Every finding on record at Village on the Isle

Based on record review and staff interviews, the facility failed to obtain daily weights as ordered for 1 (Resident #4) of 1 resident reviewed with congestive heart failure, which may cause the resident to retain fluids. The findings included: The facility policy Physician Services with a date of June 13, 2018, documented, . All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift . Review of the clinical record revealed Resident #4 had a readmitted [DATE]. Diagnoses included dementia, chronic kidney disease, and congestive heart failure(CHF). On 4/29/24 at 8:58 a.m., the Advanced Practice Registered Nurse (APRN) documented in a progress note Resident #4 had non-pitting edema (swelling that feels firm to touch) to the right lower leg, right ankle, and left ankle. The APRN noted the edema was dependent upon positioning. On 4/29/24 at 11:02 a.m., the physician issued an order for daily weight to be completed before breakfast and confirmed by the nurse for a diagnosis of heart failure. The order specified to notify the physician if Resident #4 gained more than two pounds (lbs.) in 24 hours or greater than five lbs. in a week. On 4/29/24 at 2:04 p.m., the Registered Dietitian documented a readmission assessment noting Resident #4 had 2+ pitting edema (swelling that leaves an indentation when pressed) to both lower extremities, and daily weights were being monitored. Review of the weight record showed the following recorded weights: 4/29/2024: 139.2 lbs. 5/1/2024: 134.9 lbs. 5/5/2024: 136.0 lbs. 5/6/2024: 135.8 lbs. 5/9/2024: 130.6 lbs. 5/11/2024: 130.9 lbs. 5/13/24: 140.1 lbs. There were no weights documented on 4/30/24 and no documentation Resident #4 refused to be weighed. On 5/2/24 at 3:03 p.m., the nurse documented the resident refused to get out of bed to be weighed. On 5/3/24 at 6:52 a.m., the nurse progress note documented resident does not want to get up, get dressed now, will have day Certified Nursing Assistant (CNA) obtain weight before breakfast. On 5/4/24 at 6:44 a.m., the nurse documented day CNA will obtain weight when resident is ready to get up and dressed. On 5/7/24 at 7:06 a.m., the nurse documented day CNA to obtain the weight before breakfast. On 5/8/24 at 6:09 a.m., the nurse documented day CNA will obtain weight when dressed and awake. On 5/10/24 there was no documentation of why the weight was not obtained as ordered. On 5/12/24 at 5:52 a.m., the nurse documented day CNA will obtain weight when resident is dressed and ready to wake up. On 5/14/24 at 1:19 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said the resident refuses to be weighed at times. The LPN said, today, she refused, and I documented it in the progress note. LPN Staff A was not able to locate the missing weights in the electronic clinical record and said the weights would not be written anywhere else. Staff A said, I go with the CNA to weigh the resident. On 5/14/24 at 1:50 p.m., in an interview the Director of Nursing (DON) said the Certified Dietary Manager or the Unit Manager had the missing weights on a paper and had not put them into the electronic record yet. The DON said, I understand what you are saying when asked how the nurses would know and notify the physician if the resident had a weight gain of two lbs. in 24 hours or five lbs. in one week if the weights were not documented. On 5/15/24 at 8:35 a.m., in an interview the DON, said she was not able to locate Resident #4's missing weights but was told the resident refused to be weighed. The DON verified there was no documentation Resident #4 consistently refused to be weighed and no documentation the physician was notified of the missing weights. On 5/16/24 at 9:13 a.m., in an interview the APRN said she was not aware the weights were not consistently obtained as ordered. The APRN said the fact that the facility did not follow the physician order was a concern.

