (Assisted): A 3 foot section of the Formica floor was lifting up and creating a fall hazard. Dining room chairs (10) exterior were noted to be worn and seat cushions torn (10). Second Floor TV Sitting Area (2) - the floors of the sitting areas were noted to be covered with large scrapes and tears. Room #322 - The room walls were noted to have numerous large black scuff marks. Room # 427 - The room privacy curtain was noted to have a large yellow stain, and room walls were noted to have numerous large black scuff marks. Following the 11/8/22 tour the findings were again reviewed with the Administrator who stated that facility staff are failing to utilize the facility TELS system where staff are required to document housekeeping and maintenance environment issues to the facility's maintenance services .

Based on record review, observations and interviews, the facility failed to comply with the state minimum staffing requirements for 48 consecutive hours and failed to comply with the stated minimum weekly average of 3.6 hours of care by direct care staff per resident per day. There were 140 residents residing in the facility at the time of the survey. The findings included: On 11/07/22 at 12:12 PM, an interview was conducted with Staff R, Certified Nursing Assistant ( CNA) stated she had worked for the facility for [AGE] years. Staff R stated having 13 residents assigned to her today and sometimes she had more than that. Staff R added she normally she had 10 residents assigned. Staff R stated that they usually had six (6) CNAs working, but they had five (5) today. On 11/07/22 at 12:25 PM, an interview was conducted with Staff S, an agency CNA. Staff S stated having 14 residents assigned to her today, but usually had 8-10 residents assigned to her. Staff S was asked why of the residents caseload bigger that normally and stated she could not tell what happened or why she had 14 residents today. Staff S was asked if she was able to complete the resident scare and the tasks assigned to her by the end of the day and stated, that she will but that it is hard/rough. On 11/07/22 at 12:35 PM, during an interview, the Unit Supervisor stated one CNA called off on another floor and a CNA from her unit (2nd floor) was sent to the 3rd floor. On 11/07/22 at 12:37 PM, an interview was conducted with Staff O, and stated she had been working in the facility for about 2 years. Staff O stated having 14 residents assigned to her and usually had 8 residents. On 11/14/22 at 11:54 AM, an interview was conducted with Staff H, CNA who stated she had not done Resident #12's morning care. On 11/14/22 12:02 PM, observation revealed Resident #12 in bed, eyes opened. Resident was not interviewable. Further observation revealed the residents left hand with black matter underneath her fingernails. The resident right hand with contracture continues to have long thick yellow fingernails. The resident's right arm was paralyzed and had her hand closed and unable to straight her finger out. On 11/14/22 12:14 PM, a side by side review of Resident #12's both hand fingernails was conducted with Staff J, Registered Nurse (RN) and Staff H, CNA. During the review, Staff J, RN stated that Yes her fingernails are too long. Staff J added she used to cut the resident's fingernails with a special nails cutter. Staff J, RN stated she will cut the resident fingernails. During the review, Staff H, CNA stated that Resident #12 placed her hands on the food and then in her mouth and added that the staff can't leave her alone when she was eating. On 11/14/22 at 9:19 AM, observation revealed Resident #22 sitting at the edge of her bed. An interview was conducted with the resident who stated that they staff had not trimmed her nails and added that she will be glad if they do it. Observation revealed the residents left and right hand fingernails continue to be long and jagged. On 11/14/22 at 11:33 AM, an interview was conducted with Staff J, RN who stated that Resident #22 was sometimes confused, had Dementia and [CONDITION(S)]. Staff J stated that sometimes the resident refuses care, but they go back and they are able to do the care needed to be done. Staff J was asked who is responsible to do the residents fingernails care and stated the activities staff do the nail polish and the CNA and the nurses cut their nails. Staff J was asked where do the staff document fingernail care and stated they did not document nail care. On 11/14/22 at 11:37 AM, an interview was conducted with Staff H, CNA who state she had been working at the facility for 3 years. Staff H stated she gave Resident #22 a shower this morning, dressed up, combed her hair, assisted with oral hygiene and cleaned her nails. Staff H, CNA was asked if she will cut/trim the residents fingernails and stated that sometimes they had some people that come in to cut the residents fingernails. Staff H was asked if she file/trimmed Resident #22's fingernails and stated that she did not file her fingernails on Saturday because she had 13 residents assigned to her and did not see that the resident's fingernails need to be filed. A side by side review of Resident #22's fingernails was conducted with Staff H and stated she will file the residents fingernails. During the review, the resident showed to Staff H her own box with nail polish and [NAME] board that the resident kept on her own room. Furthermore, Staff J, RN came in to Resident #22's room and acknowledge that the residents fingernails need to be trimmed and cut. On 11/14/22 12:14 PM, a side by side review of Resident #12's both hand fingernails and right hand was conducted with Staff J, Registered Nurse (RN) and Staff H, CNA. During the interview, Staff J was asked if the resident wore a splint or a device on her contracted hand and stated that the resident did not wear a splint or a device on her right hand. Staff H, CNA stated Resident #12's right hand had been like that for a longtime and she did not put any device on her right hand. On 11/15/22 at 9:37 AM, a joint interview was conducted with the facility's Therapy Director (TD) and Staff K, Restorative Certified Nursing Assistant (RCNA). The TD stated the therapists do screen residents quarterly and when referred by nursing. Staff K, RCNA stated that he did not have Resident #12 on caseload for the RNP. The TD stated that the resident had been in the facility since 05/26/22 and the last screen was done on 07/20/22. The TD stated that the referral was received for a Geri chair appropriateness. The TD stated the Physical Therapist (PT) screening documented that the patient was noted with fixed left ankle plantar flexion contracture and right residual limb knee flexion contracture. The TD stated that the recommendations were at the time as Patient able to sit in Geri chair without sliding. No further skilled PT intervention indicated. The TD was asked if Resident #12 had been assessed quarterly as per facility's policy by the occupational therapist and stated that she will need to check on that further. The TD stated that that they had a new electronic reporting system since 2021. The TD was asked if Resident #12 had an occupational therapy screen completed for the year 2022 and stated she did not see one in the system. The TD stated Resident #12 had RNP on 11/05/21 for Left lower extremities and right residual limb PROM (passive range of motion), but not for a splint and it was discontinued on 01/25/22. The TD was not able to find out why the RNP was discontinued. During the interview, the TD stated the therapy department received a referral on 11/14/22 for Physical Therapy (PT) and Occupational Therapy (OT) screen due to increased flexor tone on right lower and right upper extremity. The TD was apprised that the surveyor brought to nursing attention regarding Resident #12's right hand contracture and no care and services been provided to maintain function of the hand or arm. The TD stated that after Resident #12's OT screen completion, the OT informed her that the resident would have an OT evaluation to address her right hand contracture via orthotic management. The TD added that a specialist will come to the facility on [DATE] Wednesday to fit Resident #12 for a right hand orthotic. The TD stated this was an oversight. On 11/14/22 at 3:38 PM, an interview was conducted with Staff N, CNA who stated that Resident #47 was on the RNP, but she did not see anyone coming today. Staff N added unless they came while she was in another room. Staff N stated they resident holds a carrot on her hand. On 11/15/22 at 7:56 AM, an interview was conducted with Staff H, CNA usually works in the 2nd floor. Staff H stated that on 11/14/22 she stayed until around 6:00 PM to help residents with dinner because a CNA called off. On 11/15/22 at 8:00 AM, an interview was conducted with the Unit Supervisor (US) who stated that on 11/14/22 a CNA for the 3 to 11:00 PM shift, called off and a day shift CNA stayed until dinner was over to help because they have a lot of residents that need to be fed. The US added that sometimes the administrative staff will come up to assist. On 11/15/22 at 8:07 AM, an interview was conducted with the facility's Staffing Coordinator (SC). The interview was conducted in Spanish because she verbalized that she understood part of the conversation in English. Arrangement was made with the SC to review the facility's staffing reports. On 11/15/22 at 9:56 AM, a joint interview was conducted with the facility's TD and Staff K, RCNA. Staff K stated he did not have Resident #47 on the RNP caseload and was not applying any splints to the residents. The TD stated the resident had a Speech Therapy treatment from 08/24/22 thru 09/12/22. The TD stated that the resident had a PT screening done on 07/20/22 for Geri chair and a Geri Chair was recommended for the resident to be seated when out of bed. The TD stated no Occupational Therapy (OT) screen done in July, August, September, October 2022. The TD added that the resident was under hospice care at the time of the PT screen on 07/20/22. The TD stated that Resident #47 was discharged from Hospice care on 08/26/22 and that neither physical nor occupational therapist had screened the resident after discharged from hospice on 08/26/22. The TD was asked if the facility management talk about hospice discharged resident during daily meeting and she stated they do. The TD stated that she needed to pay more attention to residents that are discharged from hospice so they can be screened. The TD stated this resident fell thru the cracks and was not screened after discharged from hospice care as it should had been. On 11/15/22 