Every finding on record at Upland Hills Nursing and Rehab

Based on interview and record review the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs for 1 or 2 residents (R28). R28 has a history of a Gastrointestinal bleed (GI bleed; bleeding that occurs in the digestive tract) and R28 did not receive adequate monitoring for bleeding while taking an anticoagulant (blood thinner) medication. A Certified Nursing Assistant (CNA) notified RN G (Registered Nurse) of R28 possibly having blood in her stool. RN G did not assess R28 when it was first reported and initiate continued monitoring for bleeding for R28. R28 continued to decline and was sent to the emergency department (ED) where she received 2 units of blood due to a GI bleed and anemia. This is evidenced by: Facility policy, titled Notification of Change of Condition, last reviewed in 07/2025, includes in part, Purpose: To inform the resident, resident's physician, and resident representative of any significant change of condition.Procedure: The following symptoms indicate a change of condition and are further categorized by need for physician response as critical, urgent, or non-urgent, but the categories may not be all inclusive. Based on the total resident assessment the staff will determine urgency of response needed. The resident representative will be notified of change of condition as soon as possible and/or as directed in the resident's plan of care.Urgent: those conditions requiring a physician to respond one hour after the first attempt to contact him/her.Includes but not limited to the following conditions: .4. Any onset of sudden bleeding.Non-Urgent: those conditions requiring a physician to respond prior to their regularly scheduled visit per nurse discretion. May be called or faxed to clinic. State of Wisconsin Nurse Practice Act states in part: . N 6.03 Standards of practice for registered nurses (1) General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or UAPs.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis . Per the Mayo Clinic, symptoms of GI bleeding can be easy to see (overt), or not so obvious, known as occult. Symptoms depend on the rate of bleeding as well as the location of the bleed. Overt bleeding might show up as: Vomiting blood, which might be red or might be dark brown and look like coffee grounds. Black, tarry stool. Rectal bleeding, usually in or with stool. With occult bleeding, you might have: Lightheadedness. Difficulty breathing. Fainting. Chest pain. Abdominal pain. R28 admitted to the facility on [DATE] with diagnoses that include paroxysmal atrial fibrillation (irregular heartbeat, with irregular heart rhythms starting and stopping on their own), aphasia following cerebral infarction (language disorder affecting the ability to communicate after a stroke), essential hypertension (high blood pressure with no identifiable medical cause), acute cystitis without hematuria (bladder inflammation symptoms without blood in the urine), hyperlipidemia (high cholesterol), and long term (current) use of anticoagulants (medications that prevent or reduce blood clot formation). R28's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/10/25 indicates R28's cognition is moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. R28's hospitalist discharge summary notes, dated 11/11/25, summarize her hospital stay from 11/3/25 to 11/11/25, prior to being admitted to the facility. The summary notes include the following, in part: Final diagnoses: .2. Paroxysmal atrial fibrillation previously not on anticoagulation due to history of GI bleeding, now on Eliquis (an anticoagulant medication).Hospital Course: .Paroxysmal atrial fibrillation.Discussed with Neurology: resumed apixaban (Eliquis) on 11/8. Prior history of GI bleed appeared minor. Will stop aspirin at that time. R28's Preadmission Nursing Assessment was completed on 11/10/25 and GI bleed was noted in her medical history. R28's physician orders upon admission to the facility included the following, in part: Eliquis oral tablet 5 mg (Apixaban) Give 1 tablet by mouth two times a day for Afib (atrial fibrillation). Start date: 11/11/25. Surveyor reviewed R28's care plan and medication/treatment administration record (MAR/TAR) and did not note any precautionary instructions for staff related to R28 being on an anticoagulant.(It is important to note that for other residents taking anticoagulants, the facility has the following information addressed in the care plan: Monitor/document/report PRN (as needed) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs).) R28's nurses' note on 12/20/25 at 10:31 AM by RN G indicates: Orders - Administration Note: Monitor temp and urinary symptoms every shift while on antibiotics for UTI. Chart a progress note. Current sx (symptoms): increased confusion and c/o (complaint of) back pain.Continues on monitoring d/t (due to) UTI (urinary tract infection). PO abx tx (oral antibiotic therapy) completed. Up and about per baseline. Reports feeling 'alright.' A&Ox3. Denies sx UTI. Denies back pain this AM.VSS. Afebrile @ 97.4 (degrees).R28's nurses' note on 12/21/25 at 8:01 PM by RN G indicates: Continues to be confused.Stated it was 1955. Did not know what day of the week it was despite us just discussing that it was Sunday. Has had intermittent reports of back pain and weak feeling today. DX (diagnosed) with UTI this week and completed 3 day dose of Bactrim which was completed yesterday. Urine remains medium yellow and clear without sx of sediment or blood. Continues to state she has burning with toileting. Reminded she has a catheter.Appetite good. Up and abpout [sic] in room with walker and 1A per baseline. R28's nurses' note on 12/22/25 at 11:00 AM by RN E indicates: .clinic updated of continued symptoms of confusion and back pain, concern for continuing antibiotic treatment. Any additional monitoring was reviewed. R28's blood pressure was recorded on 12/16/25 at 10:10 AM (121/47), 12/23/25 at 11:52 AM (132/72), 12/26/25 at 12:15 PM (108/58), and was then monitored each shift beginning on 12/28/25, as ordered. R28's nurses' note on 12/27/25 at 4:15 PM by RN G (Registered Nurse): Rec'd (received) call from CNA (certified nursing assistant) stating resident had 'bloody stool'. When asked of [sic] the sample was still in the toilet replied, 'No. I flushed the toilet but the wipes I used are still in the garbage.' 1:1. Reminded CNA that if any further bloody stools are noted they should not be flushed and writer should be notified immediately. Wipes noted to have deep brown stool with some area [sic] having light red discoloration. No evidence of blood noted on wipes. Resident denies GI upset. Will monitor. (of note: RN G did not conduct a GI (gastrointestinal) assessment on R28.)The following was added to R28's care plan on 12/27/25:-Need: The resident has an alteration in gastro-intestinal status possible blood in stools.-Approaches/Support Actions: If needed obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and update MD if needed and follow up as indicated.-Update Nursing and do not flush discolored stools. The following orders were entered for R28 on 12/27/25: Monitor for bloody stools. If noted update MD & obtain order for guaiac. Three times a day until 12/30/2025. R28's nurses' note on 12/28/25 at 3:00 PM by RN G: Called into bathroom by CNA. Resident sitting in toilet. A&OX2-3 (alert and oriented) per baseline. Awake. Able to talk and answer questions appropriately. Diaphoretic (sweating) and feels weak. 'I feel like I might pass out'. Pale in color. CNA states resident has been sitting on the toilet for 20 minutes trying to go to the bathroom. Cool cloth applied to forehead. Assisted resident to standing position with 2A (two-person assist). Tolerated wiping, cleaning, and pulling up pants with one sitting break. Transferred into bed. Diaphoresis had stopped by the time resident was in bed. Abd (abdomen) soft, nontender, nondistended. BSAX4 (bowel sounds active in all four abdominal quadrants). Denies nausea or abd (abdominal) disc (discomfort). CNA's have been reporting 'bloody stools' for several weeks but nursing staff unable to view stool. Has medium soft formed stool while on the toilet. Stool was tarry in nature. Brick red/brown in color. Slight foul odor noted. No coffee ground appearance. No bright red visible clots or blood. Hat obtained and placed in bathroom to attempt a sample with next occurrence. Resident reports feeling better. 1:1. Informed that lightheaded feeling and diaphoresis was probably related to sitting on the toilet too long trying to have BM (bowel movement). Enc (encouraged) to limit to 10 minutes or less in future. Discussed blood appearance in stool. Informed that writer would be contacting on call MD to inform them and obtain order for guaiac (test to detect hidden blood in stool). Informed that she may have a GI bleed. Informed that her condition does not seem to be emergent at this time but needs to be addressed with PCP (primary care provider) in am. Resident shook her head in agreeance and stated 'you know best' and smiled. Will attempt to update POA (power of attorney) when more information is obtained. Monitoring set up to assess VS and condition q (every) shift. R28's nurses' note on 12/28/25 at 3:10 PM by RN G: Rec'd call back from [on-call doctor]. Informed of resident's recent vasovagal episode on the toilet. Also informed of reports of bloody stools over the past 1-2 weeks. Witnessed today by writer and noted to be formed soft. Tarry brick red/brown color without evidence of coffee ground substance, bright red blood, or clots. Informed that resident is feeling better and resting in bed. VSS (vital signs stable). Rec'd order to obtain stool for guaiac sample. Informed MD that staff will monitor VS every shift and update PCP in am unless condition worsens. The following orders were entered for R28:12/28/25: Per.on call MD .Obtain guaiac stool sample. Three times a day.12/28/25: Monitor VS and condition every shift. Questionable GI bleed. Three times a day until 12/31/25.12/28/25: Update PCP in clinic Monday 12/29/25 in regard to bloody stool. On 1/27/25 at 12:25 PM, Surveyor spoke with RN G via telephone and asked about her note indicating CNAs had been reporting R28's bloody stool prior to her hospitalization. RN G indicated she only works weekends at the facility. RN G indicated she had worked the weekend of December 20th and 21st and a CNA reported to her that she thought R28 had blood in her stool but had flushed it. RN G indicated she wanted to look at it herself to know for sure. She looked at the toilet but noted no blood. RN G indicated she did not chart this information but kept an eye on R28 throughout the weekend and passed the information along to the next nurse. RN G indicated a week later, on Saturday afternoon (12/27), a different CNA reported that R28 was having bloody stool. The CNA flushed the stool but left wipes in the garbage. RN G looked at the wipes and indicated they did not appear to be truly red - they were mostly brown with a red discoloration / red tone to them, like eating lasagna. RN G indicated it did not look like blood on the wipes. RN G indicated that R28 did not feel good on the toilet on Sunday (12/28), and the incident happened with her almost passing out.Surveyor asked why RN G had not charted anything about the bloody stool after being told about it the first time. RN G indicated she did not chart anything because she hadn't seen the stool. RN G indicated R28 was feeling perfectly fine, wasn't having any stomach issues, and nothing else was wrong. RN G said, I wanted to visualize it. RN G indicated the CNA who had initially approached her was newer and she wasn't sure she knew what she was talking about. RN G indicated the CNA never reapproached her about R28's stool looking bloody. RN G worked 12 hour shifts that weekend. The PM CNAs never said that anything was abnormal either and she was there all weekend.Surveyor asked RN G if she knew R28 had a history of GI bleeds. RN G indicated she never knew R28 had a history of GI bleeds but knew she was on Eliquis and had a history of reflux. RN G indicated she did not see any other signs of bleeding or bruising at the time.RN G indicated she could have put a hat in the toilet or tried to get a sample. RN G said she certainly should have started monitoring earlier, but indicated she has been a nurse for 27 years and her gut feeling was that R28 was feeling okay. RN G indicated if something would have been wrong, she would have followed up but wanted to see what happened throughout the weekend. RN G indicated her perspective probably wouldn't have changed if she had known about R28's history of GI bleeds, but it would have been in the back of her mind to keep an eye on things. (of note per RN G's note and interview, R28 was indicated as having blood in her stool prior to this date. R28 did not have ongoing assessments conducted regarding her GI status or monitoring for bleeding until 12/27 after RN G was informed by a 2nd CNA that blood was noted in R28's stool.) R28's nurses' note on 12/28/25 at 6:29 PM indicates: Resident noted left esophageal pain under left ribs no pain with palpation repositioned laying in same position several hours skin pink warm resident noted to be tired, no further stools at this time. The following order was entered for R28 on 12/29/25: Please draw a CBC. One time only for 1 day. On 12/29/25 at 9:27 AM: CBC (complete blood count lab) drawn from R AC (inner elbow area on right arm). R28's nurses' note on 12/29/25 at 1:05 PM RN F wrote: At about 12:00 when entering room resident was attempting to get up from recliner. She stated she had to go to the bathroom. CNA in room. Resident was too weak to stand up and already had a BM in pants. Resident became unresponsive at the time. Had a vasovagal response. Sat resident back in her recliner. Sternal rubbed resident. Within a minute she became more responsive. Vital signs were 107/51, HR (heart rate)-86, O2 sat (oxygen saturation) 96% on room air and temp (temperature) 97.4. Resident unaware of what happened. Hoyered (mechanically lifted) resident to bed with 2 people. Collected stool sample. Stool dark red and tarry. Called.POA and updated him about situation and he gave the ok to if MD wanted her transferred to ER. Called [DO H (Doctor of Osteopathic Medicine - R28's primary care provider)] office and spoke with her RN and updated her regarding situation and the CBC results. She spoke with [DO H] and got the order to transfer her to ER.POA called and updated about the transfer to ER. EMS (emergency medical services) called regarding need for transport. Writer called ER and gave report.EMS here to transport resident and appropriate paperwork with them. EMS left with resident at 1240. R28's nurses' note on 12/29/25 at 12:10 PM RN F wrote: Called.POA and updated him about situation and he gave the ok to if MD wanted her transferred to ER (Emergency Room). R28's nurses' note on 12/29/25 at 1:07 PM RN F wrote: Called and updated [POA] that [DO H] wanted her to go to ER and we are going to transfer her via EMS. Verbal consent for a bed hold . R28's nurses' note on 12/29/25 at 5:07 PM indicates: Call from Med surg with update. resident admitted . plan is to monitor, recheck hemoglobin tomorrow morning and if lab result is under 7 will give blood transfusion. at this time family does not wish to scope resident.R28's hospital discharge summary notes, dated 12/31/25, summarize her hospital stay from 12/29/25 to 12/31/25, before being readmitted to the facility. The summary notes include the following, in part: Discharge diagnoses: GI bleed, acute blood loss anemia (rapid drop in red blood cells after losing blood), paroxysmal atrial fibrillation, hypertension, hyperlipidemia.Hospital Summary: .presented to the emergency room after a syncopal episode at her nursing home setting. She is [sic] apparently being helped up from a sitting position when she lost consciousness. Hemoglobin was down and was found to be 7.5 Staff also reported to family that she has had bloody stools dating back at least several weeks. She was hospitalized nearly 2 months ago for a stroke and was changed from aspirin to Eliquis at that time due to paroxysmal atrial fibrillation. She was sent to the emergency room for further evaluation. Stool was found to be heme positive (containing blood). She was otherwise medically stable. Goals of care were discussed with the activated power of attorney for healthcare . They were hoping she could be managed conservatively without invasive procedures excetra [sic] but would be willing for blood transfusions and more supportive type care if necessary.She (R28) was aware of the spell earlier but is not able to add additional information. Hospital Course: 1.) GI bleed/Acute blood loss anemia: patient has a past history of GI bleeding, this was likely exacerbated by the addition of Eliquis last month. Eliquis is discontinued. No more episodes of blood in stool or black stools. S/p (following) 2 units of PRBC (packed red blood cells) transfusion. Hb (hemoglobin) remained stable. Repeat Hb this morning is around 8.8.(Of note: According to the Mayo Clinic, Hemoglobin is a protein in your red blood cells. Your red blood cells carry oxygen throughout your body.When your hemoglobin level is low, it means your body isn't getting enough oxygen, making you feel very tired and weak. A normal hemoglobin level is between 12.3 gm/dL and 15.3 gm/dL for women. A severely low hemoglobin level is below 12 gm/dL (https://my.clevelandclinic.org/health/symptoms/17705-low-hemoglobin).) R28's nurses' note on 12/31/25 at 1:51 PM states: Resident re-admitted to the NRC (nursing and rehab center) about 1245. On 1/26/25 at 1:45 PM, Surveyor interviewed CNA D. CNA D indicated she has worked at the facility for 4 or 5 months and works on the hallway where R28 resides often. CNA D indicated she was working with R28 on the day she went to the hospital for the GI bleed in December. CNA D indicated R28 had been having bloody stools for about a week before she went to the hospital. Surveyor asked if CNA D had told the nurses about this. CNA D indicated she told RN E about R28's bloody stool a few days before she went to the hospital. CNA indicated RN E had looked at the stool and said she would check to see what R28 ate for lunch that day. CNA did not chart this information anywhere and did not hear that any other CNAs had observed bloody stool. The next time CNA D observed bloody stool, she told RN G but flushed it before RN G could look at it. RN G told CNA D to leave it in the toilet next time it happened. CNA D was working with RN F when R28 was incontinent of bloody stool and RN F looked at it before R28 went to the hospital.On 1/26/25 at 2:27 PM, Surveyor spoke with RN E via telephone and asked if she had been informed that R28 was having bloody stools prior to being admitted to the hospital for the GI bleed. RN E indicated she was never personally told by any CNA that R28 was having blood in her stool prior to being admitted to the hospital. RN E indicated if this had occurred, the protocol would be to update the doctor to see if she should be evaluated in the ER. On 1/26/25 at 3:39 PM, Surveyor interviewed IP C (Infection Preventionist). Surveyor asked IP C if she had been informed that R28 was having bloody stools prior to being admitted to the hospital for the GI bleed. IP C indicated CNAs occasionally give her updates on residents, but she was never told anything about R28 having blood in her stool. On 1/27/25 at 11:23 AM, Surveyor interviewed RN F and asked if she had been informed that R28 was having bloody stools prior to being admitted to the hospital for the GI bleed. RN F indicated she was never told by the CNAs about the bleeding. She eventually heard that the bleeding had been going on for a week or two but was not sure who had said it or if anything was being done about it. When RN F was informed of the bloody stool, she started monitoring R28 and indicated that she held R28's Eliquis. RN F indicated after the monitoring, it was determined that R28 had a GI bleed and that is when she went to the hospital. On 1/27/25 at 11:27 AM, Surveyor interviewed DON B (Director of Nursing) and asked if any care planning had been done for the anticoagulant (Eliquis) R28 was on when she was admitted to the facility. DON B reviewed R28's care plan but did not see anything on it pertaining to anticoagulants. DON B indicated she would double check to see if she could pull it up. DON B indicated the facility does an initial admission care plan and has specific care plan parameters which are selected for anticoagulants and diabetic medications. Eliquis is included in that, but not aspirin. The facility also does a review at the initial care conference as a double-check, and it includes checking to see if the resident is on an anticoagulant. DON B indicated this should have been caught. Surveyor also asked DON B about RN G's note in R28's chart that referenced CNAs knowing about R28's bloody stool for 1-2 weeks prior to her going to the hospital. DON B indicated she looked into this issue but knew nothing about it. DON B had talked to RN E and she said she was never told about this. DON B indicated she looked through paper notes from December standup meetings and there was nothing noted about R28's change of condition.On 1/27/25 at 12:05 PM, DON B informed Surveyor that she checked with a few people, and the anticoagulant had never been care planned for R28.On 1/27/25 at 1:34 PM, Surveyor spoke with DO H via telephone and asked what her expectation would be if a CNA had notified a nurse that R28 was having blood in her stool, given her history of GI bleeds. DO H indicated the nurse should have contacted her or a provider on call immediately. DO H indicated an assessment should have been completed upon receiving that information. DO H indicated that R28 has a complicated and well-known history of strokes, a-fib, and GI bleeds, and is at high risk for being on medications or off of them. R28 is in a no-win situation. DO H indicated this has been communicated to R28's family and to the staff that these issues are ongoing. The decision was made to start and stop Eliquis, but R28 alternates between GI bleed and strokes, so they are unable to aggressively manage symptoms well. DO H indicated the facility should communicate these risks to staff.On 1/27/25 at 2:08 PM, Surveyor interviewed DON B. DON B indicated nurses always want to observe reported bloody stool, as the CNAs do not always know what blood may look like. DON B indicated collection hats are easily accessible and would be helpful at that moment if there's ever a suspicion of something that wasn't observed.Surveyor asked if RN G should have charted this information after hearing about it from the CNA. DON B indicated charting might not be necessary until a nurse has actually observed the stool in question, but her expectation would be to ensure that a stool sample has actually been captured. DON B also indicated that monitoring R28 for 24 hours would have been a good idea to be proactive.DON B indicated that she looked into R28's history and noted she had a GI bleed sometime in 2023 and noted that R28 had been put back on a medication (Eliquis) that put her at higher risk of this occurring again.DON B indicated RN G had reported R28 was acting normal the weekend of December 20th and 21st. Surveyor indicated nurses' notes state R28 was reporting back pain and confusion, which is why her doctor was contacted and the antibiotic she had been on for a UTI was continued longer. DON B indicated the staff must have been focused on other things, like the UTI, and not only on her stool being potentially bloody.Surveyor asked about R28's care plan being updated on 12/27 to include monitoring for bloody stool. DON B indicated RN G must have put this monitoring in place. R28's TAR included monitoring beginning 12/28 and a notification to staff was put out to contact R28's PCP on 12/29. A CBC lab was drawn on 12/29.DON B indicated in hindsight, yes, the nurse should have put in some monitoring right away. If the nurse had observed the stool earlier, there could have been an order for guaiac and a CBC lab. She should have put a collection hat in the toilet to observe for bloody stool. DON B indicated, I can also see where the nurse is coming from. No other staff members reported this - only the one CNA.DON B indicated if this had been brought up at a morning meeting, knowing R28's history, basic labs could have been ordered and completed to figure this out sooner - potentially the week before she had to go to the hospital.R28 was noted to possibly have blood in her stool by a CNA, RN G did not assess R28. There is no evidence of continued monitoring while taking an anticoagulant and R28 continued to decline and was eventually sent to the Emergency Department (ED) where she received treatment for a gastrointestinal (GI) bleed and two units of blood.