Based on observation, staff interviews, record review, and review of facility policy and procedure, the facility failed to ensure 1 (Residents #3) of 3 residents reviewed with grab bars was assessed for alternative interventions prior to the use of grab bars. The facility failed to assess for danger of entrapment prior to use of the use of the grab bars and failed to conduct periodic maintenance of the grab bars to ensure they remained safe for resident's use. The facility had a total of 30 residents using grab bars. The findings included: The facility policy bedrails dated 6/11/18 documented, The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being. Procedure: 1) The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. 2) If a bed or side rail is used, the facility will ensure correct installation, use and maintenance of bedrails, including: Assess the resident for risk of entrapment from bedrails prior to installation . Follow the manufacturers recommendations and specifications for installing and maintaining the bedrails. The manufacturers User-Service Manual for the bedrails specified, Warning, risk of serious injury or death. Do not use this assist device if any openings within the assist body will allow a resident to get his/her head or neck lodged within these openings . Proper combinations of bed, mattress, head/foot panels and assist devices are needed to minimize the risk of entrapment. Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather than the manufacturer. Therefore, compliance is the responsibility of the facility . Long term care facilities have particular exposure since serious entrapment events, typically involve frail, elderly or dementia patients. On 5/13/24 at 12:41 p.m., Resident #3 was observed in bed on a scoop (raised borders) mattress, over the bed trapeze (helps to move in bed), and grab bars on both sides of the bed in a raised position. Review of the clinical record revealed Resident #3 had a readmitted [DATE], with diagnoses including depression, anxiety, morbid obesity, cerebral infarction, macular degeneration, and weakness. A physician order dated 1/29/24 specified assist rail to left and right side of the bed to assist with bed mobility, and transfers, per resident request. A side rail consent form was signed by the resident on 1/1/29/24. The quarterly side rail assessment screen dated 2/16/24 documented side rails were indicated to enable positional changes and improve bed mobility. There were no documentation of alternatives interventions attempted before the grab bars were applied. On 5/14/24 at 2:35 p.m., in an interview the Director of Rehabilitation (DOR) said the therapy department screens the residents upon admission. If the resident is unable to turn in bed or sit up then they try the grab bar and if the resident is able to use it to increase function, then it is recommended. The DOR said there was no alternative intervention to use other than a trapeze, the facility did not have enough of them, and not all residents were able to use the trapeze due to lack of muscle strength. The DOR said therapy staff did not document the alternatives attempted and why they were not appropriate for the resident. The DOR said, That is a nursing thing. Review of the Occupational Therapy and Physical Therapy evaluation and plan of treatment for Resident #3 dated 9/10/23 did not document the use of a trapeze, scoop mattress or grab bars. The Director said he had no documentation alternate interventions were attempted prior to recommending the grab bars. On 5/14/24 at 3:07 p.m., in an interview the Director of Nursing (DON) said she was aware the therapy documentation did not include screening for the use of the grab bars. On 5/15/24 at 8:47 a.m., the DON said the beds do not have the grab bars on them until therapy evaluates the resident and if they feel the resident will benefit from them, that is when we get an order and have them placed on the beds. The DON said Resident #3 was admitted several years ago and had a recent admission to the hospital. She said, we just left the trapeze and everything on the bed because we knew she would be back, we did not remove it. On 5/15/24 at 2:54 p.m., in an interview the Maintenance Director said, Every month I do bed inspections. I check the gaps between the mattress and headboard and the footboard. I check the wires and the locks. The Maintenance Director said there is a lock that hold the mattress from moving up or down, but it can move sideways. When therapy asks him to put the grab bars on, that is when he puts them on the bed. He removes them when a resident leaves. The Maintenance Director said, Like I said, I check the welds, wires the whole bed, I move it up and down to make sure it is functioning. I do not check the entrapment zones for the grab bars. I do not check for entrapment with the grab bars and I don't do routine maintenance on them.

Based on observation, review of facility's policy and procedure, staff and resident interviews, the facility failed to label, and safely store medications for 3 (Resident #19, #21, #16) of 4 residents observed with unsecured medications at the bedside. The findings included: The facility policy titled Resident Self-Administration of Medications dated June 13, 2018 Specified, If medications are stored at the resident's bedside, a lockbox or locked drawer must be used to store the medication(s). 1. On 1/17/23 at 11:02 a.m., and on 1/18/23 at 12:45 p.m., an over the counter bottle of Tylenol and Tylenol PM were observed stored unsecured at Resident #16's bedside. On 1/18/23 at 3:06 p.m., Licensed Practical Nurse (LPN) Staff G said if a resident self-administers medications, they are stored in a locked cabinet in the bathroom. On 1/18/23 at 3:09 p.m., Resident #16 said he's had the two bottles of over the counter medications at his bedside for six months. 25618 2. On 1/17/23 at 10:45 a.m., during a tour of the facility, observation of one bottle of Refresh Relieva Ophthalmic Solution 0.5-0.9% eye drops sitting on Resident #21's bedside table. The medication did not have a pharmacy label with the resident's name, the name of the medication with directions for use, and/or any other pertinent information. On 1/17/23 at 10:46 a.m., Resident #21 said, she was admitted to the facility in September 2021. She said she uses the Refresh eye drop to moisturize her left eye. She is unable to put the eye drops in her eyes so when she needs the eye drops, she would call the nurse and they would put the eye drops into her eyes. She said the Refresh eye drops are kept in her room on her over the bed table even when she is not in her room. She said she did not remember the nursing staff explaining to her the directions for the use of the eye medication and how to safely keep the medication in her room. On 1/17/23 at 3:15 p.m., a bottle of Refresh Relieva Ophthalmic Solution 0.5-0.9% eye drops was observed sitting on Resident #21's bedside table. Resident #21 was not in her room during the observation. On 1/17/23 at 3:30 p.m., Registered Nurse (RN), Staff E said Resident #21 was out of the facility for an appointment. She confirmed a bottle of Refresh Relieva Ophthalmic Solution 0.5-0.9% eye drops was sitting on Resident #21's bedside table, and the medication did not have a pharmacy label with the resident's name, the name of the medication with directions for use, and/or any other pertinent information. Staff E said residents were allowed to self-administer and keep the medication in their room after a self-administration assessment was completed and the interdisciplinary team (IDT) determined it was safe for the resident to administer the medication. Then it would be safe for the resident to keep the medication in their room. Staff E said she had seen the Refresh eye drops on Resident #21's bedside table for the past couple of months but did not know how long she's had them. On 1/19/23 at 10:53 a.m., the DON confirmed Resident #21's Refresh eye drops were kept on Resident #21's bedside table, not in a secure area, and the medications did not have a pharmacy label with the resident's name, the name of the medication with directions for use, and/or any other pertinent information. 44824 3. On 1/17/23 at 12:40 p.m., an unlabeled box of individual use Retaine eye drops was observed stored on Resident #19's bedside table. Resident #19 was in a recliner, watching television. Resident #19 said her significant other brought the box of eye drops for her in case she needed them. She said she nurses administer the eye drops. On 1/18/23 at 11:00 a.m., Resident #19 was in her room watching television. The Retaine eye drops remained unsecured on the bedside table. On 1/19/2023 at 3:22 p.m., Licensed Practical Nurse (LPN) Staff H verified Resident #19 had an unsecured box of Retaine eye drops stored at the bedside. On 1/20/2023 at 11:00 a.m., in a joint interview the Director of Nursing (DON) and the facility Administrator said no medication should be stored unsecured at the bedside.