at 8:17 AM, an interview was conducted with Staff O, CNA who stated that Resident #54 was able to move his extremities with assistant. Staff O stated that the resident had a blue splint that it was always on top of the night's stand. Staff O added that she had not seen the resident wearing the splint. Consequently, a side by side review of Resident #54's night stand and drawers was conducted with Staff O and revealed the light blue splint was not there. Staff O stated the splint was there on Sunday (11/13/22) when she took care of the resident. A side by side review of the resident's closet was conducted with Staff O and revealed the splint was stored in the closet. Subsequently, a joint interview was conducted with Resident #54 and Staff O. The resident stated that he did not know who put it in the closet and that no one placed the splint on him last week or this week. The resident stated that he would like the splint back on. The resident stated they used to put it on but had not for the last two weeks. On 11/15/22 at 8:36 AM, an interview was conducted with the Unit Supervisor (US) who stated that the facility used to have a RNP and now they have a Part-time Nurse doing the program. A side by side review of the Restorative Census was conducted with the US. The review revealed that Resident #54 was not listed meaning the resident was not receiving RNP. The UM was asked who is responsible of applying the splint and stated that therapy or RNP. On 11/15/22 at 8:40 AM, an interview was conducted with the facility's Therapy Director who stated that she had been working at the facility for about one year. The TD stated that Resident #54 was seen by PT and OT from 07/21/22 thru 08/19/22. The resident got to his maximum potential and was discharged from therapy on 08/19/22. The TD was asked regarding Resident #54's splint and stated that the RNP was discontinued on 07/22/22. The TD was asked about the splint and stated that she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TD was asked to provide information regarding the resident's splint as to when was ordered, when it was discontinued. At the end of the survey, the TD did not provide feedback related to the residents splint in his room. The TD stated the facility used to have a RNP and added she was not sure how accurate the facility's RNP was working now. On 11/15/22 at 9:13 AM, a joint interview with Staff K,RCNA and the TD was conducted. The TD stated that Restorative staff were in charge of applying the residents splint. Staff K RCNA stated been working in the facility since 08/2022 and reports to a nurse that works in the evening. Staff K stated he did not have Resident #54 on the RNP caseload for splint application. The TD was asked what they were doing to prevent Resident #54's right hand and right arm from losing function. The TD stated that resident last OT assessment documented that the resident's left arm was weaker. The TD was asked if OT assessed the resident for a splint and stated that OT did not assess the resident for a splint. The TD added there were no goals for a splint, the resident's upper extremities ROM was impaired. The TD stated that the resident right arm was impaired and the left arm was within functional limits according to the OT evaluation. The TD stated that the OT recommendations then were for 24 hrs nursing care, no RNP, did not address splint. The TD stated that the resident's ROM was discontinued but did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/15/22 at 9:21 AM, a joint interview was conducted with the US and TD. The US stated that she discontinued Resident #54's RNP on 07/22/22 because the resident was referred to therapy. On 11/15/22 at 9:34 AM, during the interview, the TD was asked to submit the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's PT discharge summary dated 08/19/22 provided by the TD documented under discharge status and recommendations RNP- nursing caregivers to encourage patient to participate in bed mobility and to transfer out of bed as tolerated to maintain functional gains in therapy. On 11/15/22 at 11:18 AM, during an interview, the SC stated that she had been in the position for 5 years. The SC stated that it was very difficult to staff on the weekends because she had no staff, a lot of salary competition, and agencies CNAs do not want to work on weekends. The SC added that she was a CNA and that she worked as a CNA the 3 to 11:00 PM shift on Thursday and Friday. The SC stated that she also had worked as CNA on Sundays. The SC stated that she was using agencies CNA for all three shift. The SC stated that the CNAs minimum daily average as 2.0 hours and that the minimum direct care staff combined hours was 3.0 hours. The SC was informed that the minimum direct care staff combined hours was 3.6 hours per regulation. The SC stated she was told wrong then. A side by side review of the facility's two weeks staffing from 03/27/22 to 07/09/22 and from 10/01/22 to 11/12/22 was conducted with the SC. The review revealed the facility had a combined Nursing, CNA, and Direct Care Staff weekly average of less than 3.6 hour on the following weeks: -05/01/22 to 05/07/22- 2.40 hours -05/08/22 to 05/14/22- 2.80 hours -05/15/22 to 05/21/22- 2.81 hours -05/29/22 to 06/04/22- 2.77 hours -06/05/22 to 06/11/22- 2.80 hours -06/12/22 to 06/18/22- 2.78 hours -06/19/22 to 06/25/22- 2.82 hours -06/26/22 to 07/02/22- 2.97 hours -07/03/22 to 07/09/22- 2.92 hours -09/25/22 to 10/01/22- 2.48 hours -10/02/22 to 10/08/22- 2.17 hours -10/09/22 to 10/15/22- 2.29 hours -10/30/22 to 11/05/22- 2.17 hours -11/06/22 to 11/12/22- 2.40 hours Continue side by side review of the facility's Calculating State Minimum Nursing Staff for Long Term Care Facilities from 10/01/22 to 11/12/22 with the SC. The review revealed the facility had a daily average of less than 2.0 hours for Certified Nursing Assistant for 48 consecutive hours on the following dates: -10/01/22- 1.80 hours -10/02/22- 1.70 hours -10/03/22- 1.90 hours -10/07/22- 1.80 hours -10/08/22- 1.90 hours -10/15/22- 1.90 hours -10/16/22- 1.60 hours -10/30/22- 1.70 hours -10/31/22- 1.90 hours -11/04/22- 1.80 hours -11/05/22- 1.90 hours -11/06/22- 1.90 hours On 11/15/22 at 1:24 PM, an interview was conducted with the DON and she was apprised regarding the facility's CNA daily average hour below 2.0 for 48 consecutive hours in the month of October 2022 and November 2022. The DON was asked if they did a moratorium and stated that she had to check with the administrator. A side by side review of the facility's census for 10/01/22, 10/02/22, 10/03/22, 10/07/22, 10/08/22, 10/15/22, 10/16/22, 10/30/22, 10/31/22, 11/04/22, 11/05/22, 11/06/22, and 11/12/22 was conducted with the DON. The review revealed that the facility had one new admission on 11/04/22. The DON was informed that a review of the facility's Minimum weekly average hours by direct care staff per resident per day from 03/27/22 to 07/09/22 and 09/25/22 to 11/12/22 was conducted with the Staffing Coordinator. The DON was apprised that the facility's combined Minimum weekly average of 3.6 hours by direct care staff per resident per day was less than 3.6 hrs from 05/01/22 to 11/12/22. During the interview, the DON was asked to state the amount of combined hours for the direct care and stated it was 3.0 hours combined. The DON was apprised that the state regulation read that the direct care staff's combined hours is not less than 3.6 hours combined. On 11/15/22 at 2:43 PM, during an interview with the facility's Administrator and the DON regarding staffing concerns, the administrator stated she was doing the calculation wrong and added we are doing the calculations over again.

Based on record review, observation and interview, the facility failed to ensure that 1 of 3 (third floor unit) medication storage room was kept free of expired medications. The findings included: Review of the facility's policy titled Storage of Medications with no revision date, provided by the Director of Nursing, documented discontinued, outdated .drugs .are returned to the dispensing pharmacy or destroyed. On 11/08/22 at 8:51 AM, a side by side review of the facility's third floor medication storage room was conducted with the Unit Supervisor. Observations revealed a bright yellow (tackle box like) locked with a green plastic tie. The Unit Supervisor was asked to open the box and the box contained the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -1 box of 30 vials of Asthmanephrin (used to treat asthma)- Inhalation solution with an expiration date on 07/2020. -1 box of 25 vials of [MEDICATION(S)] 1.25 mg (milligrams) (used to treat wheezing and shortness of breath) Inhalation solution with an expiration date on 08/2020. -1 box 25 vials of [MEDICATION(S)] 1.25 mg (milligrams) Inhalation solution with an expiration date on 06/2020. -1 box of 25 vials of [MEDICATION(S)] 0.63 mg inhalation solution with an expiration date on 10/2020. -1 box of 25 vials of [MEDICATION(S)] 2.5 mg inhalation solution with an expiration date on 03/2020. -1 box of 30 ampules of Budesonide 0.25 mg (used to prevent and treat seasonal and year-round allergy symptoms) inhalation suspension with an expiration date on 06/2020. -1 box of 30 ampules of Budesonide 0.5 mg inhalation suspension with an expiration date on 09/2020. -2 boxes of 30 vials of [MEDICATION(S)] 0.5 mg/2.5 millimeters (ml) (used for treating shortness of breath, coughing, and chest tightness) with an expiration date on 03/2021. -1 box of 25 vials of [MEDICATION(S)] 0.63 mg (used to treat wheezing and shortness of breath) inhalation solution with an expiration date on 09/2020. -1 box of 25 vials of [MEDICATION(S)] 1.25 mg inhalation solution with an expiration date on 10/2020. On 11/08/22 at 3:30 PM, surveyor was approached by the Director of Nursing (DON) to inform that the expired medications belong to a resident who was discharged . The DON was asked why those expired medications were not returned to the pharmacy and stated that they had checked all medication storage room, so many times and that yellow box was missed. The DON added that the expired medications were supposed to be returned to the pharmacy. On 11/15/22 at 1:52 PM, during an interview, the DON stated nobody was paying attention and the kit (yellow box) was supposed to be returned to the pharmacy. The DON added that the yellow box was created for one resident. The DON stated that the yellow box with the expired medications was kept in the area where the nurses keep the medications that are to be returned to the pharmacy. The DON added that she did not know how they missed that box.