Based on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 (R4) out of 4 sampled residents during the medication administration task.R4 has an order for metoprolol succinate (medication used to lower blood pressure) ER (extended release) 50 MG (milligrams) Tablet Extended Release 24 Hour dose to be administered once a day by mouth. This medication is labeled and ordered as an extended-release medication, meaning it is designed to release the active ingredients slowly over time, and are not to be crushed. During the medication administration observation, Surveyor observed Staff crushing and administering R4's metoprolol. Evidenced by:The facility policy entitled Medication Management Policy, dated 7/2025, states, in part: . Policy and Procedure:Medication AdministrationPolicy: Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice.Procedures: .5. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines.a. Long acting or enteric coated dosage forms should generally not be crushed; an alternative should be sought. The facility policy entitled Crushed Medications, dated 1/2026, states, in part: . Purpose: Medication management is a multi-faceted process of reconciling, monitoring, and assessing the medications an individual takes to assure compliance with a specific medication regimen, while also ensuring the individual avoids potentially dangerous drug interactions and other complications.Procedure: .A variety of oral solid dosage forms should not be crushed or chewed prior to administration because of their formulation. In general, these include:Extended-release, a term used synonymously with controlled-release, prolonged-action, and sustained release formulations R4 admitted to the facility on [DATE] and has diagnoses that include essential hypertension (high blood pressure) and pulmonary hypertension (serious, progressive type of high blood pressure in the lung arteries that forces the heart to work harder, often leading to right-side heart failure).R4's Physician Orders, dated 1/1/26, states, in part: . Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG. Give 1 tablet by mouth one time a day for a fib (atrial fibrillation- chronic heart rhythm disorder). Order Date: 2/27/24. Start Date: 2/28/24.R4' Medication Administration Record (MAR) states, in part: . Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG. Give 1 tablet by mouth one time a day for A-FIB. Start Date: 2/28/24.On 1/26/26 at 9:04 AM, Surveyor observed RN F (Registered Nurse) administer R4's medications. Surveyor observed RN F crush R4's metoprolol succinate ER 50 mg tablet and administer to R4 in applesauce.On 1/26/26 at 4:40 PM, Surveyor notified NHA A (Nursing Home Administrator) of the observation of R4's metoprolol succinate ER being crushed and administered during medication administration observation task. Surveyor asked NHA A if metoprolol succinate ER should be crushed. NHA A indicated no. Surveyor asked NHA A if any extended-release medications should be crushed for safety reasons and NHA A indicated no.