Based on policy review, observation, and staff interview, the facility failed to prepare and serve food in a sanitary manner to prevent potential contamination for 3 of 3 meal service observations. This failure has the potential to cause food borne illness in residents receiving an oral diet. The findings included: The facility's policy for Employee Sanitary Practices Chapter 4: Sanitation and Infection Control 4-4, from 2019 indicated, All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Staff are to Keep fingernails clean and neat. Acrylic or painted nails must be covered when handling or serving food .Keep jewelry to a minimum. Only a plain band ring such as a wedding band can be worn. When handling clean dishware staff are to pick up dishes up by their rims. The facility's Hand Washing policy Chapter 4: Sanitation and Infection Control 4-8, from 2019, indicated hands are to be washed after engaging in other activities that contaminate the hands. Staff are to Turn on the faucet using a paper towel to avoid contaminating the faucet. Wet hands and forearms with warm water (minimum 110 (degrees) F (Fahrenheit)) and apply an antibacterial soap. Scrub well with soap .for a minimum of 10 to 15 seconds . Rinse with clean, running warm water .Dry hands with paper towel .Use the paper towel to turn the faucet off. On 9/30/19 at 11:31 a.m., during observation of noon meal service, Dietary Aide Staff M was placing food brought from the main kitchen into the steam table, with her bare hands removed the plastic wrap and prepared to serve residents. Staff M was noted to have fingernails that extended past the tip of her fingers. When taking plates from the stack on the plate warmer, Staff M was observed to repeatedly lay her thumb on the inside surface of the plate; and sliding her hand under each plate touching the inside surface of the plate underneath. Staff M was observed handling potentially contaminated items under a counter and resumed serving without washing her hands. Dietary Aide Staff I was assisting with meal service and observed with long painted fingernails extending over a quarter inch past her fingertip, and a bracelet on each wrist. Staff I was removing plastic covers which were stacked with the inside surface up, to place on top of the food plates. Staff I, with her bare hands, was handling the inside surface of each cover then placing the cover over the resident's food. Staff I was handling resident meal tickets and the inside surface of the sandwich plates when taking them from the top of the steam table. On 10/1/19 at 10:58 a.m., Dietary Aide Staff M was observed preparing to serve the noon meal. After washing her hands, Staff M started removing utensils from bins, removed a cleaning rag from a bucket with sanitizer to wipe off the front of the steam table and counter in front of toaster, and touched other potentially contaminated surfaces including her uniform pants. At 11:15 a.m., Staff M left the kitchen and upon returning did not wash her hands before handling the resident's plates. Staff M was observed repeatedly handling the inside surfaces of the resident's plates when serving food. On 10/1/19 at 3:53 p.m., kitchen staff were preparing to serve the evening meal. Dining Technician Staff A was placing pans of food onto the steam table. Staff A was observed to have long fingernails, not to be wearing gloves, was wearing 3 rings, a watch, and a bracelet on each wrist. At 4:05 p.m., Staff A left kitchen to bring the meal cart out into the hallway. Staff A returned to the kitchen, washed her hands for 3 seconds, turning off the faucet with her wet hands. Staff A preceded to take the temperature of the food, handling the thermometer with her bare hands. Staff A removed a paper and pen from her pocket and set them on the steam table in front of the open food pans. After taking the temperature of the food, Staff A washed her hands again for 3 seconds and turned off the faucet with her wet hands. Staff A, with bare hands, after setting utensils into the food on steam table, touched push pins and a menu paper posted on the bulletin board behind her. Staff A then began to serve the food from the steam table. Staff A was observed repeatedly laying the side of her left palm and thumb on the inside surface of the plate as she was serving with her right hand. The dangle bracelet on her right wrist was frequently hanging over the food on the steam table. In an interview on 10/2/19 at 1:47 p.m., the Kitchen Manager confirmed staff should not be wearing excessive jewelry as it was not acceptable practice. She acknowledged dietary staff did not wash their hands in accordance with facility policy and did not handle plates in a manner to prevent contamination.

Based on record review, and staff interview, the facility failed to ensure an advance directive was followed correctly for 1 (Resident #21) of 3 residents reviewed for advance directives. This has the potential for the wishes of the resident to not be followed. The findings included: On 10/2/19, record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/19 and a quarterly MDS with an ARD of 5/1/19 for Resident #21 revealed a brief interview for mental status score of 4. A score of 4 indicates severe cognitive impairment. On 10/2/19, record review of Resident #21 revealed a Health Care Surrogate directive signed on 12/2/03 that would become effective if it had been determined Resident #21 was unable to provide express and informed consent regarding her medical treatment. The directive named Resident #21's niece as the Health Care Surrogate. Further review revealed no documented evidence Resident #21 had been determined unable to provide express and informed consent. Despite this, there was evidence the niece signed election for Hospice Services for Resident #21 on 6/10/19. On 10/02/19 at 11:57 a.m., in an interview, the facility Social Service Director confirmed there was no evidence of documentation that Resident #21 was unable to provide express and informed consent regarding her medical treatment. He confirmed the Health Care Surrogate directive signed by Resident #21 was not followed correctly.

Based on record review, and staff interview, the facility failed to assess, evaluate, and plan care to provide individualized approaches to restore as much normal elimination function as possible for 1 (Resident #17) of 1 resident with the identified problem of a decline in bladder incontinence. The findings included: The facility's Bowel and Bladder Program Procedure dated 6/13/18; indicated residents who are continent of bladder on admission received services and assistance to maintain continence. Further the procedure included, All residents admitted ti facility will have a Bowel and Bladder Continence Evaluation performed at the time of admission, in conjunction with each quarterly and annual assessment, with any significant change assessment and as deemed necessary by the Interdisciplinary Team .The DON (Director of Nursing) or designee will then be responsible for initiating the 3-Day Resident Tracking/Trending Bowel and Bladder Pattern .After the 3 days the DON or designee will review the documentation looking for an established pattern .The DON or designee along with the Interdisciplinary Team will evaluate the appropriate program for the resident and refer to Restorative if appropriate. Resident #17's clinical record revealed a Continence Program Decision Tree form and a Screen for Bowel and/or Bladder Training form were completed by Registered Nurse (RN) Staff J on 8/3/18. Staff J indicated on the forms, Resident #17 was continent of bladder on admission. An Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE], indicated Resident #17 was occasionally incontinent of bladder. The Care Area Assessment worksheet for the triggered area of Urinary Incontinence indicated the decision was to proceed to care plan this problem to assist the resident to maintain or improve current level of continence prevent skin breakdown and assist with all toileting needs. A Quarterly MDS completed on 2/6/19, indicated Resident #17 was always continent of bladder. On 8/2/19, a significant change MDS was completed and indicated Resident #17 was now frequently incontinent of bladder. A 3-Day Resident Tracking/Trending Bowel and Bladder Pattern Form was completed for Resident #17 on 8/10/19. There was no documentation of any evaluation of the 3-Day pattern or recommended program for the resident to improve continence. On 6/14/19 at 10:04 p.m., Licensed Practical Nurse (LPN) Staff L noted Resident #17 was having increased urinary incontinence. Staff L noted incontinent care given each episode and the resident did not call for assistance. On 8/8/19 at 10:42 p.m., LPN Staff L noted the resident was mostly incontinent of urine this shift. On 9/15/19 at 2:55 a.m., RN Staff D noted Resident #17 has had increased episodes of urinary incontinence. In an interview on 10/1/19 at 2:15 p.m., Certified Nursing Assistant (CNA) Staff B said she has taken care of Resident #17 since his admission to facility. She said the resident would put himself on the toilet and did not ask for help. He sometimes would ask to be toileted or she would offer to assist him with toileting. Staff B said when the resident first came to facility, he was continent, but now had more frequent incontinence. She was not aware of any toileting plan but did try to offer assistance with toileting every 2 hours. In an interview on 10/1/19 at 3:04 p.m., CNA Staff K said she uses the CNA Caretracker Kardex for information on caring for residents. She tried to take Resident #17 to the bathroom when she came on duty and sometimes he was dry and sometimes had been incontinent. In an interview on 10/1/19 at 3:27 p.m., CNA Staff F said she sometimes took care of Resident #17 and got her information from the CNA Caretracker Kardex. She said the resident would go to the toilet but had to make sure to check on him as needs help. Staff F said when she goes to check Resident #17's brief, he may have already been incontinent. She was not sure about any toileting plan for the resident. On 10/2/19, Resident #17's care plan and CNA Caretracker Kardex were reviewed. Under the problem of at risk for complications related to episodes of bladder incontinence, revised on 8/7/19, the goal was to be free of complications. The approaches included to assist the resident with toileting and incontinence care as needed. The CNA Caretracker Kardex did not have any approaches for staff regarding toileting. The care plan developed to address the resident's problem of incontinence did not include a measurable goal and specific approaches to help the resident maintain his highest level of continence and to prevent decline. There was no toileting plan in place for the resident on the CNA Caretracker Kardex. In an interview on 10/2/19 at 3:34 p.m., the DON confirmed there was no assessment of Resident #17's continence after admission and no documentation of any evaluation of the 3-Day bladder pattern. The DON acknowledged a care plan should have been developed to assist the resident to achieve continence and prevent further decline.

Based on observation and staff interview, the facility failed to ensure proper storage/labelling of medications in 1 storage room reviewed for proper storage and labeling. This has the potential for expired medications to be administered to residents. There were 9 medications expired. The findings included: On 11/8/18 at 8:51 a.m., observation of the Medication Storage room with Licensed Practical Nurse (LPN) Staff B revealed 9 containers of expired medication on the shelves. This included: Geri-Mucil, 2 bottles expired on 10/2018 and 1 bottle expired on 7/2018, [MEDICATION NAME] X-150, 150 milligrams (mg), 1 bottle expired on 5/2018, Zinc 50 mg 2 bottles expired on 10/2018, and One Daily Multi-Vitamin with Iron, 3 bottles expired on 6/2018. On 11/8/18 at 8:57 a.m., LPN Staff B acknowledged the medications had expired. LPN Staff B said either Unit Secretary/Central Supply Clerk or Administrative Support Specialist would check the medication storage room for expired medications. On 11/8/18 at 8:58 a.m., the Unit Secretary/Central Supply Clerk said she did the ordering. She said she did not have a key for the medication storage room. She said one of the nurses opened the door for her to stock the over the counter medications on the shelf. She said she did not check for expired medications. On 11/8/18 at 8:59 a.m., Administrative Support Specialist said the nurses should check the medication storage room for expired medications. She said she did not check for expired medications and did not have a key to get into the medication storage room. On 11/8/18 at 9:15 a.m., the Director of Nursing (DON) said, Unit Secretary/Central Supply Clerk was responsible for checking the medication storage room for expired medications. The Unit Secretary/Central Supply Clerk did the ordering and stocking. On 11/8/18 at 9:20 a.m., the DON observed the expired medications in the Medication Storage Room and acknowledged they were expired. On 11/8/18, a review of Unit Secretary/Central Supply Clerk's personnel file showed a job description dated 11/18/18. The job summary did not include checking for expired medications in the medication storage room. On 11/8/18, a review of the Consultant Pharmacy summaries dated 6/13/18, 7/11/18, 8/24/18, 9/13/18 and 10/10/18 documented (3) Med Room Drug Storage and Management: (h) Over the counter Stock Drugs adequate/in date, and (k) Expired medications disposed of properly. The Consultant Pharmacy quarterly report dated (MONTH) (YEAR) for the months of July, August, and September, documented inspection of medication storage areas including med rooms: (1) Drug Storage and Management: Expired and Discontinued meds should be removed daily. On 11/8/18, a review of the Pharmacy services policy and procedure (dated June13, (YEAR)) documented (10) Drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. On 11/8/18 a review of the policy Storage of Medications (no effective date) documented (2) the nursing staff shall be responsible for maintaining medication storage. **Photos on file**