Based on observation, interview and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all residents in the facility. Surveyor observed a food item in dry storage with open and expiration dates and wwas beyond the labeled discard date. Surveyor observed a frozen food item uncovered in freezer. Surveyor reviewed facility's documentation and found staff did not document the water temperature or the sanitizing solution. Surveyor observed staff touching fresh cantaloupe with contaminated gloves. Findings: Example: Dry and frozen storage The 2022 FDS Food Code documents at ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding .Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. The facility's policy titled, NRC food dating, revised ,d+[DATE], stated in part: .Procedure: Refrigerators: 1. Both Culinary Services & NRC CNA staff (noc shift) are responsible for monitoring the expiration/Discard By dates of all food items in the refrigerator on a daily basis. a. All expired food will be removed and discarded. b. Culinary staff will additionally monitor on a monthly basis for pantry-type items that will expire that month (ie salad dressing, ketchup, mustard, etc.) 2. Once a food item is opened, it must be labeled and dated with a manually written Discard By date on it . Cupboards: 1. Culinary Services staff are responsible for ensuring that all food stored in the cupboards is rotated in a First-In-First-Out (FIFO) basis. 2. Culinary staff will monitor on a monthly basis for pantry-type items that will expire that month On [DATE] at 10:45 AM, during initial tour of the kitchen with Dietary Manager (DM) C, Surveyor noted a can of sesame oil had a handwritten opened date and an expiration date. The handwritten expiration date was [DATE]. Surveyor asked DM C about this. DM C indicated that the food has a best if used by date that is greater than the expiration date, but because we opened it, it must be thrown out by [DATE]. DM C replied, I will get rid of that. DM C took this Surveyor into the freezer. Surveyor noted a box of mixed vegetables opened and uncovered and asked DM C if this was appropriate to be uncovered. DM C replied, I will take care of that. Example: Dishwasher/sanitization log Facility policy titled, Dishwashing and Manual Dishwashing revised ,d+[DATE], stated in part: .DISHWASHER PROCEDURE: *Use detergents and rinse aides that are approved for the dishwasher *Ensure wash temperatures of ,d+[DATE] degrees. Document wash and rinse temperatures with each meal cycle . On [DATE] at 10:50 AM, during the same initial tour of the kitchen with DM C, Surveyor noted the Dishwasher/Three compartment sink log was missing temps and PPM on certain days. Dishwasher temperatures were missing on [DATE], 12, 13, and 14. Documentation for the three-compartment sink was missing parts per million (PPM) on [DATE], 13, 14 and 15. Surveyor asked for copies of this log as well as the last 2 months. DM C replied, I can get that for you. Review of July documentation showed missing dishwasher temperatures on [DATE], and 31. The three compartment sink for July was missing on the 14th. Review of the August documentation showed missing dishwasher temperatures on [DATE], 19, 21, 24, 25, and 27th. The three compartment sink for August was missing on [DATE] and 25th. Example: Touching food with contaminated gloves The 2022 FDA Food Code documents at ,d+[DATE].15 Gloves Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Facility policy titled, Personal Hygiene, Handwashing and Glove Use revised ,d+[DATE], stated in part: Procedure: .C. Gloves 1. Gloves are to be changed when switching from raw food to ready-to-eat food . 3. Gloves are used when handling ready to eat foods without utensils . 5. Gloves are changed in between separate tasks. 6. If Gloves become contaminated, they must be discarded, and hand washed. On [DATE] at 11:43 AM, Surveyor observed Certified Nursing Assistant (CNA) touch cupboard doors, chocolate milk powder packet, countertop and coffee faucet with single use gloves then pick up a ladle of cantaloupe with the same contaminated gloves and touched the cantaloupe as CNA D put it in a bowl. Surveyor asked CNA D about that observation, and CNA D indicated that CNA D should not have touched the cantaloupe with the same gloved hand as CNA D touched other things. Surveyor asked DM C about the observation of touching foods with gloved hands. DM replied, It is okay if the gloves are new and clean. Surveyor informed DM C the other surfaces that CNA D touched before touching the food. DM C replied, Yeah, that is not okay.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 2 (R20, R8) of 12 sampled residents to meet a resident's medical and nursing needs that are identified. R20 did not have a comprehensive person-centered care plan developed for the use of an anticoagulant, a high risk medication. R8 did not have a comprehensive person-centered care plan developed for diabetes. Findings: The facility policy titled, Baseline Care Plan, dated last reviewed 05/2024, states in part: It is the policy of the facility to develop a baseline care plan within 48 hours of admission. Along with the baseline care plan is a summary of care plan that is provided to the resident and representative in a language that can be understood The objective is the completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan 3. The care plan will include at the minimum the following information: a. Initial goals based on admission orders b. Physician orders .g. Instructions needed to provide effective and person centered care that meets professional standards of quality care . Example 1 R20 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation and long term use of anticoagulants. Admission orders for R20, dated 04/16/24, include the anticoagulant, Warfarin 2.5 mg Take as directed by anticoagulation clinic. R20's physician orders, dated 09/10/24, include Warfarin Sodium Oral Tablet 5 MG. Give 1 tablet by mouth one time a day every Mon, Wed, Fri and Give 0.5 tablet by mouth one time a day every Tue, Thu, Sat, Sun for atrial fibrillation. Review of R20's care plan on 09/16-17/24 did not reveal a plan of care for the anticoagulation medication use and what symptoms to monitor for, such as bleeding. On 09/17/24 at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B and requested information about R20's care plan and anticoagulation medication use. DON B stated she would go and print a copy of the care plan to show Surveyor. On 09/17/24 at 1:44 PM, Surveyor interviewed DON B who stated, There was not a care plan in place for the anticoagulant. DON B stated that the MDS nurse would normally put those initial care plans in place when entering diagnosis. DON B stated the MDS nurse is no longer with the facility so she cannot ask her why the care plan was not entered. DON B stated she just put the anticoagulation care plan in place now. 40590 Example 2 R8 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with hyperglycemia, bilateral diabetic retinopathy, type 2 diabetes mellitus with foot ulcer and long-term use of insulin. R8's Minimum Data Set (MDS) assessment, dated 07/04/24, indicates that R8's primary medical condition is type 2 diabetes mellitus with foot ulcer. R8's physician orders show that R8 receives Lantus insulin 2 times a day and Humalog insulin per sliding scale 3 times a day with meals. R8 receives a regular consistency diabetic diet with thin liquids. Review of R8's care plan did not reveal a plan of care for diabetes mellitus type 2. On 09/17/24, Surveyor received a diabetes mellitus care plan for R8 with created date of 09/17/24. On 09/17/24 at 1:44 PM, Surveyor interviewed DON B who stated there was not a care plan in place for diabetes. DON B indicated the MDS nurse who was responsible is no longer with the facility.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 4 residents reviewed for accidents (R1 and R4.) R1 experienced a fall with major injury on 2/9/24 and again on 6/25/24. The facility noted R1's impulsivity, lack of using her call light and bell, and frequent attempts to self-transfer and did not put measures in place to ensure she was supervised. On 6/25/24, R1 was left alone in the dayroom while other staff tended to other residents and R1 got up, walked to her room, and fell , fracturing her hip. R4 had multiple falls due to self-transferring which resulted in a left wrist fracture. Findings include. The facility's falls policy states, in part: *The falls prevention team meets weekly and will review new admissions, any new falls, significant change, and on a quarterly basis. *Post fall, the falls prevention team will audit residents post fall to ensure new [NAME] II fall risk assessment was completed, ensure new interventions were put into place and are on the care plan, and ensure effectiveness of interventions. *In the event of a fall, staff working in that area will huddle to discuss any details regarding the fall and any precipitating factors. The focus is to find the root cause of the fall. *In the event of a fall, staff will complete a safety zone with all details of the event. *Interdisciplinary team meets daily Monday through Friday at which time falls, care plan changes, and any interventions are discussed. Example 1 R1 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease. Her most recent MDS (Minimum Dat Set), dated 5/23/24, includes a BIMS (Brief Interview for Mental Status) score of 9, indicating R1 is moderately cognitively impaired. R1's care plan states the following: *Scheduled toileting: Toilet upon rise in am (around 6:00 AM), before and after meals at HS, and on 1st or 2nd NOC rounds (initiated 2/6/23) *Ambulate: 1 assist with 4 wheeled walker in hallway (initiated 4/12/24) R1 spends most of her waking hours in her own recliner in the TV room/dayroom on her unit. A call bell is placed by R1 to use if she needs help. On 2/9/24, R1 fell in her room at approximately 8:45 PM as a result of self-transferring herself to the bathroom. R1 had been toileted and helped into bed at 8:30 PM by CNA C (Certified Nursing Assistant). Upon discovering R1, staff assessed her and sent her to the ED (Emergency Department). It was discovered that R1 had suffered fractures of the right femur and humerus, which required screw fixation on 2/12/24. The facility provided better gripper socks for R1 as an intervention. The facility documented the following progress notes for R1: *2/14/24 at 3:04 PM: Resident occasionally does use call light appropriately, but also forgetful and self-transfers at times. High fall risk per [NAME] II fall risk screen. *2/16/24 at 5:32 AM: Resident rang light to go to bathroom, CNA entered room and resident was sitting at side of bed and holding onto bedside table to pull herself up. Resident stated that she was going to take herself to the bathroom because she didn't want to wait for help. *3/18/24 at 5:52 AM: Resident self-transferring times 1 in living room and walked approximately 100 ft. Toileted and placed back into the bedroom with increased supervision throughout the night. *4/13/24 at 5:30 AM: Resident was found by CNA to be standing in front of recliner in living room, resident stated she was just going to take herself to the bathroom. Resident's bell was in front of resident; however, she did not attempt to use it. Staff had just stepped away from hallway to answer call light. *4/15/24 at 4:53 PM: RN notified by cleaning lady that resident was on the floor. RN found resident on her knees holding on to a chair in the TV room. The intervention for this fall was leaving R1's walker next to her recliner. *4/20/24 at 6:00 PM: Has been up frequently performing self-transfers and ambulating in hallway without assistance. Will sit down in recliner and within several minutes is up again. Intermittently telling staff that she is going home. *4/22/24 at 12:30 PM: Noted to have increased agitation, confusion, stating repeatedly that she is going to leave and go home today. *4/24/24 at 2:40 PM: Writer was with resident 1:1 for about an hour. Resident repeated several times, If you don't get someone to take me home, I'll sue you. *4/24/24 at 7:58 PM: Resident has been 1:1 all shift. Continuously repeating I'm going home when you leave. Let's go. Don't try sneaking out either. You're keeping me against my will. *4/27/24 at 1:29 PM: Resident will not stay sitting in recliner. She is watching everyone go by asking to take her home. She is self-transferring walking around looking for someone to take her home. *5/26/24 at 1:56 PM: Has had several self-transfers today. Ambulated to the bathroom with walker independently this AM. When reminded to not get up by herself, replied, I know. I didn't want to p*** myself. *6/6/24 at 5:01 PM: Resident discussed in falls team due to quarterly assessment. 3 falls this quarter. Remains 1 assist with walker for transfers and ambulation. Does not use call light appropriately. *6/8/24 at 2:00 PM: Found ambulating in hallway with walker. Was taking self to the bathroom. Did not ding her bell for assistance. Reminded to call for assistance so she doesn't fall and get hurt. *6/12/24: .impulsive to transfer on own. Resident is a fall risk. On 6/25/24 at approximately 6:50 PM, R1 transferred herself from her recliner in the dayroom to her room and fell , fracturing her left hip, which required intramedullary nailing. According to facility documentation on the event, CNA C was 1:1 with R4 (who is not care planned as a 1:1) in the dayroom. CNA E was in another resident room who required 2 staff assist to transfer to bed. CNA E used her facility phone to call CNA D from a neighboring unit to assist. Around that time, R4 began to wander, so CNA C walked with R4 back to her room to toilet her. While CNA C was walking with R4, she (CNA C) saw R1 getting up out of her recliner in the dayroom and began to walk to her room. Moments later (time unknown), CNA D arrived to help CNA E but was interrupted by CNA C and told to go and assist R1, who had already made it into her room. At that time, R1 could be heard falling in her room. Upon arriving to R1's room, staff could see R1 had gotten clothes out and laid them on the bed. R1 stated she was going to go sit out front. It should be noted that during this time, the nurse was on a neighboring unit in an isolation room with another resident. After the fall, the facility's intervention for R1 was, Working with therapy, OT and PT as indicated on documentation provided to Surveyors. Surveyors gathered the following interviews on 7/10/24: *9:35 AM: CNA D stated that on 6/25/24, when she arrived on the unit, she was flagged by CNA C to go help R1. CNA D stated that she did not see R1 as she was already in her room at that time, but then heard her fall. *10:55 AM: CNA E stated that on 6/25/24 before she had gone into another resident's room to assist, she witnessed R1 sitting in her recliner in the TV room/dayroom. *11:20 AM: CNA C stated that on the night of 6/25/24, she was 1:1 with R4 and R1 was in her recliner in the TV room/dayroom when R4 started to get up, so she (CNA C) took her to the bathroom. She then saw R1 getting up to walk to her room. CNA C stated that moments later she saw CNA D arriving on the unit and yelled at her to go assist R1, who had already gotten into her room. CNA C stated that although the facility has individual phones for staff as well as tracker devices to know where other staff are, she did not have one with her on the night of 6/25/24. CNA C stated it definitely would have helped in getting help to R1 faster. CNA C stated that it was maybe a minute or so between when she noticed R1 get up and when she was able to wave for help to CNA D. CNA C stated that NHA A (Nursing Home Administrator) had talked to her after the event about using better communication. CNA C also stated that R1 seems to wait for staff to leave the area before she gets up out of her recliner. CNA C stated that she has seen R1 often looking around for staff and then trying to get up. CNA C stated that R1 definitely needs to be prompted as she does not use her call bell. *1:30 PM: RN G (Registered Nurse) stated that she and other staff would routinely do 1:1 with R1, when able, due to R1's impulsiveness, behaviors, and self-transferring, but that was just with the staff they had scheduled. RN G stated she asked why R1 could not have a regular 1:1 and was told it was a scheduling issue. RN G stated that sometimes R1 would have a 1:1 from 6-8 in the morning but that was only when staff were able. RN G also stated that R1 would not use her call light or bell. *1:40 PM: RN F stated that R1 does not use her call bell in the dayroom. *1:52 CNA H stated that the plan after R1's most recent fall was just keep a close eye on her. CNA H stated that R1 self-transfers a lot, but only when people are not in the dayroom. CNA H stated that when she sees R1 self-transferring or walking around by herself, it is when she (CNA H) has left another room and notices the dayroom has no other staff. CNA D, CNA E, and CNA H all stated that they did not receive any education or guidance on how to monitor R1 after her most recent fall, nor did they receive any education on communication or ensuring they had their facility provided phones or other communication system. It should be noted that Surveyors observed the dayroom where R1 resides with no staff present from 1:40 PM to 1:50 PM on 7/10/24. On 7/10/24 at 11:52 AM, Surveyor interviewed NHA A who stated, We talked about communication after the fall on 6/25/24. NHA A stated this was done during stand up but there was no record of education. NHA A stated the information was passed along. On 7/10/24 at 2:48 PM, Surveyor interviewed DON B (Director of Nursing) who stated that the facility has enough phones for floor staff to communicate with one another. Additionally, DON B stated that they passed along information to staff about communication and supervising R1. When asked if CNA C should have helped R1 on the night of 6/25/24 when she saw her self-transferring to her room, DON B stated that because R4 was a 1:1, she believed CNA C did the right thing by staying with R4. DON B confirmed that R4 was not care planned as a 1:1 and that 1:1 is scheduled at certain times when only when additional staff are available. The facility was aware that R1 had a history of fall with major injury, was impulsive, did not use her call bell, and would frequently self-transfer and did not put robust measures in place ensure her supervision. R1 was known to self-transfer when staff were not present. On 6/25/24, R1 was observed to be self-transferring, and staff did not attend to her timely, due to a lack of communication. The facility did not educate staff on the use of their available communication devices and the need to use them to promptly notify fell ow staff of emergencies or the need for assistance. 36192 Example 2 R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's disease with dyskinesia (involuntary erratic movements), Dementia, anxiety disorder, depression, history of falling and muscle weakness. R4 was diagnosed on [DATE] with an unspecified injury of the head, contusion of other parts of the head and unspecified injury of the neck. R4's MDS (minimum Data Set) dated 5/16/24 indicates R4 has a BIMS (brief interview of mental status) of 6 out of 15, indicating R4 is severely cognitively impaired. R4 has adequate hearing, is able to make self-understood, and usually understands others. Section GG indicates R4 needs substantial/maximal assistance for toileting, dressing and personal hygiene. R4's Care plan (CP) indicates the following: Resident has been admitted from (place name) for long term care related to Parkinson's, dementia, hospice care. (initiated 2/9/24) approaches/support actions: Scheduled toileting: toilet upon rise, before and after meals, at HS (bedtime) and on 2nd Noc rounds (initiated: 5/10/24) (no previous toileting schedule indicated on CP prior to 5/10/24) Week II: The resident has had an actual fall with injuries notes: 1) forehead hematoma, 2) abrasion to bridge of nose, 3) superficial abrasion to top of left knee and 4) small bump to back of neck/base of scalp. Dementia/confusion, impaired vision, poor balance (initiated 5/28/24, created 5/28/24, revision on 5/28/24). Goal: The resident's facial bruising will resolve without complications (5/28/24). Approaches/support actions: anti-rollback brakes to be added to wheelchair (5/28/24); Complete a new [NAME] II falls risk (5/28/24); Complete multidisciplinary progress note (5/28/24); complete safety zone with appropriate details (5/28/24) keep touch call light near hip to alert staff of movement during the night (7/10/24); notify MD of fall (5/28/24); PT/OT consult for strength and mobility (5/28/24). Week II: the resident has had an actual fall with no injury d/t (due to) dementia/confusion, poor balance twice on 6/9/24. Date initiated 6/9/24. Created on: 6/9/24, revision on: 6/9/24. Goal: the resident will resume usual activities without further incident through the review date. Approaches/support actions: assist resident to call (name), son, every evening (6/12/24). Complete a new [NAME] II falls risk (6/9/24). Complete multidisciplinary progress note (6/9/24) complete safety zone with appropriate details (6/9/24). Follow standard of care for falls (6/9/24). If resident is up. night shift CNA should stay on unit until 630 to help watch resident to cover through nurse shift report. (6/9/24). Monitor vital signs and assess for injuries every shift (for) 72 hours. (6/9/24). PT (Physical Therapy) teaching restorative aid balance techniques to continue working with resident on. (6/12/24). Week II: The resident has had an actual fall with no injury r/t (related to) dementia/confusion (6/9/24). (initiated 6/9/24, created on 6/12/24, revision on 6/12/24). Goal the resident will resume usual activities without further incident through the review date. Approaches/support actions: 1:1 during increased busy times roughly 0600-0800 (6am to 8am), 1030-1200 (10:30am to 12PM), 1630-2000 (4:30pm - 8pm) (6/12/24). Huddle completed with all staff to discuss details regarding the fall and any precipitating factors. (6/12/24). Week II: The resident has had an actual fall with no injury r/t dementia/confusion. (Initiated 6/12/24, created on 6/19/24, revision on 6/19/24). Goal the resident will resume usual activities without further incident through the review date. Approaches/support actions: complete a new [NAME] II falls risk, complete multidisciplinary progress note; complete safety zone with appropriate details; (6/19/24). Family meeting pursuing memory care (6/28/24); monitor/document/report PRN x 72 h (as needed for 72 hours) to MD for s/sx (signs/symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. (6/19/24); neuro-checks (6/19/24); notify MD of fall (6/19/24). Week II: The resident has had an actual fall with no injury r/t dementia/confusion 6/22/24. (Initiated 6/22/24, created on 6/25/24, revision on 6/25/24). Goal the resident will resume usual activities without further incident through the review date. Approaches/support actions: complete a new [NAME] II falls risk (6/22/24), complete multidisciplinary progress note (6/22/24); complete safety zone with appropriate details (6/22/24); Huddle completed with all staff to discuss details regarding the fall and any precipitating factors (6/22/24); monitor/document/report PRN x 72 h (as needed for 72 hours) to MD for s/sx (signs/symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. (6/22/24); notify MD of fall (6/22/24). Week II: The resident has had an actual fall with no injury r/t dementia/confusion and unsteady gait. (Initiated 6/29/24, created on 6/29/24, revision on 6/29/24). Goal the resident will resume usual activities without further incident through the review date. Approaches/support actions: complete a new [NAME] II falls risk (6/29/24), complete multidisciplinary progress note (6/29/24); complete safety zone with appropriate details (6/29/24); Follow standards of care for falls (6/29/24); notify MD of fall (6/29/24); Orthostatic BPs, update PCP (7/1/24). Please note, that R4 has 6 different fall care plans on her care plan and several resolved. Resolved care plan items are as follows: Sign hung in room as a reminder to call for assistance (resolved: 5/30/24) Dycem to recliner (resolved 6/19/24), dycem to recliner seat (Resolved 6/19/24), Gripper socks or shoes must be on while sitting in recliner (resolved 6/19/24), Gripper socks on when in recliner (resolved 5/30/24), encourage to be out of room/sit in living room for added assistance (resolved 5/30/24), keep items within reach on dresser or bedside table (resolved 5/30/24). There is no documentation indicating why these interventions were resolved or why they were not re-implemented on R4's current fall care plans. R4's CNA care plan dated 7/9/24 indicates the following: mobility, uses wheelchair for locomotion, ambulates with 1 assist with walker. Assistive devices used walker, wheelchair, and commode. Restorative: walk to dine, in addition take for longer walk in the hallway at least once. Cognitive status alert and orientated x 2, pleasant and cooperative. Forgetful. Toileting: continent of bladder, continent of bowel, 1 assist for toileting. Scheduled toileting: toilet upon rise, before and after meals, at HS (bedtime) and on 2nd NOC (night) rounds. Transferring: 1 assist with walker. Resident preferences: wake time: offer to get up around 0800, if resident wants to sleep in to 0900 (but at times, no pref (preference)) bedtime: 20:00-23:00 (8pm-11pm) (varies) lights off, extra blankets, door cracked open. Teaching needs: sign hung in room as a reminder to call for assistance. Safety: If resident is up. Night shift CNA should stay on unit until 6:30 to help watch resident to cover through nurse shift report. Anti-rollback brakes to be added to wheelchair. At risk for falls. Dycem to recliner. Gripper socks on when in bed and recliner vs regular socks. Place assistive devices (i.e. walker) within reach. Anti-rollback brakes to be added to wheelchair. (note, this is on the cp twice) if resident is awake on Noc/am shift change. Noc CNA to stay with resident until nurse/CNA get to floor. R4's CNA care plan dated 7/10/24 indicates the following: Safety: 1:1 24/7 (one on one twenty-four seven). Anti-rollback brakes on wheelchair. Anti-rollback brakes to be added to wheelchair. At risk for falls. Dycem to recliner. Gripper socks on when in bed and recliner vs regular socks. If resident is aware on Noc/am shift change, Noc CNA to stay with resident until nurse/CNA get to floor. If resident is up. Night shift CNA should stay on unit until 6:30 to help watch resident to cover through nurse shift report. Keep touch call light near hip to alert staff of movement during the night. Place assistive devices (i.e. walker) within reach. Toileting: continent of bowel and bladder. Scheduled toileting: toilet upon rise, before and after meals, at HS and on 2nd Noc rounds. Surveyor asked for R4's fall investigation/reports, Surveyor was provided with R4's Nurses Notes related to R4's falls. No staff interviews or root cause analyses were provided to go along with R4's documented falls. On 2/13/24 at 12:56 PM, R4's Nurses Note states in part: .New bruise to posterior right hip. Per caregiver, resident did have a fall within 2 days prior to arriving at facility where she landed on her bottom side [sic] . On 2/14/24 at 2:20 AM, R4's Nurses Note states in part: Type: Fall . summary of event: writer was checking on resident and resident was noted to be sitting on the floor on her buttocks with her legs straight out in front of her and resting her back on her bed. Resident had removed call light that was previously clipped to the top of her blanket and laid call light over side of bed. Resident was wearing regular socks at time of fall. Resident states she was going to get up and use the bathroom and didn't want to bother anyone by calling for help .fall prevention intervention: Gripper socks on resident when in bed. On 2/16/24 at 12:15 AM, R4's Nurses note states in part: Type: behavior note .Resident has been toileted in bathroom and returned to bed with CNA (Certified Nursing Assistant) assistance. CNA then noted several minutes later that resident self-transferred and was back in bathroom brushing her teeth. Resident assisted back to bed afterwards. No further self-transfers noted . On 2/16/24 at 10:19 PM, R4's Nurses note states in part: Behavior note it was reported to writer that resident self-transferred a few times during the shift. Staff did remind resident to use her call light and ask for help before moving on her own. Resident stated she is just used to doing everything on her own. On 2/23/24 at 5:32 AM, R4's Nurses note indicates Resident noted to have self-transferred to bathroom and back to bed. Resident rang for assistance once back in bed due to needing help getting a dry brief put back on. Resident call light was within reach before self-transferring and resident's commode was at the bedside. Resident reminded to call for assistance. On 2/28/24 at 3:30 AM, R4's Nurses note indicates resident removed call light and placed on floor next to bed. Resident ambulated to bathroom without walker and was found by CNA in the dark in the bathroom. Residents walker and commode were right next to bed, but resident did not use either device. Resident reminded to call for assistance. On 3/7/24 at 6:46 AM, R4's Nurses Note indicates Resident had multiple self-transfers during the night. Resident noted to move tray table and walker out of her way and proceed to the bathroom without the walker. Resident would often set her call light off while she was getting back into bed. Frequent reminders to call for assistance and frequent checks throughout the night. On 3/7/24 at 1:54 PM, R4's Nurses Note indicates: Resident was found this afternoon walking at the end of the rehab hallway by herself with no walker. She stated to staff that she ate so much for breakfast that she didn't eat lunch and she thought she better get up and go for a walk. Staff reminded her that she needs to call for assistance and walk with staff. She laughed and state she will try to remember to do that. On 3/10/24 at 6:00 PM, R4's Nurses Note indicates: Has made several self-transfers today. had closed her room door earlier and was found walking in the bathroom with no walker. This afternoon prior to supper ambulated with walker independently into hall .Reminded that it is not safe to get up on her own. Instructed to use call light and staff would gladly go for a walk with her . Reminded if she fell , she could break a bone such as a hip. I certainly don't want to do that.instructed to call for staff if she wants to get up or needs something. Verbalized understanding I will. On 3/14/24 at 5:50 PM, R4's Nurses Note states in part: Type: Fall. Summary of Event: CNA heard resident Can I get some help in here? Resident sitting on floor with her feet towards the toilet. I thought I could go by myself.Fall prevention intervention: Reinforce use of call light. Of note, there is no indication in the fall note, when resident was last toileted or seen, if R4 was incontinent when staff found her, what footwear she was wearing, what the environment was like etc., Per R4's Fall timeline provided by DON B (Director of Nursing), R4 was found on the floor in the bathroom. Resident had been toileted after supper, 10 minutes prior to fall. Intervention was a sign hung in room to remind resident to call for assistance. On 3/22/24 at 11:59 AM, R4's Fall team note indicates: Resident was discussed in falls team d/t (due to) recent fall. Intervention: signs placed in room to remind resident to use call light for assistance. High fall risk. 1 assist with walker for transfers and ambulation. Does not always use call light appropriately. Care plan reviewed and updated. (Staff continue to remind R4 to call for assistance when found self-transferring, but there is no indication of any other interventions to help prevent/limit self-transferring when Resident is noted to not always use call light appropriately.) On 4/7/24 at 10:00AM R4's Nurses Note states in part: Type: Fall. Summary of Event: Resident had been toileted at 930 (9:30AM) and placed in recliner with call light. Reminded to call for assist and not get up alone if needed. Voiced understanding but memory is poor and does not retain. Blood noted to lt (left) sleeve of sweatshirt. Removed top. Skin tear noted .assisted into recliner with Hoyer (full body lift) and 3A (three assist). Ambulated into bathroom with walker. Checked skin. No other injuries noted .MD and Family notified: .informed of increase in self-transfers without use of walker. Notified of fall this am with skin tear Lt upper arm . Fall Prevention intervention: Spoke with (name) RN on call for hospice. Informed of fall with skin tear .notified that self-transfers are on the rise. Frequently walking without walker . Of note: it is unclear where R4 was found during this fall, what she was trying to do that resulted in her falling. Per R4's Fall timeline provided by DON B, on 4/7/24, R4 had been sitting in the recliner in her room and was found sitting on the floor next to recliner, leaning back against bedside table. On 4/10/24 at 10:54 AM, R4's Fall team note indicates resident was discussed in fall teams d/t recent fall. Intervention from fall: dycem to recliner; hospice is looking into getting her therapy. High risk for falls per fall risk screen. Resident uses call light appropriately at times but also forgets to use it at times. Care plan updated. On 4/17/24 at 1:28 PM, R4's Nurses Note states in part: Type: Fall. Summary of event: Resident was heard yelling help from her room by RN and CNA in hallway @ (at) 1255 (12:55PM). Both entered Residents room and was found to be sitting on her but in her bathroom with her back against the wall with the lights off. Resident stated that she thought she could take herself to the bathroom. She stated she was on her way to the toilet when she lost her balance and fell on to her left hand and butt . Resident was last toileted approximately 45 minutes prior and was last seen sitting in her recliner approximately 5 minutes prior to fall. Resident did not have her shoes on, had taken them off when she sat in recliner to nap. Call light was clipped to her blanket on her lap, and she removed call light and placed it on the bedside table.Fall prevention intervention: intervention is to make sure resident has her gripper socks on whenever she is sitting in her recliner and does not have her shoes on . (Of note: this is the 2nd fall in the bathroom for R4.) Per R4's Fall timeline provided by DON B; the intervention is: Encourage resident to sit in recliner in living room; strongly encourage gripper sock at all times. On 4/19/24 at 12:06 PM, R4's Nurses note states in part: type: Fall team . Resident was discussed in falls team d/t recent fall. Intervention from fall - wear gripper socks when in recliner. High risk for falls .resident has been removing call light from herself or next to her when self-transferring . On 5/10/24 at 5:20 AM, R4's Nurses Note states in part: type: Fall. Summary of event: CNA walking by resident room, noticed bed was empty and walker was by the bed. CNA checked bathroom, bathroom light was off, and resident was sitting on floor with back against toilet and legs/feet pointing towards sink. Resident was sitting under grab bar. Resident had brief and nightgown off and had been incontinent of urine on the floor. Resident states she slid on the floor when standing up and fell on her butt, gripper socks were on. She bumped her left forehead above her eye on the grab bar when she fell resulting in a goose egg bruise.assisted off floor with three staff assist.ice applied to forehead, skin tear cleaned and 3 steri strips and Opti foam applied. Resident assisted to get washed up and dressed for the day and was brought out to living room. When resident asked why she didn't use call light, resident stated she didn't have a phone to call for staff assistance. Call light was clipped to resident in bed. [NAME] was next to resident bed. Resident was in bathroom at 0300 (3:00AM) and was last seen sleeping in bed 10 minutes prior to being found in bathroom . Fall prevention intervention: will discuss intervention with team . (Of note: this is the 3rd fall R4 has had in her bathroom) On 5/22/24 at 1:49 PM, R4's Fall team note indicates: Resident discussed in falls team d/t recent fall. Intervention from fall - trialed use of baby monitor (no screen) having it at the nurses station to hear resident when in room. Baby monitor did not work, too much static. Trial evening dose of lorazepam helped a little. Reached out to PCP and now have HS (bedtime) dose of lorazepam scheduled. Also trialing 1400 (2pm) dose of lorazepam as behaviors begin around 1600 (4pm). Resident does not use call light appropriately. Staff continue to educate her to use call light and try to anticipate her needs. Care plan reviewed and remains appropriate at this time. On 5/27/24 at 3:32 PM, R4's Nurses Note states in part: Type: Fall. Summary of event: resident sitting at a card table in the living room folding napkins, CNA was 1:1 but walked away to throw her tissues away, was coming back when resident stood up. Resident decided to stand up to put the napkins on the dining room table herself. Possibly tripped over leg of table, resident wasn't for sure. She tipped over her walker and landed on her back. back of her head hit the bottom wheel of her walker. CNA witnessed fall Fall prevention intervention: will discuss with fall team . Of note: staff walked away from R4 to throw an item away when she was to be 1:1 supervision. On 5/28/24 at 12:48 AM (0048), R4's Nurses note indicates in bed resting with soft touch call light within reach, reminded and encouraged to use call light for assistance. On 5/28/24 at 12:47 PM, R4's Nurses Note states in part: Type: Fall. Summary of event: unit CNA alerted facility staff via emergency button .of resident falling to the floor around 1206 (12:06 PM) between her dining room table and kitchenet stove. Resident noted to have large hematoma to frontal forehead, slightly to the left side with an abrasion to the bridge of her nose. Superficial abrasion to top of left knee. Slight bump noted to back of neck at the base of skull. Resident reported feeling nauseous during assessment and that her head hurt really bad. EMS (emergency medical services) paged, and they arrived at facility around 1225 (12:25PM) to transfer resident to ER (emergency room ) for further evaluation. Resident did report when asked how she fell that when she got up, she must have tripped over her feet. Resident did not specify why she got up from her wheelchair in the dining room. Pain assessment and intervention: Resident reported that she had 10/10 head/neck and left knee pain during her assessment when she was on the floor. Fall prevention intervention: anti-[NAME] back brakes to be added to wheelchair . On 5/30/24 at 5:35 AM, R4's Nurses Note indicates Resident found self-transferring three times during the night by staff. Reminded resident to use call light but resident states she doesn't need any help. staff