Based on observation, interview, and record review the facility failed to ensure proper procedures were used to wash and sanitize pots and pans. The facility also failed to ensure dietary aides were appropriately restraining their hair. This has the potential of spreading harmful microorganisms, which can cause food borne illness to residents receiving an oral diet. The findings included: On 11/2/17 at 10:05 a.m., the process of pot washing was observed in the main kitchen of the facility. The three-compartment pot/warewashing sink observed to be filled with water. The water in all three compartments was mucky, and had a large amount of food debris floating on the surface of the water. Dietary Aide (DA) Staff I was observed washing pots at the time of the observation. Manufactures recommendation for testing sanitizing solution was posted over the three-compartment sink and read as follows: Withdraw and tear off approximately 2 inches of paper from dispenser. Dip paper for 10 seconds. Don't shake. Compare colors immediately with color on test strip package to determine PPM (parts per million). Always compare against package scale. DA Staff I tested the sanitizer in the third compartment of the sink (final rinse). The sanitizing solution was quaternary ammonia, which requires the test strip to read between 150 through 400 PPM solution to eradicate harmful bacteria. DA Staff I placed the strip in the water and immediately with drew the strip (instructions document the strip should stay in the water for a least 10 seconds). Upon retrieving, the strip observed absent of color. DA Staff I said she would have to change out the water, as there was no sanitizing solution in the final rinse water. Further observation of DA Staff I revealed she had a chief's cap on the top of her head, which failed to restrain her hair. Her hair was long and flowed down past her shoulders. The facility's Certified Dietary Manager (CDM) was present during the observations. Review of the facility approve policy dated 2008 tilted Preventing Food Bourne Illness-employ Hygiene and Sanitary Practices documents the following: Policy statement Food service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness . Item 12. Hair nets or caps and /or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linen. Interviewed the CDM on 11/2/17 at 10:30 a.m. in reference to Staff I not restraining her hair and not having sanitizer in the final rinse sink. The CDM said this employee works in the main kitchen, and not part of the nursing home staff, but the policy for restraining hair is the same as our policy. The CDM commented that sanitizer should have been present in the final rinse cycle of warewashing.

Based on record review and staff interview, the facility failed to follow the plan of care for bathing preferences for 1 (Resident #47) of 5 residents reviewed for unnecessary medication use. Resident #47 received a psychoactive medication as a result of this failure. The findings included: Resident #47's clinical record revealed the resident had a [DIAGNOSES REDACTED]. A monthly summary completed by Registered Nurse Staff F noted normally see behaviors during showers and resident is afraid of showers. On 11/1/17, the Resident #47's care plan was reviewed. Under the problem of resident requires assistance with activities of daily living, approaches included, resident is very fearful of showers; is okay to wash in the bathroom per her request; family member in agreement. The Medication Administration Record [REDACTED]. The September MAR indicated [REDACTED]. The October MAR indicated [REDACTED]. The reasons listed where either anxiety or prior to shower. On 10/31/17 at 1:00 p.m., Certified Nursing Assistant (CNA) Staff A said Resident #47 gets a shower twice a week on the day shift and used to scream during the shower. Staff A said she thinks the resident is medicated before the shower. On 10/31/17 at 1:13 p.m., CNA Staff B said sometimes when she tries to give Resident #47 a shower, the resident will say she does not want to go in there. She said the resident can get very upset when she sees the shower room and if brought in they can hear her screaming to stop. On 10/31/17 at 1:21 p.m., Licensed Practical Nurse (LPN) Staff C said Resident #47 is given [MEDICATION NAME] every Tuesday and Friday because of how she acts in the shower, screaming, fighting and yelling. Staff C said the [MEDICATION NAME] calms her down so staff can get her in there. Staff C said staff try to give her a shower between 6:30 a.m. and 7:00 a.m., so the [MEDICATION NAME] is given to her around 5:30 a.m. On 11/1/17 at 8:40 a.m., LPN Staff G said on Resident #47's shower days, night shift staff when getting her up, will tell the resident she is going to get a shower. She said the resident will start getting upset and tell them the reasons she does not want one. When day shift staff come in and take her into the shower, the resident will scream. Staff G said the resident does not like a shower and is usually given the [MEDICATION NAME] on shower days for her anxiety. On 11/1/17 at 11:15 a.m., Social Worker Staff H said Resident #47 is usually calm and quiet but she has heard the resident gets anxious during her showers. Staff H confirmed the resident's care plan was not being followed by giving the resident a shower and causing her to be distressed.

Based on record review, and staff interview, the facility failed to attempt the non-pharmacological intervention as outlined in the resident's plan of care, prior to administering an anti-anxiety medication for 1 (Resident #47) of 5 residents whose medication regime was reviewed. This failure caused the resident to receive unnecessary medications. The findings included: Resident #47's clinical record revealed the resident had a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment 3.0 ((MDS) dated [DATE], indicated the resident had a BIMS (Brief Interview for Mental Status) score of 2. A score of 0 to 7 indicates severe cognitive impairment. The MDS also indicated the resident was dependent on staff for bathing. A monthly summary completed by Registered Nurse Staff F noted normally see behaviors during showers and resident is afraid of showers. On 11/1/17, the resident's care plan was reviewed. Under the problem of assistance required with activities of daily living, the approaches included, resident is very fearful of showers; is okay to wash in the bathroom per her request; family member in agreement. On 10/31/17 at 1:00 p.m., Certified Nursing Assistant (CNA) Staff A said Resident #47 gets a shower twice a week on the day shift and used to scream during the shower. Staff A said she thinks the resident is medicated before the shower. CNA Staff A said the resident is usually cooperative with care. On 10/31/17 at 1:13 p.m., CNA Staff B said sometimes when she tries to give Resident #47 a shower, the resident will say she does not want to go in there. She said the resident can get very upset when she sees the shower room and if brought in they can hear her screaming to stop. Staff B said the resident has no issues with a bed bath or other personal care. On 10/31/17 at 1:21 p.m., Licensed Practical Nurse (LPN) Staff C said Resident #47 is given [MEDICATION NAME] every Tuesday and Friday because of how she acts in the shower, screaming, fighting and yelling. Staff C said the [MEDICATION NAME] calms her down so staff can get her in there. LPN Staff C said staff try to give her a shower between 6:30 a.m. and 7:00 a.m., so the [MEDICATION NAME] is given to her around 5:30 a.m. LPN Staff C said the resident does not have any anxiety during the day. On 11/1/17 at 8:40 a.m., LPN Staff G said on Resident #47's shower days, night shift staff when getting her up, will tell the resident she is going to get a shower. She said the resident will start getting upset and tell them the reasons she does not want one. When day shift staff come in and take her into the shower, the resident will scream. LPN Staff G said the resident does not like a shower and is usually given the [MEDICATION NAME] on shower days for her anxiety. The Medication Administration Record [REDACTED]. The September MAR indicated [REDACTED]. The August MAR indicated [REDACTED]. On 11/1/17 at 11:15 a.m., Social Worker Staff H said Resident #47 is usually calm and quiet but she has heard the resident gets anxious during her showers. She discussed the resident's care plan, identified the resident as being very fearful of showers, and was alright for staff to wash the resident in the bathroom instead. The Social Worker acknowledged eliminating the cause of the resident's distress would be the appropriate intervention to use instead of the antianxiety medication. The Social Worker said she would talk with staff and stop the showers if that is the case.

Based on observation, record review and staff interview, the facility failed to ensure proper storage and labeling of medications on 2 of 2 medication cart observations. This has the potential to expose vulnerable residents to administration of expired medications. The findings included: On 11/1/17 at 12:20 p.m., observation of the Ocean unit medication cart revealed a vial of Lantus insulin for Resident #61 with an opened date of 10/3/17. Review of the facility policy #ID2 dated 8/22/16 for storage of insulin revealed the Lantus insulin is considered expired 28 days after opening. Therefore, the insulin expired on 10/31/17 and should have been discarded. On 11/1/17 at 12:24 p.m. observation of the Beach unit medication cart revealed a Lantus insulin pen for Resident #10. There was no evidence of a date opened or when the first dose was given. On 11/1/17 at 12:26 p.m., in an interview with Licensed Practical Nurse Staff C, she confirmed there was no evidence of a date opened on the insulin pen or when the first dose was given. On 11/1/17, review of the facility policy for storage of insulin found no literature related to storage of insulin pens. On 11/1/17 at 1:02 p.m., in an interview, the facility Director of Nursing confirmed the above and stated, We will pull them immediately and start from scratch. On 11/2/17 at 2:31 p.m., the facility Consulting Pharmacist, she said when someone takes the insulin pen out of the refrigerator, they are to place it in a plastic bag supplied by the pharmacy and label the date they placed the insulin pen in the bag. From that point, the insulin would be considered expired after 28 days. The pharmacist confirmed the insulin vial for Resident #61 was expired and the insulin pen for Resident #10 was not dated/labeled when removed from the refrigerator. She offered, We will have an action plan and put it in the policy.