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 34 residents. Ice and water were observed in food items. Food items were not dated to reflect open and/or use by date. Findings include: Example 1 On 7/25/23 at 8:18 AM, Surveyor observed frozen chunks of ice falling from the air handler in the facility's main kitchen freezer. Chunks of ice were observed hanging from the air handler and sitting on top of the food items, which consisted of pre-made leftovers inside plastic containers and an open box of cranberries with 2 individual packs, one sealed and one opened but tied. Chunks of ice were observed directly inside the box of cranberries. DM E (Dietary Manager) stated to Surveyor that the changes in the weather with the extreme heat and humidity may have caused the rapid condensation and cooling, creating the ice. At the time of the observation, DM E stated the food items should be removed and away from the underside of the air handling portion of the freezer. Example 2 The facility applies a dating label to all dried goods when they are received from their food supplier, prior to being stored. On 7/25/23 at 8:14 AM, Surveyor observed the following in the facility's main kitchen: *3 bags of opened pasta with no open dates *1 opened packet of dried stuffing seasoning with no open or use by date *1 bag of opened crushed peanuts with a use by date of 4/20/23 *An opened gallon of vitamin D milk with no open date *3-7 lb. cans of unopened blueberry pie filling with a received date of 7/26/21, but no use by date Additionally, on 7/25/23 at 8:41 AM, Surveyor observed 8 partially frozen nutritional shakes in a Ziplock bag in a refrigerator on one of the resident units, no thaw dates. 3 additional nutritional supplements were observed in this same refrigerator, completely thawed with no thaw dates. 5 additional undated nutritional shakes were observed in a refrigerator on a separate resident living unit. It should be noted that these nutritional supplements have manufacturer printed recommendations to thaw and use supplement within 14 days. On 7/26/23 at 8:04 AM, Surveyor interviewed RN F (Registered Nurse), who stated the kitchen brings the nutritional shakes up, puts some in the freezer, and sometimes puts some in the refrigerator. RN F stated she was not sure when the undated, thawed nutritional shakes were pulled from the freezer, but stated she was aware that they are good for 14 days. On 7/26/23 at 9:06 AM, DM E stated that she did notice the nutritional shakes in the refrigerators and that they were not dated. DM E stated she was not sure when they were put in the refrigerator but removed the undated shakes. Additionally, DM E stated the facility-opened bags of pasta and stuffing seasoning in the main kitchen should have been dated with an open date, the peanuts should have been thrown away before 4/20/23, and milk should be dated when opened. DM E also stated that she contacted the manufacturer of the blueberry pie filling, and stated the manufacturer assured the pie filling was good for 3-4 years from manufacture/[NAME] date; however, DM E stated she was still unaware of when the pie filling was canned as she was waiting for a response from the manufacturer.

Based on observation, interview and record review the facility did not ensure a resident with pressure injuries (PI) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infections, and prevent new PI's from developing for 1 of 1 resident (R23) reviewed with pressure injuries out of a total sample of 12. R23 developed a deep tissue injury (DTI) to left heel. R23 was observed with left heel not being floated while in her recliner. This is evidenced by: Facility's policy and procedure titled Wound assessment dated [DATE] states in part: .Implementation *A wound assessment is to be completed upon initial identification of a wound .*A wound assessment is performed weekly .Documentation *Measurement of wounds is documented as length x width x depth .*Documentation includes wound location, wound characteristics, amount and characteristics of exudate, odor, peri-wound skin condition, tunneling and undermining . The facility document titled Skin Team Guide, no date, states in part: .Wound Assessments: Weekly perform wound assessments on pressure injuries or chronic wounds/ sign out in TAR (Treatment Administration Record), chart under assessments. Complete PUSH (Pressure Ulcer Scale for Healing) Tools weekly for all pressure related areas weekly chart under assessments .New wounds: Safety zone if needed, Plan of Care, Order, Wound assessment/ PUSH tool as needed (if wound assessment needed add an order for weekly wound assessment to be completed by WCC RN (Wound Care Certified Registered Nurse) pick a day of the week) also go to assessments edit schedules and activate weekly wound assessment to be completed on which day of the week. R23 was admitted to the facility on [DATE] with diagnoses that include: congestive heart failure, aortic valve stenosis, type 2 diabetes mellitus, muscle weakness, and rheumatoid arthritis. R23's most recent Minimum Data Set (MDS) dated [DATE] states that R23 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating the R23 is cognitively intact. R23's MDS also indicates that R23 requires extensive assist of 2 staff for bed mobility and extensive assist of 1 staff for transfers, dressing, toilet use, and personal hygiene. R23's care plan dated 6/10/23 states: Need: Week 1: The resident has potential/ actual impairment to skin integrity of the left buttock friction/ right head hematoma, right shin abrasion, mid scalp (chronic accident) r/t (related to) abrasion, fragile skin. Goal: The resident will have no complications r/t of the through the review date Approaches: Follow facility protocols for treatment of injury. Follow standards of care for skin. Revision dated 7/21/23 states: Need: left heel crack/ soft/ tender Approach: Float heels when in bed. Nurse's notes state in part, the following: 7/21/23 9:18 AM: Wkly mtg (Weekly meeting) .Discussed new OA (open area) Lt. (left) heel. 3:06 PM: Updated MD (Medical Doctor) via fax of another open area to LLE (left lower extremity) located on post heel . 7/22/23 10:00 AM: Late entry: .Lt heel Opti foam assessed. Nickel sized area bloody drng (drainage) on drsg (dressing) dated 7/21/23. Has purple area heel. Small pinhead size oval area with blood blister appearance. Reapplied Opti foam . 7/23/23 10:00 AM: Late entry: .Opti foam intact Lt. heel OA. Nickel sized area bloody drng on Opti foam. No sx (symptoms) of active drng. Opti foam applied 7/21/23 . It is important to note that the facility staff did not identify this as a pressure injury. The facility staff did not measure the wound and update the MD with the appropriate wound type. MD order dated 7/21/23 states: Monitor non intact slit to L post heel. Apply Opti foam after cleansing every 3 days and PRN (as needed) until resolved. One time a day continue until resolved. On 7/25/23 at 10:06 AM Surveyor observed R23 sitting in her recliner with her heels resting on the footrest, not floated. 0n 7/26/23 at 10:02 AM, Surveyor observed R23's wound care. Upon entry to the room, R23 was observed to be sitting in her recliner with her bilateral heels resting on the footrest, not floated. The facility nurse performed wound care and it was noted that R23 did not have a dressing on her left heel. Surveyor observed the wound and found the area to be approximately the size of a quarter with an outer purple ring, pinkish-white peri-wound, and an approximately 1 purple area in the center of the wound. On 7/26/23 at 11:13 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the area on R23's heel would be considered a Deep Tissue Injury, DON B reported that it could be and that she hasn't read the note. Surveyor asked DON B if the WCRN D (Wound Care Registered Nurse) had seen the wound, DON B stated that she didn't see a note and that the other nurse must have said that she took care of it. Surveyor asked DON B if she would expect that nurses measure the area, DON B stated yes, that it would have been helpful. DON B also reported that the floor nurses know that they are not allowed to stage a wound and that it must go through the Skin Team. Surveyor asked DON B what interventions were in place for R23 prior to developing the PI, DON B stated that they have the Standards of Care that all staff know and implement, and that floating her heels was an intervention added after R23 obtained the wound. Surveyor asked DON B if staff document on whether heels were floated, DON B stated that they don't have a sign off for the standards of care expectation. Surveyor asked DON B how she knew that staff was implementing the intervention, DON B stated that they do not have documentation of that. On 7/26/23 at 1:23 PM, Surveyor interviewed CNA C (Certified Nursing Assistant). Surveyor asked CNA C what interventions are in place for R23 to prevent pressure injuries, CNA C reported they use pillows for position in bed and her recliner, and that she has a Roho cushion. Surveyor asked CNA C if they float her heels while in the recliner, CNA C stated that if R23 asks, then they will float her heels. On 7/26/23 at 2:16 PM, Surveyor interviewed WCRN D. Surveyor asked WCRN D what the process is when a resident has a new wound, WCRN D reported that she is alerted through Safety Zone and that she will assess the wound when she comes to work. Surveyor asked WCRN D if she was made aware of the wound on R23's left heel, WCRN D stated no. Surveyor asked WCRN D if she worked the weekend the wound was discovered, WCRN D stated that she did work, but she had the other nurse complete dressing changes for her. Surveyor asked WCRN D if she would have expected the wound to have been measured, WCRN D stated that she would not necessarily expect the nurse to measure it if she didn't feel it was pressure related. It is important to note that at the time of the survey, there has not been a complete assessment or measurement of the wound the suspected deep tissue injury.

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R1). CNA C did not follow R1's care plan which resulted in a fall with multiple fractures. Findings include: R1 was admitted to the facility on [DATE]. According to R1's care plan, initiated 9/19/19, she is to be transferred by EZ stand with 1 staff. On 10/21/20, R1 experienced a fall while being transferred. The facility recorded the following nursing notes: *1:25 PM: Resident was being transferred to bathroom by CNA C (Certified Nursing Assistant). CNA C was transferring resident via 1 assist with gait belt, stand pivot in the bathroom - attempting to put resident on toilet. CNA C stated resident's knees buckled, CNA C was standing behind resident, so she had resident sit on her legs and lowered her to the ground. When staff entered room resident was sitting on the ground knees bent beneath her leaning towards her right hip/buttock. Resident is a 1 assist EZ Stand transfer. CNA C stated to staff she and previous CNA did rounds at shift change, she knew she was an EZ Stand transfer, had it wrote on her sheet but it slipped her mind. *Late entry for 10/21/20 fall was at about 3:25 PM not at 1:25 PM. *3:28 PM: Called doctor's office .asked for an order to transfer resident to ED (emergency department) to be evaluated/get x-rays. Resident was lowered to ground and resident now c/o BLE (bilateral lower extremity) leg pain. R thigh/femur deformed. Clear indentation and large bump following indentation. Also c/o L (left) knee pain. L knee may be slightly swollen. *7:35 PM: Update from ED - will be transferred into Madison this evening due to bilateral femur fractures. R1 was admitted to the ED (Emergency Department) on 10/21/20 at 10:41 PM. ED documentation shows X-rays revealed a right mid distal spiral femoral shaft fracture and left distal femur fracture. R1 was then transferred to another hospital for further care, which included surgery to repair the right femoral shaft fracture. She was discharged back to the facility on [DATE]. The facility provided immediate education for CNA C and began conducting transfer audits of all nursing staff between 10/23/20 and 12/29/20. In addition, the facility placed memos on each unit detailing expectations for reading care plans, with importance on transfer methods. A reminder was sent out via email to all staff stating, All care plans must be followed as written. Walking rounds must be done at the beginning/end of every shift--high points to hit during walking rounds include transfer status, diet, last void time, any changes in status. Please be sure to review the memo place in the household binders with reminders. On 1/13/21, Surveyors interviewed CNA C who stated she was doing walking rounds when R1 needed to use the bathroom. The CNA from the previous shift had told her the transfer status for R1. CNA C stated she didn't know why she forgot because she knew she was a to use a lift for transfers with R1. CNA C stated that R1 said I use that bar thing, so CNA C thought she (R1) meant the assistive bars near the toilet. CNA C stated she stand pivot transferred R1 from the wheelchair to the bathroom. R1 began to fall near the toilet and was assisted to the ground. On 1/5/21, Surveyors interviewed CNA's and RN's (Registered Nurse). RN D, CNA E, CNA F, and RN G did not recall receiving specific training regarding following care plans and transfers. While all staff stated they receive ongoing training and have regular stand up meetings, none were able to recall the specific training as highlighted in the facility memo and email. Additionally, the facility did not have any documentation indicating who had actually received the specified training, such as sign-in sheets, read-receipts from the email, etc. On 1/5/21 at 1:43 PM, Surveyors interviewed NHA A (Nursing Home Administrator). NHA A stated they had conducted education for CNA C multiple times following the event but did not audit her after the event, like they had for all other nursing staff. Additionally, NHA A stated the facility has electronic tools to ensure that staff are reading and engaging in ongoing education, but did not use those tools for this event to know who, in fact, received and understood the training that was sent out. NHA A indicated the facility did not ensure all staff received education regarding following care plans. The facility was aware of a deficient practice that resulted in a fall with major injury, but did not ensure all staff were educated in order to help prevent future falls.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 38 residents. The facility failed to ensure the dishwasher was reaching the appropriate temperature. Findings include: The facility's dishwashing policy states, Ensure water temperature is 160 (degrees) for wash and 180 or greater for rinse cycle. If unable to reach correct temperature, call plant operations. The facility's main kitchen uses high-temperature test strips to test the internal temperature of the dishwasher. The strips are used once per week, while the external digital thermometer is read three times daily and documented by dietary staff to ensure correct internal temperature. The strips feature an orange bar with a dark blue strip that turns orange when the appropriate temperature is reached. The strips state, Pass when blue bar turns orange -180 F. Packaging for the strips features directions that state: 1. Attach the test strip to a utensil or rack by wrapping around and slipping the color bar through the slit. 2. If the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. 3. When finished with the test, sign, date and place the strip in dishwasher temperature log. On 3/6/19 at 9:35 AM, Surveyor, along with DM C (Dietary Manager), observed kitchen staff using the test strips to test the internal temperature of the dishwasher. The strip was wrapped around a utensil and placed in the dishwasher. When the wash cycle was finished, the test strip's dark blue line had not changed to orange. Surveyor then checked the dishwasher log. A total of 10 test strips from (MONTH) (YEAR) thru (MONTH) 2019 were attached to the log. Each had failed to change to the orange color stated by the manufacturer's directions. In addition, daily logs documented by dietary staff showed the rinse temperature had failed to reach 180 degrees Fahrenheit twice in (MONTH) (YEAR), 15 times in (MONTH) (YEAR), 21 times in (MONTH) 2019, and 11 times in (MONTH) 2019. On 3/6/19 at 10:50 AM, Surveyor interviewed DM C. DM C stated the test strips, dating back to (MONTH) (YEAR), had not changed colors as outlined by the manufacturer. DM C also stated there had not been any issues with the dishwasher that DM C was aware of and that dietary staff should alert maintenance or DM C if test strips or exterior temperature readings are not reaching 180 degrees Fahrenheit.