Based on staff interview and resident record review, the facility failed to ensure 1 (Resident #2) of 3 residents sent to the hospital for a significant change in their physical and mental status was coordinated with the attending physician. The findings included: Review of Resident #2's medical records revealed on 4/8/17 Resident #2 had a fall while transferring from a wheelchair to a recliner with assistance from a certified nursing assistant (CNA). The nurse wrote no injuries noted except Resident #2 is complaining of left flank pain. Resident #2 is very agitated, combative with staff related to her personal care, and very paranoid. The progress note indicated the family and physician were notified of the fall, the left flank pain, and the behavioral issues. A nursing progress note written on 4/9/17 at 2:30 p.m. noted Resident #2 had nausea with emesis and frequent diarrhea and a blood pressure of 88/48 with a pulse rate of 50. Resident #2 was complaining of increased pain and was medicated with a pain medication. The nurse also wrote Resident #2 had increased behaviors and an increase in confusion. The nurse wrote she contacted the daughter and explained to her the physician wanted the facility to send Resident #2 to the hospital for evaluation and treatment. The nurse then wrote Resident #2 was sent to the hospital via ambulance at 1:00 p.m. A physician telephone order to send Resident #2 to the hospital related to a change in mental status, nausea, vomiting, and diarrhea was dated 4/9/17 at 12:00 p.m. Resident #2 was sent to the hospital at 1:00 p.m., which is 1 hour after receiving a physician order [REDACTED]. Review of the facility's policy and procedure for Change in a Resident's Condition or Status, version 2.1 (H5MAPL0118) indicated the facility shall promptly notify attending physician or on-call physician of changes in resident's condition. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required. In an interview on 7/3/17 at 11:48 a.m. with Staff A, she said she was the nurse who wrote the 4/8/17 and 4/9/17 nursing progress notes in Resident #'2's medical record. She said the facility's policy states if they do not see any injuries they do not have to call the physician; they can fax the physician the information about the incident or place the report about the incident in their in-box. She said she had examined Resident #2 after her fall on 4/8/17; and even thought the resident complained of left flank pain and was showing a change in mental status, they did not call the physician but sent his office a fax of the fall and the complaint of left flank pain. She further said she had noted on 4/9/17 Resident #2 was having nausea, vomiting, diarrhea, a change in mental status, and a blood pressure of 88/48, which was a significant change in her physical and mental status. They called Resident #2's physician, who ordered the facility to send Resident #2 to the hospital for an evaluation and treatment. She said she called the daughter who told them to wait for an hour before sending Resident #2 to the hospital. She said they waited an hour before they sent Resident #2 to the hospital as ordered by the physician. She said they did not call the attending physician to inform him they were not sending Resident #2 to the hospital as ordered. She said there was no documentation they completed a comprehensive assessment and/or monitored Resident #2's physical and mental status during the hour they waited to send her to the hospital as ordered by the physician. She confirmed they did not coordinate with the physician regarding the delay in transferring Resident #2 to the hospital as ordered. In an interview on 7/3/17 at 1:00 p.m., the Director of Nursing (DON) said Staff A called her on 4/9/17 about Resident #2's significant change in her physical and mental status. She said she told Staff A it was okay to keep Resident #2 at the facility for the hour, even though the physician had given orders to send Resident #2 to the hospital due to her significant change in physical and mental status. She reviewed Resident #2's medical records and confirmed they waited more than an hour before sending Resident #2 to the hospital as ordered by the physician. She further said there was no documentation the nursing staff completed a comprehensive assessment and/or monitored Resident #2 during the hour delay of sending her to the hospital as ordered by the physician. In an interview on 7/3/17 at 3:10 p.m., Resident #2's attending physician said the on-call physician gave orders to the facility to send Resident #2 to the hospital due to the significant change in her physical and mental status. He said the facility should not have delayed in sending Resident #2 to the hospital. He also said the facility did not communicate or coordinate with the on-call physician as required related to the delay in transferring Resident #2 to the hospital as ordered.

Based on observation, interview, and record review the facility failed to ensure essential kitchen equipment was maintained in a safe, clean, and sanitary manner. The exhaust hood and major food preparation equipment was observed to have an excessive accumulation of grease, dirt, and food debris. This deficient practice had the potential of causing harmful microorganism to grow and spread, and may cause food borne illness to resident consuming an oral diet. The finding included: On 9/12/16 at 9:30 a.m., during the initial tour of the main kitchen, the following was observed: 1. The interior and exterior of the exhaust hood located above the food preparation equipment had a thick film of grease on the metal surface. The interior metal filters were coated with a brown greasy appearing substance. The bottom interior rim of the hood had grease oozing out of the filters. The grease cascaded over the interior rim of the hood, which was located over the range top and grill where food was being prepare. 2. The grill top exterior was encrusted with baked-on grease and food debris. The entire grill had a greasy film surrounding the whole unit. 3. The exterior of the deep fryer had grease flowing down the front and side of the unit and a significant accumulation of baked-on food debris. 4. The exterior of metal tilt skillet had an accumulation of greasy film. 5. The metal flash guard located between the oven range and fryer was covered with a black substance. On 9/14/16 at 10:00 a.m., during a follow-up observation in the kitchen, the equipment was in the same condition as on the initial visit to the kitchen. Except for the exhaust hood, which had been cleaned following a visit from the Fire Life Surveyor. On 9/15/16 at 10:30 a.m., the Certified Dietary Manager (CDM) said she was aware of the concerns with the exhaust hood. The CDM provided the cleaning schedule. Review of the cleaning schedule/analysis failed to provide any instructions on cleaning the exhaust hood. The cleaning calendar did document the exhaust hood to be cleaned every Monday. Review of the contracted company records servicing and cleaning the facility's exhausts for the kitchen documented they had serviced the equipment on 10/28/15 and 5/25/16. **Photos on file**