Based on observation and interview the facility did not ensure food was stored, prepared, distributed and served under sanitary conditions. This has the potential to affect all 41 residents of the facility. The main kitchen Hobart mixer had visible dried food on it. Expired nutritional drinks were found in cooler. Pudding mix was found with no expiration date. Multiple containers of baking ingredients were found with scoops inside. Findings include: Example 1 On 12/6/16 at 8:38 am, Surveyor observed the main facility main kitchen's Hobart mixer with visible dried food on the beater shaft. On 12/6/16 at 8:39 am, Surveyor asked Executive Chef (EC) E the last time the mixer was used. EC E stated he was not sure but knew it was used within the last week and also agreed the food appeared to be dried on the mixer. EC E also stated the mixer needed to be cleaned and would do so. Example 2 On 12/6/16 at 8:15 am, Surveyor observed a total of 9, 4 ounce (oz) Thick n' Easy orange juice cups in one of the facility main kitchen's coolers with expiration dates of November 21, 2015. On 12/6/16 at 8:16 am, Surveyor interviewed Executive Chef (EC) E regarding the orange juice cups. EC E agreed there were 9 cups of orange juice and stated he was not sure why they were there but needed to be thrown away and did so immediately. Example 3 On 12/16/16 at 8:25 am, Surveyor observed in the facility main kitchen's dry storage 10-28 oz packets and 2, 5 oz packets of dry pistachio pudding mix with no expiration dates. On 12/6/16, Surveyor interviewed Registered Dietician (RD) F. RD F agreed there was no expiration dates on any of the pudding packets and stated there was no way of knowing when those packets were received. RD F also stated they should be thrown away. Example 4 On 12/16/16 at 8:40 am, Surveyor observed in the facility main kitchen a container of flour, a 50 pound bag of corn meal and a 50 pound bag of organic wheat flour with a scoop inside each. On 12/6/16 at 8:42 am, Surveyor interviewed RD F regarding the scoops. RD F stated the scoops are an infection control issue as many people may have touched each handle which subsequently touches the baking ingredients in the bags and container. RD F also stated she was not sure if all staff using the scoops had worn gloves to use each scoop.

Based on interview and record review, the facility did not consult with the resident's physician when there was a significant change in the resident's physical condition and possibly a need to alter treatment for 1 of 11 residents (R8) reviewed out of a sample of 11 residents. R8 had a significant change of condition and her physician was not notified until the next day. This is evidenced by: The facility's policy Change of Condition dated 7/2015 includes in part, it is the policy to inform the resident, resident's physician, and family member or guardian of any significant change of condition. R8's [DIAGNOSES REDACTED]. R8's grandson is her activated Health Care Power of Attorney. Nursing notes dated 8/16/16 at 3:17 PM by Licensed Practical Nurse (LPN) H includes in part, R8 was helped out of bed by Certified Nursing Assistant (CNA) G at 3:00 PM who noted left side of face was drooping slightly. LPN H notified Registered Nurse (RN) I. Hand grasp equal and firm, no slurred speech. Will assess again later. Nursing notes dated 8/16/16 at 4:15 PM by RN I includes in part, drooping on the left side of face near corner of the mouth is resolving. Call now placed to the clinic. Spoke with triage nurse who was updated on nursing notes of today. R8's physician is out of the office today but will be informed tomorrow. No new orders. Nursing notes dated 8/17/16 at 12:17 AM by RN J includes in part, Granddaughter here reports R8 is alert but speech is less clear. R8 is smiling with slight left facial droop at corner of mouth. R8 appears tired and discussed with granddaughter who agrees to let Resident 8 get some sleep and re- evaluate in a few hours. Nursing notes dated 8/17/16 at 3:33AM by RN J includes in part, left sided hand grasp slightly weaker than right. Nursing notes dated 8/17/16 at 9:43 AM by RN K includes in part, R8 answers questions but speech slurred at times/clear other times. Left mouth /cheek with some droop, left arm flaccid at times/movement other times. Left leg weaker with transfers. Difficulty swallowing with straw. Nursing notes dated 8/17/16 at 11:24 AM by RN K includes in part, continues with left facial droop. Speech slurred. Able to move left arm/leg with command but weaker than right and movement is erratic when attempted. Coughing with initial swallowing of coffee. Call placed to clinic for a speech therapy (ST) eval order. Nursing notes dated 8/17/16 at 12:34 PM by RN K includes in part, Power of Attorney updated of ST order request and current status. Review of the nursing home visit note by the nurse practitioner dated 8/11/16 includes in part: Active problems - [MEDICAL CONDITIONS], Essential Hypertension,[MEDICAL CONDITION](Gastro [MEDICAL CONDITION] reflux disease), and [MEDICAL CONDITION]. Assessment- Benign essential hypertension, moderate [MEDICAL CONDITION]. Physician's nursing home visit note dated 10/14/16 includes in part: R8 is evaluate and no new complaints or concerns. Assessment - Stable exam with a history of [MEDICAL CONDITION]. Hypertension is controlled. To be noted, there is no mention of prior history of Tran's ischemic attack (TIA) or [MEDICAL CONDITIONS]. On 12/8/16 at 8:25 AM, Surveyor interviewed LPN H regarding R8 and the symptoms she was having on 8/16/16. LPN H indicated that during report she was told that R8 was not herself on the day shift and to keep an eye on her as she was having increased confusion and not able to lift her hand on day shift. Surveyor asked LPN H if the day shift contacted the MD. LPN H indicated that she was not sure but would guess so. Surveyor asked LPN H when the MD would be contacted for the symptoms that R8 was having. LPN H indicated that the facility should notify the MD with any changes unless told not to. LPN H indicated that she did not call the MD as she thought the day nurse did and indicated she should have looked. On 12/8/16 at 9:10 AM, Surveyor interviewed CNA G via phone. Surveyor asked CNA G what symptoms R8 was having. CNA G indicated that R8's face was drooping so she told the nurse. CNA G indicated that R8 was very weak and something was different. CNA G indicated that R8 used to be able to feed herself but now is total assist and requires a hoyer lift as she never came back from that day. On 12/8/16 at 9:30 AM, Surveyor interviewed R8's Medical Doctor (MD) L regarding R8 and her change of condition. MD L reviewed his clinic notes from 8/16/16. Surveyor asked MD L if the on call physician should have been contacted with the change of condition that R 8 was experiencing. MD L indicated that since he was out of the office the on call should have been contacted. MD L indicated that after 5:00 PM, a page would go out to whoever is on call. Before 5:00 PM, the call would get routed to a provider that is in the office. MD L indicated that he saw the information with Resident 8's change of condition on 8/17/16 at 8:40 AM. MD L indicated it looked like R8 had a TIA. Surveyor asked MD L what he would have done if he was in the office and the facility contacted him with R8's change of condition. MD L indicated that he would have the facility contact the power of attorney or he would contact the power of attorney to see what they would have wanted. MD L indicated that Resident 8 did not have a change in [DIAGNOSES REDACTED]. On 12/8/16 at 10:15 AM, Surveyor interviewed Registered Nurse (RN) I regarding when to notify the MD. RN I indicated that the MD should be contacted with any change of condition. Surveyor asked RN I if it was ok that the clinic wait until the next day to notify MD L when R8 was having facial drooping. RN I indicated that the clinic would update the MD. RN I indicated that maybe she didn't make it clear to the clinic nurse. On 12/8/16 at 11:15 AM, Surveyor interviewed RN K regarding when to notify the MD. RN K indicated that she would take vital signs and then call the MD with any change of condition. Surveyor asked what she would do if the MD was not in the office. RN K indicated that she would tell the clinic to call the on call MD as R8's clinic does not automatically do that unless asked to do so. On 12/8/16 at 11:40 AM, Surveyor interviewed Director of Nursing (DON) B regarding when the staff are to contact the MD. DON B indicated that the staff is to contact the MD if there is a change in condition. Surveyor asked DON B if R8's MD should have been contacted when she experienced facial drooping on 8/16/16. DON B indicated since the drooping was resolving it would be ok to wait until the next day but the MD should have been updated to cover yourself. Surveyor asked DON B if the POA should have been updated with Resident 8's the change of condition. DON B indicated that the POA should have been contacted.

Based on interview and record review, the facility did not use the results of the assessment to develop, review and revise the resident's comprehensive plan of care in 3 of 11 total residents reviewed (Residents 1, 2, and 10). R1 is identified as having poor sleep quality by her PSQI (Pittsburgh Sleep Quality Index) and is currently taking [MEDICATION NAME] each evening to aid in sleep. R1 does not have a comprehensive plan of care with measurable goals that addresses her sleep disturbance issue, or identifies solutions or interventions, including non-pharmacological interventions, which may help with this problem. R2 is identified as having poor sleep quality by her PSQI (Pittsburgh Sleep Quality Index) and is currently taking [MEDICATION NAME] each evening to aid in sleep. R2 does not have a comprehensive plan of care with measurable goals that addresses her sleep disturbance issue, or identifies solutions or interventions, including non-pharmacological interventions, which may help with this problem. R10 is identified as having poor sleep quality by her PSQI (Pittsburgh Sleep Quality Index). R10 does not have a comprehensive plan of care with measurable goals that addresses her sleep disturbance issue, or identifies solutions or interventions which may help with this problem. This is evidenced by the following: The facility's policy entitled Sleep Promotion in the Older Adult (undated) states in part: POLICY STATEMENT: Residents of the NCR (Nursing Care Center) that are admitted with a [DIAGNOSES REDACTED]. will have a Pittsburgh (sic) Sleep Quality Index (PSQI) assessment completed within 1 month of their admission if able, allowing time for the resident to adjust to the change in their physical environment. The assessment will be done quarterly from that time unless there has been a change in their clinical status. An individualized plan of care will be developed utilizing the least invasive interventions first and promoting good sleep habits . That (sic) interventions that are put into place shall be monitored for effectiveness and maintained or modified based on the resident response. The Sleep Quality Assessment (PSQI) instruction sheet states: A total score of 5 or greater is indicative of poor sleep quality. If you score 5 or more it is suggested that you discuss your sleep habits with a healthcare provider. On 12/8/16 at 1:30 pm Surveyor spoke with DON (Director of Nursing) B regarding how the facility address residents' sleep disturbance issues. DON B confirmed that residents with sleep disturbance should have this concern addressed on their care plans. Example 1 R1's [DIAGNOSES REDACTED]. R1's most current MDS (Minimum Data Set) with an observation end date of 11/2/16 documents R1's BIMS (Brief Interview for Mental Status) score to be 15 out of 15. R1's most recent PSQI dated 11/1/16 gives Resident 1 a total score of 10. As noted above a total score of 5 or greater is indicative of poor sleep quality. R1's current comprehensive plan of care does not address R1's sleep disturbance issues, does not have a measurable goal for this health concern, and does not have any interventions, either pharmacological or nonpharmacological, to prevent or alleviate this problem. On 12/8/16 at 8:28 am Surveyor spoke with R1 regarding her sleep habits. R1 told Surveyor that she wakes up during the night to go to the bathroom and then is up the rest of the night. Later that same morning (12/8/16) at 9:42 am Surveyor again spoke with Resident 1 regarding her sleep habits. R1 told Surveyor that she does not sleep well. R1 stated it has been this way for a long time. R1 stated if she wakes up during the night she will sometimes ask for a Tylenol to see if this will help her sleep. R1 stated she will sometimes ask for this Tylenol even though she is not having any pain. Example 2 R2 has been identified to have sleep disturbance and is currently taking [MEDICATION NAME] 25 mg (milligrams) each night for this sleep disturbance. R2's most recent PSQI dated 11/1/16 gives R2 a total score of 10. As noted above a total score of 5 or greater is indicative of poor sleep quality. Although R2's care plan does note an intervention of monitoring for sleeplessness or complaints of [MEDICAL CONDITION] as an intervention for her fall concern, R2's current comprehensive plan of care does not address R2's sleep disturbance issues, does not have a measurable goal for this health concern, and does not have any interventions, either pharmacological or nonpharmacological, to prevent or alleviate this problem. Example 3 R10's most current PSQI dated 10/29/16 gives Resident 10 a score of 13.83. As noted above a total score of 5 or greater is indicative of poor sleep quality. R10's Social Services Progress Notes dated 10/27/16 states: SS (Social Services) met with resident on this date to complete BIMS (Brief Interview for Mental Status) Res scored 6/15 on BIMS; severe cognitive impairment. POAHC (Power of Attorney for Health Care) is on file but is not activated as family and staff believe resident is able to make wishes known . SS reported resident c/o (complained) to NRC (Nursing Care Center) RN (Registered Nurse) (Name). RN states sleep has been addressed in the past and sleep assist medications have been declined. RN suggested fit bit study for sleep. Nursing will address further SS has no further concerns and will rescreen as scheduled, sooner if needed. R10's current comprehensive plan of care does not address R10's sleep disturbance issues, does not have a measurable goal for this health concern, and does not have any interventions, either pharmacological or nonpharmacological, to prevent or alleviate this problem. On 12/8/16 at 9:38 am Surveyor spoke with R10 regarding her sleep habits. R10 stated she does not sleep well. Resident 10 stated I think about my kids. I worry about them and my grandkids. That's what I think about at night. R10 went on to state that the facility does not do anything special to help her sleep. On 12/8/16 at 10:30 am Surveyor spoke with MDS Nurse C regarding several topics including R10 and her sleep disturbance. MDS Nurse C stated facility staff had spoken with R10 about her sleep habits in the past and stated: she (R10) worries at night and once that passes she goes to sleep. MDS Nurse C went on to state facility staff spoke with R 10 regarding music to assist with sleep, but does not have documentation of this discussion. Surveyor asked MDS Nurse C if R10 had a fit bit study as suggested in the SS note of 10/27/16. MDS Nurse C stated she would look into this and any other monitoring that may have been done with R10. No additional information regarding a fit bit study or sleep monitoring was provided to Surveyor .

Based on observation and interview the facility did not ensure food was stored, prepared, distributed and served under sanitary conditions. This has the potential to affect all 37 residents. The Hobart mixer was observed with dried food particles on the attachment area. A container of yogurt was expired. Buttermilk was opened and not dated. Chocolate milk was expired. A bag of streusel topping was expired. 2 boxes of wheat germ were expired. 1 container dried peas was expired. This is evidenced by: The facility's Food Storage policy, undated, includes the following: Procedure: 8. C. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food. 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates. The facility's Food Safety and Sanitation policy, undated, includes the following: 4. Food Storage b. Foods with expiration dates are used prior to the use by date on the package. The facility's General Food Preparation and Handling policy, dated 8/2012, includes the following: Procedure: E. Equipment: a. All food service equipment should be cleaned, sanitized, dried and reassembled after each use. Example 1 On 11/4/15 at 8:00 AM Surveyor observed a Hobart mixer with dried food particles on the attachment area. On 11/4/15 at 8:01 AM Surveyor interviewed Culinary Services (CS) H. CS H stated she would expect the Hobart mixer to be cleaned after each use. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the Hobart Mixer. Cook G stated he would expect the mixer to be cleaned after each use. Cook G stated he would speak with the culinary staff members regarding cleaning the mixer. Example 2 On 11/3/15 at 8:15 AM Surveyor entered the cooler Surveyor noted a 2 pound container of original Yoplait yogurt the open date was 10/23/15. The manufacturers' use by date was 10/10/15. On 11/3/15 at 8:16 AM Surveyor interviewed CS H regarding the yogurt. CS H stated the yogurt was expired and removed from shelf. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the yogurt. Cook G stated he would expect the yogurt to have been removed from the shelf. Cook G stated he is working with the staff on a new dating policy. Cook G stated it is all culinary staff members' responsibility to remove items from the shelves when expired. Example 3 On 11/3/15 at 8:17 AM Surveyor Surveyor noted a ½ gallon container of low fat Buttermilk that was open and undated. On 11/3/15 at 8:18 AM Surveyor interviewed CS H regarding the Buttermilk. CS H stated the milk products are good for 7 days once opened. CS H stated the buttermilk should have an open date on it. CS H removed from the shelf. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the buttermilk. Cook G stated he would expect the buttermilk to be dated when opened. Cook G agreed that milk products are good for 7 days once opened. Cook G stated that the milk should have had an open date on the carton. Example 4 On 11/3/15 at 8:19 AM Surveyor Surveyor noted an open package of Tru Moo 14 fluid ounce bottles of Chocolate Milk. The package of Tru Moo contained 11 bottles with one bottle missing. The Tru Moo Chocolate milk had a best by date of 10/28/15. On 11/3/15 at 8:20 AM Surveyor interviewed CS H regarding the Tru Moo Chocolate milk. CS H stated the milk was expired and removed from the shelf. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the Chocolate milk. Cook G stated he would expect the milk to have been removed from the shelf when expired. Cook G stated it is all culinary staff members' responsibility to remove items from the shelves when expired. Example 5 On 11/3/15 at 8:25 AM Surveyor noted a bag of streusel topping was open with a use by date (USB) of 8/15/15. On 11/3/15 at 8:26 AM Surveyor interviewed CS H regarding the streusel topping. CS H stated the topping was expired and removed from shelf. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the streusel topping. Cook G stated the streusel topping should have been removed from the shelf. Cook G stated it is all culinary staff members' responsibility to remove items from the shelves when expired. Example 6 On 11/3/15 at 8:27 AM Surveyor noted 2 14 ounce boxes of wheat germ. One box of wheat germ was open on 3/2/15 with a USB date of 9/21/15. The 2nd box of wheat germ was opened on 5/2/15 with a USB of 11/2/15. On 11/3/15 at 8:28 AM Surveyor interviewed CS H regarding the wheat germ. CS H stated the wheat germ was expired and removed from shelf. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the wheat germ. Cook G stated the wheat germ should have been removed from the shelf. Cook G stated it is all culinary staff members' responsibility to remove items from the shelves when expired. Example 7 On 11/3/15 at 8:29 AM Surveyor noted a large container of opened dried peas. The container had a USB date of 8/25/15. On 11/3/15 at 8:30AM Surveyor interviewed CS H regarding the dried peas. CS H stated the dried peas were expired and removed from shelf. On 11/4/15 at 9:25 AM Surveyor interviewed Cook G regarding the dried peas. Cook G stated the dried peas should have been removed from the shelf. Cook G stated it is all culinary staff members' responsibility to remove items from the shelves when expired. The facility failed to ensure that equipment was cleaned properly after each use and that all products used for consumption were properly dated and removed from use prior to expiration date.

Based on observation and interview the facility did not provide food that is palatable and at the proper temperature for 1 of 1 test trays and 4 of 6 residents (Residents 4, 11, 12 and 13). During the group interview Residents 4, 11, and 12 voiced concerns about the food. A test tray on Resident hall 2 was noted not to be palatable. Residents 1, 12, and 13 were observed at lunch indicating that the pork patty was very tough and unpalatable. This is evidenced by the following: On 11/3/15, at 1:00 PM, Surveyor and conducted the group interview with 6 residents. During this interview the following was expressed: Resident 4 stated the meat is tough and chewy and it is not always hot especially the vegetables. Resident 11 also stated the vegetables were not hot enough. Resident 12 stated the food is not hot enough. All the residents agreed the breadsticks are hard and they can't eat them. On 11/4/15, at 11:45 AM, Surveyor noted Resident 4 had the pork for lunch. Surveyor asked how it was. Resident 4 stated it was too tough and she could barely cut it let alone eat it. Resident 4 ate the rest of her meal except the pork. Example 2 On 11/4/15 at 11:50 AM Surveyor received a test tray for the lunch meal. The following was noted: Pork patty temperature was 124.2 degrees and was tough and did not have flavor. Broccoli temperature was 111.0 degrees and was cold. Corn temperature was 92.4 and was cold. Example 3 On 11/5/15 at 11:40 AM, Surveyor observed Resident 1 in the dining room. Resident 1 was served a pork patty, mashed potatoes and gravy, and jello with fruit. Resident 1 used her fork to stab the pork patty and hold it up in the air above her plate. Resident 1 looked at it then placed it back on her plate. She attempted to cut it with her fork and put the fork down. Resident 1 started to eat her mashed potatoes. On 11/5/15 at 11:50AM, Certified Nursing Assistant (CNA) F asked Resident 1 if she could assist her cut the pork. Resident 1 indicated she could. Resident 1 picked up a forkful of pork brought it to her mouth and put it back on the plate. Resident 1 ate the mashed potatoes and gravy and did not eat the pork. Surveyor interviewed Resident 1 regarding the pork. Resident 1 stated, Would you eat it. Example 4 On 11/5/15 at 11:40 AM, Surveyor observed Resident 12 in the dining room. Resident 12 was served a pork patty, mashed potatoes and gravy, and jello with fruit. Resident 12 was observed to push the pork patty around on her plate. Resident 12 did not cut the pork patty and left 100% of it on her plate. On 11/5/15 at 11:40 AM, Surveyor observed Resident 13 in the dining room. Resident 13 was served a pork patty, mashed potatoes and gravy, and jello with fruit. Resident 13 stated, I'm not eating that and did not touch her pork patty. Resident 13 asked Resident 12 if she was going to try the pork. Resident 13 was observed laughing. On 11/5/15 at 12:00PM, CNA F indicated to Surveyor , that she feels bad for the resident's. CNA F stated, I wouldn't eat that either. CNA F stated, I bet they are still hungry. I will make sure they get a snack.

Based on record review, and interview, in 1 of 10 total residents reviewed (Resident 2) the facility did not conduct initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of each resident's needs. Resident 2 did not have a sleep assessment completed. This is evidence by: Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 2's medications included in part [MEDICATION NAME] 0.5 mg Give 1 tablet by mouth one time a day for anxiety at bedtime and [MEDICATION NAME] 7.5 mg Give 1 tablet by mouth one time a day for anxiety/[MEDICAL CONDITION]. On 11/4/15 Surveyor reviewed Resident 2's complete medical record including the Nursing Comprehensive Admission Data collection and assessment, and noted there was not a sleep assessment completed. On 11/4/15 at 12:15 PM, Surveyor interviewed Registered Nurse (RN) D regarding the initial sleep assessment for Resident 2. RN D stated, There is no sleep assessment for Resident 2. RN D indicated that the facility will be starting a sleep assessment for anyone on a Hypnotic. RN D indicated that she will be developing a policy and a plan to complete all sleep assessments. On 11/5/15 at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B regarding sleep assessments. DON B indicated that Resident 2 should have had a sleep assessment. DON B stated, There is not a policy for sleep assessments but RN D is going to work on this. DON B indicated that RN D will be utilizing a Fit Bit on the residents.

Based on observation, interview and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 3 of 17 independently mobile residents (Residents 6, 13 and 14). The facility did not ensure the stoves and steam tables were locked out so residents could not turn them on and that residents could not burn themselves on the steam tables. This is evidenced by the following: The facility is designed with four neighborhoods/units that each have a kitchen area. The kitchen area is a counter that is open to the dining room with no barrier between. It includes an electric stove and a steam table with two wells. The knobs to turn on the steam table are just below the counter within reach of residents. The facility has 17 residents that are independently mobile on the unit. Of those Resident 13 and 14 have moderate cognitive impairment and Resident 6 has a severe cognitive impairment per the Brief Interview for Mental Status on their most recent Minimum Data Set. Example 1 The facility has 17 residents that are independently mobile on the unit per interview with Registered Nurse D on 11/5/15 at approximately 1:00 PM. Of those Resident 13 and 14 have moderate cognitive impairment and Resident 6 has a severe cognitive impairment per the Brief Interview for Mental Status on their most recent Minimum Data Set. On 11/3/15, at 10:06 AM, Surveyor checked the temperature of the lid on the steam table on Residential 3. The temperature was 140 degrees Fahrenheit. The lid was too hot to touch and the surrounding counter was also hot. The steam table was turned off, however it was not locked out and Surveyor was able to turn the knob and turn it on again and there were no staff in the area. A sign on Resident hall 3 states Certified Nursing Assistant's (CNA's) please turn both steam tables on 5 at least 15 - 20 minutes prior to food delivery. This is extremely important to assure food quality and safety. There was no staff present prior to the meal while the steam table was warming or immediately after the meal to ensure residents safety. At 10:10 AM, Surveyor brought this to the attention of Nursing Home Administrator (NHA) A. NHA A stated there is usually staff in the dining/living area. NHA A and Surveyor went to Residential 3. By this time Certified Nursing Assistant (CNA) E stated she just emptied the water from the steam table. The lids and surrounding counter were still hot. CNA E stated when the dietary staff takes the food out the steam table is turned off. CNA E then will empty the water and clean up the area. CNA E stated she did not know anything about a lock out switch. NHA A opened the cupboard where the switch was and locked out the steam table. NHA A stated the stove and steam table should always be locked out when not in use. NHA A and Surveyor then noted the kitchen area on Residential 2. The steam table was not locked out. Example 2 On 11/3/15 at 9:20 AM, Surveyor observed the kitchenette on the Resident 1 unit. Surveyor noted steam escaping from the two steam units on the unprotected counter. Surveyor touched the metal covers on the steam units and pulled her hand back immediately. They were very hot to the touch. A sign on Resident hall 1 states Certified Nursing Assistant's (CNA's) please turn both steam tables on 5 at least 15 - 20 minutes prior to food delivery. This is extremely important to assure food quality and safety. There was no staff present prior to the meal while the steam table was warming or immediately after the meal to ensure residents safety. On 11/3/15 at 9:30 AM, Surveyor observed the kitchenette on the Rehab unit. Surveyor noted steam escaping from the two steam units on the unprotected counter. Surveyor touched the metal covers on the steam units and pulled her hand back immediately. They were very hot to the touch. A sign on Rehabilitation hall states Certified Nursing Assistant's (CNA's) please turn both steam tables on 5 at least 15 - 20 minutes prior to food delivery. This is extremely important to assure food quality and safety. There was no staff present prior to the meal while the steam table was warming or immediately after the meal to ensure residents safety. On 11/3/15 at 10:10 AM, Surveyor verified the temperature on the top of the steam unit on the Resident 1 unit. The temperature was noted to be 140.9 degrees Fahrenheit (F). Certified Nursing Assistant (CNA) C stated, Be careful, those are really hot. On 11/3/15 at 10:15 AM, Surveyor verified the temperature on the top of the steam unit on the Rehab unit and the temperature was noted to be 100 degrees F. The oven and the steam table unit was not locked out and could be turned on at any time. Surveyor brought this information to the Nursing Home Administrator (NHA) A.

Based on observation and, interview, the facility did not prepare or distribute food under sanitary conditions. This has the potential to affect all residents in the facility. Census at the time of survey was 42. Staff did not have their hair restrained while plating food from the steam tables on all units. Staff touched toast with gloved hands after touching the outside of the butter container taken from the unit refrigerators. Staff left the steam table uncovered while unattended. Hash browns did not meet standard hot holding food temperature. Evidenced by: The facility's "Nutrition Services Dress Code" policy, effective date 9/12, includes the following: Procedure: 3. Hairnets or surgical type caps, provided by Nutrition Services Department, must be worn, covering hair completely. The facility's "Sanitation: Food Serving Standards" policy, effective date 7/12, includes the following: Procedure: D. Food in steam table will be partially covered throughout meal service to help retain heat. E. No foods will be directly handled with bare hands. 2. Use gloves if utensils will not handle the food efficiently. The facility's "Holding Food Prior to Service" policy, effective date 7/96, includes the following: Procedure: 3. Check Temperatures. b. Hot foods must maintain a temperature of 135 degrees or higher. Example 1 On 6/13/13 at 7:45 AM Surveyor observed Certified Nursing Assistant (CNA) F plating food from the steam table on Residential 2 Unit. CNA F did not have her hair restrained. On 6/13/13 at 8:00 AM Surveyor interviewed CNA H. CNA H was working on the Residential 3 Unit. CNA H stated the breakfast meal is plated and served by the CNAs on the individual units. CNA H stated she never restrains her hair. On 6/13/13 at 8:40 AM Surveyor observed CNA G plating food on the Residential 2 Unit. CNA G did not have her hair restrained. On 6/13/13 at 11:30 AM, Surveyor onserved CNA J plate food in the Rehab Unit. CNA J did not have hair restrained. On 6/13/13 at 11:35 AM Surveyor observed CNA H plate food on the Residential 3 Unit. CNA H did not have her hair restrained. On 6/13/13 at 12:00 PM Surveyor observed CNA F plate food on the Residential 2 Unit. CNA F did not have her hair restrained. On 6/13/13 at 12:05 PM, Surveyor observed CNA K plate food on Residential Unit 1. CNA K did not have hair restrained. On 6/13/13 at 1:30 PM Surveyor interviewed Dietary Manager (DM) E. DM E stated she would expect all staff that plate food should have their hair restrained. Example 2 On 6/13/13 at 7:45 AM Surveyor observed Certified Nursing Assistant (CNA) F pick up a butter container from the refrigerator with gloved hands. CNA F touched the outside of the butter container with her gloved left hand, and then held a piece of toast with her gloved left hand as she buttered it. On 6/13/13 at 11:35 AM Surveyor observed CNA H pick up a butter container with her gloved left hand, and then held a piece of toast with her gloved left hand as she buttered it. On 6/13/13 at 12:00 PM Surveyor observed CNA F pick up a butter container with her gloved left hand, and then held a piece of toast with her gloved left hand as she buttered it. On 6/13/13 at 1:30 PM Surveyor interviewed Dietary Manager (DM) E. DM E stated she would expect staff to use a utensil or paper to hold the toast when buttering it. Example 3 On 6/13/13 at 8:30 AM, Surveyor observed the breakfast service from the kitchenette on the Rehab Unit. Upon walking on the unit Surveyor observed uncovered food in the steam table, a 1/2 gallon jug of 2% milk sitting out on the counter, uncovered fruit in a container on the counter, bags of opened bread and a uncovered container of butter sitting out on the counter. There was no staff or residents in the dining area. On 6/13/13 at 1:30 PM Surveyor interviewed Dietary Manager (DM) E. DM E stated she would expect the steam table to be covered when unattended during meal service. Example 4 On 6/13/13 at 12:10 PM, Surveyor observed DA C temping the food before lunch service on the Residential 1 unit. The temperature of the hash brown patties reached 100 degrees Fahrenheit. On 6/17/13 at 9:30 AM during group interviews Resident 12 stated that the hash browns were cold during the lunch service on 6/13/13. On 6/13/13 at 1:30 PM Surveyor interviewed Dietary Manager (DM) E. DM E stated she would expect the temperature of the hash browns to be 135 degrees or greater.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food under sanitary conditions. This had the potential to affect any Residents who consume food from the Residential 1 unit of the facility. Census of Residential 1 was 11 residents. Dietary Aide (DA) D did not appropriately clean the thermometer when taking temperatures of the food items. A cooler in the main kitchen contained a bag of raw chicken. This bag was not sealed and the raw chicken was not covered. This is evidenced by the following: The facility's policy titled, "Sanitation: Food Serving Standards," dated 12/13/02 states the following: "Purpose: to assure quality and safety standards are met for food served by department ...Procedure: ...C.Temperatures shall be recorded before and after food preparation. At the Nursing and Rehab Center, once the food arrives in the household, food temperatures will be taken before serving to the residents. Thermometers should be cleaned with an alcohol wipe between food items. Allow thermometer to dry for 1 minute before inserting it in food again ..." According to the 2009 FDA Food Code, "Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. 1(A) Food shall be protected from cross contamination by: ...(4) Except as specified under Subparagraph 3-501.15(B)(2) and in ? (B) of this section, storing the food in packages, covered containers, or wrappings; ..." Example 1 On 5/22/12 at 11:25 AM, Surveyor observed Dietary Aide (DA) D measure temperatures of the items in the steam table on the Residential 1 unit. DA D first took the temperature of the fried chicken. DA D did not sanitize the thermometer with an alcohol wipe but wiped the thermometer with a paper towel. DA D then placed the thermometer into a container of potatoes and measured the temperature. DA D wiped the thermometer with the same paper towel and then obtained the temperature of the mashed potatoes. DA D did not sanitize the thermometer with an alcohol wipe. DA D then obtained the temperature of a container of soup. DA D did not sanitize the thermometer before obtaining the temperature of the soup. Surveyor spoke with Cook C on 5/23/12 at approximately 9:45 AM. Surveyor asked Cook C how temperatures should be obtained from the steam tables on the units. Cook C stated that she uses an alcohol wipe and wipes off the thermometer between each item. Example 2 On 5/23/12 at 9:35 AM during the tour of the facility's kitchen, Surveyor observed a walk-in cooker. Surveyor noted a plastic bag of raw chicken that was noted to be opened and uncovered. Cook C, who accompanied Surveyor during the tour, stated that the raw chicken should not be open. Cook C then closed the bag of raw chicken.

Based on observation, record review and interview, in 1 of 10 residents reviewed, (Resident 4), the facility did not develop, review and revise the resident's comprehensive plan of care. Resident 4 has a moderately displaced C2 (Cervical Vertebrae #2) fracture. Resident 4 is to wear a cervical collar at all times except when changing the pads, at which time her head requires hand support. This significant intervention is not noted on Resident 4's comprehensive care plan. This is evidenced by the following: Resident 4's [DIAGNOSES REDACTED]. Resident 4 was readmitted to the facility on [DATE] with orders that included: "Collar 24/7 (24 hours/7 days a week) for the next 3 months. Change pads daily, wash in sing (sic) and air dry for next day. Head requires hand support while changing / out of collar. Keep collar as snug as pt (patient) can tolerate comfortably. Neck should not move in collar." Surveyor observed Resident 4 each day of this 3 day survey (5/21/12, 5/22/12 and 5/23/12). In each observation Surveyor observed Resident 4 sitting in a wheel chair. Resident 4 had a cervical collar in place. Resident 4's record shows a TAR (Treatment Administration Record) which include the entries of "Cervical neck collar on at all times", and "Change and wash cervical neck collar pads daily; wash pads in sink and air dry; support head when changing". These entries are signed out by the licensed staff. Resident 4's comprehensive care plan does not include the interventions to keep the collar on at all times, or the intervention to provide head support when changing the collar pads. On 5/23/12 at 10:25 am Surveyor spoke with CNA (Certified Nursing Assistant) F regarding facility care plans. CNA F was working on the unit that Resident 4 resides, and is familiar with Resident 4. Surveyor asked CNA F: if she needed to look at a resident's care plan, where would she look? CNA F stated: "We would come out here (to the nurses' desk) and use the care plan book." The care plan book is a book that contains each resident's comprehensive care plan for those residents who reside on this unit. Surveyor asked CNA F if CNAs ever utilize the treatment book to make note of care plan interventions. CNA F stated she does not look in the treatment book or the medication administration book for care plan interventions. On 5/23/12 at 12:45 pm Surveyor spoke with CNA G. CNA G was working on the adjacent unit that Resident 4 resides on, but is familiar with Resident 4. Surveyor asked CNA G where she would go to review a residents plan of care? CNA G stated: "We use the care plan" and showed Surveyor the care plan book. Surveyor asked CNA G if she would ever use the treatment book or the medication administration book to review a resident's plan of care. CNA G stated: "No, we use the care plan". On 5/25/12 at 12:55 pm Surveyor spoke with RN (Registered Nurse) E regarding several topics including the use of care plans. Surveyor asked RN E where the CNAs go if they need to review a resident's plan of care. RN E stated the CNAs use the care plan book. Surveyor asked RN E if Resident 4 is to have her collar on at all times. RN E confirmed that Resident 4 was to have the collar on at all times. Surveyor asked RN E if that intervention would be on the care plan. RN E stated that it would be on the care plan. Surveyor informed RN E that she (Surveyor ) was unable to find this intervention on Resident 4's care plan. RN E, along with Surveyor , reviewed Resident 4's care plan at this time. RN E confirmed this intervention was not on Resident 4's comprehensive care plan. Surveyor asked RN E if this care plan (in the care plan book) was Resident 4's most current care plan. RN E stated that indeed it was the most current. RN E stated: "I don't see it. I know it was on the temporary care plan". RN E and Surveyor were unable to find a temporary care plan for Resident 4. RN E stated "I don't understand" why this intervention is not on Resident 4's care plan.

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food under sanitary conditions. This has the potential to affect 11 residents on one wing of the facility. Staff touched a banana with bare-hands. The facility did not remove out-dated items from a refrigerator on one residential wing of the facility. Pureed food was served below the appropriate holding temperatures. This is evidenced by the following: Example 1 The facility's policy and procedure titled "Sanitation: Food Serving Standards when serving on Tray Line and in the Cafeteria" effective 12/13/02 states the following: "...E. No foods will be directly handled with bare hands. 1. Use utensils: scoops, tongs, spoons, and ladles; 2. Use plastics gloves if utensils will not handle the food efficiently; 3. All food service workers while on tray line will be wearing gloves while serving..." On 3/30/11 at 12:13 PM, Surveyor observed Certified Nursing Assistant (CNA)C assist Resident 3 with lunch. CNA C peeled a banana for Resident 3. CNA C was not wearing gloves or using a device to prevent bare-hand contact with food. CNA C peeled the entire banana, removed the peel, and carried the banana to the counter where she placed the banana on a plate. CNA C touched the peeled banana with bare hands. Surveyor interviewed Food Service Supervisor (FSS) E on 3/31/11 at 1:10 PM. FSS E stated that nothing is supposed to be touched by bare hands. Surveyor asked how staff are expected to peel a banana. FSS E stated that gloves are supposed to be used to peel bananas. Example 2 The facility's policy titled "Stocking" effective 8/02 states the following: "...3. Nursing and Rehab kitchenettes are stocked with a par level of items...b. Items will be delivered by Nutrition Services daily including Saturday and Sunday; C. Nutrition Services staff organizes the refrigerators daily. All refrigerators will be organized the same. Any out dated food will be disposed of...E. If a family member brings in a food item for a patient will can be stored in the freezer or refrigerator only if a name and date is placed on it. It may remain in the refrigerator for a maximum of three days and then must be discarded. If an item has no date on it, it will be discarded." A document titled "Dating: Refrigerated Foods" states the following: "Dating is required for: Any ready to eat, Potentially Hazardous food prepared in-house held more than 24 hours; Any opened commercially prepared ready to eat, potentially hazardous food held more than 24 hours What is a "Potentially Hazardous Food"? Foods that bacteria will grow in when the temperature is in the Danger Zone (between 41 and 135 degrees F); Examples: milk, eggs, meat; What is a ready to eat food? Food that may be safely eaten without additions preparation; Example: cheese, fresh fruit, cookies; Rules and Regulations: Discard food when: ready to eat, potentially hazardous food is opened or prepared more than 3 days ago without being frozen. Ready to eat, potentially hazardous food is not date marked and you are unsure when the food was opened or prepared; Date all food if it is kept more than 24 hours; Mark the date that the food was OPENED. From there, we can determine when the three days is up. If unopened, the food is okay until the "use by" date from the manufacturer." On 3/29/11 at 11:40 PM, Surveyor inspected a refrigerator in one wing of the facility. Surveyor noted a small package of "Strawberry Gelatin" with a "best by" date of 3/26/11, a small package of "Fruit-N-Gel" with a best by date of 10/3/10, 2 eggs in a clear, undated, plastic container, a small package of "Orange Gelatin" with a best by date of 3/26/11, a small, manufacturer's container of cheese spread with a sticker that read "Lot 10/26/09" and a date on the container that read "01 26 11"; an opened manufacturer's container of sharp cheddar cheese that read "Lot 7/15/09" and was dated with " 10 15 10." Surveyor asked Nursing Home Administrator (NHA) A and Registered Dietician (RD) H about the process for removing out-dated items from the refrigerators. NHA A stated that it was okay for the cheese to be in the refrigerator as long as it was not opened. NHA A stated that sticker stating "Lot" and the date was not a sticker that the facility placed on the cheese spreads. RD H stated that the cheeses should be dated and should be thrown in the garbage and should not be in the fridge. On 3/31/11 at 1:10 PM, Surveyor spoke with Food Service Supervisor (FSS) E about the facility's process for storing refrigerated foods on the wings. FSS E stated that the dietary staff takes the food up to the wings but does not put it away. Surveyor asked FSS E who was responsible for ensuring that outdated items were removed from the refrigerators. FSS E stated that the jell-o items were the dietary department's responsibility. FSS E stated that if items were brought in by family members, they should be dated and labeled with the resident's name. FSS E stated that the eggs were in the fridge for an activity and that they should be dated. Example 3 On 3/30/11, at 8:20 AM, Surveyor observed Dietary Aide (DA) K serving food. DA K placed the non-pureed food on the steam table and then set the two containers of pureed food on the counter. DA K took temperatures of the food on the steam table. Sausage patties were at 135 degrees Fahrenheit. DA K stated that the food needed to be at least 139 degrees Fahrenheit, then warmed the sausage patties up in the microwave. Then DA K served the pureed food to two residents. Surveyor requested a temperature for the pureed sausage and pureed French toast immediately after serving. The temperature of the pureed sausage was 122 degrees Fahrenheit and the pureed French toast was 120 degrees Fahrenheit. DA K commented that the food has been sitting uncovered for a little bit that's why the temperatures are low. DA K did not offer to heat up the food for the 2 residents that had been served.