Based on observation, interview, and record review the facility failed to ensure the main kitchen exhaust hood was maintained in a safe operating condition. Observed the interior metal filter coated with an accumulation of a greasy film and grease oozing out of the filter. The grease was cascading down the interior rim of the exhaust hood. This had a potential of causing a grease fire in the kitchen. The findings included: On 9/12/16 at 9:30 a.m., during the initial tour of the main kitchen, the following was observed: The interior and exterior of the exhaust hood located above the food preparation equipment had a thick film of grease on the metal surface. The interior metal filters were coated with a brown greasy appearing substance. On the bottom interior rim of the hood, grease was oozing out of the filters and cascading over the interior rim of the hood, which was located over the range top and grill were food was being prepared. On 9/15/16 at 10:30 a.m., the Certified Dietary Manager (CDM) said she was aware of the concerns with the exhaust hood. The CDM provided the cleaning schedule and invoices/reports of the contracted service for the exhaust hood. Review of the cleaning schedule/analysis failed to provide any instructions on cleaning the exhaust hood. The cleaning calendar did document the exhaust hood to be cleaned every Monday. Review of the contracted company records servicing and cleaning the facility's exhausts for the kitchen documented they had serviced the equipment on 10/28/15 and on 5/25/16. **Photos on file**

Based on interview and record review the facility failed to ensure 2 (Residents #11 and #16) of 2 residents reviewed for grievances had their grievance addressed and resolved in a timely manner. The findings included: 1. On 9/12/16 at 12:50 p.m., Resident #11 said when she was admitted (on 6/4/15) her favorite necklace went missing. She told the staff about the missing necklace and they said they would look for the necklace. As of this time no one had gotten back to her about the missing necklace and what they were doing to find the necklace. On 9/13/16 at 2:00 p.m., Resident #11's step daughter said she had spoken to someone in the admission department and several other staff members about Resident #11's missing necklace several months ago. She told them while the necklace was not expensive it meant a lot to Resident #11 and she would like it back. As of this time no one from the facility had spoken to them about the missing necklace and what they were doing to find the necklace. 2. On 9/13/16 at 2:55 p.m., Resident #16 said when she was admitted to the facility on [DATE] she had all of her clothes labeled with her name on them. Since her admission several of her clothing items had gone missing. When her clothes went missing she told the staff and they were able to find some of the missing items. She was still missing her favorite blue butterfly night gown, pants and a blouse. No one from the facility had told her what might have happened to them or what they planned on doing to replace the missing items. Review of the admission packet under the theft or lost section said resident's personal property the facility would make a reasonable effort to safeguard the resident's personal belongings. They would document any theft or loss of resident's personal belongings. Review of the grievance policy revealed all grievance/complaints received by the staff were required be forwarded to the Social Service Director (SSD) or administration. The SSD would fill out a grievance form for each grievance/complaint, complete an investigation and within 7 working days notify the resident and/or family of the outcome of the investigation. Review of the grievance log revealed a total of 7 grievances/complaints filed in 2015 and 2016. Resident #11 and Resident #16 grievances were not listed on the log. On 9/14/16 at 10:10 a.m., housekeeping team leader Staff D said she was aware of Resident #16's missing clothing items and confirmed they were not able to find all of her missing clothing items. She said she had reported the missing items to the SSD who was responsible to document the missing items and get back to the residents. On 9/14/16 at 10:42 a.m., the Activity Director said they did a customer service survey where they interviewed all the residents and/or family members. During the survey several residents and family members told them of missing personal items which were never found by the staff. He confirmed the facility's policy for grievance/complaints. On 9/14/16 at 12:10 p.m., the SSD confirmed the facility's policy for grievances/complaints and said several weeks ago the facility conducted a customer service survey where they learned several residents were missing personal items. She said none of the grievances voiced by the residents of missing clothing items were written on the grievance form as required and there was no documentation the grievances were investigated. The SSD said she was aware of Resident #11's missing necklace but did not write a grievance form as required by their policy. She said she had no documentation the facility had conducted an investigation and/or talked with Resident #11 about the missing necklace as required. The SSD said she was aware of Resident #16's missing clothing items but did not write a grievance form. She also said she did not fill out a grievance form and had no documentation an investigation was conducted to find Resident #16's missing clothing. On 9/15/16 at 11:25 a.m., the Administrator said the facility conducted a customer service survey several weeks ago. She confirmed the SSD did not follow their policy for filing a grievance/complaint for Resident #11 and Resident #16's missing personal items.

Based on observation, interview and record review the facility failed to ensure 2 (Residents #45 and #16) of 4 residents reviewed had an ongoing activity program which was individualized to them, met their interest and enhanced their mental, and psychological well-being. The findings included: 1. On 9/13/16 from 12:30 p.m. to 1:22 p.m. Resident #45 was observed in the hallway next to her room door not involved in an activity or staff interaction. At 1:22 p.m. staff was observed putting Resident #45 to bed and did not turn on the television and/or radio. Resident #45 was observed in her bed at 2:48 p.m. awake without the television and/or radio on for entertainment. No staff member invited Resident #45 to the cookie social in the main dining room which started at 2:45 p.m. On 9/13/16 at 3:15 p.m., Activity Assistant Staff A said only 11 residents attended the cookie social activity today. She said if she saw a resident in in their bed, she didn't bother them and would not invite them to the activity. She confirmed Resident #45 did not attend the cookie social activity. On 9/14/16 at 9:06 a.m., review of the activity calendar noted Hymns and Devotion was scheduled at 10:00 a.m. On 9/14/16 at 9:59 a.m., Resident #45 was observed in her wheelchair in the hallway next to her room door. On 9/14/16 at 10:30 a.m., Resident #45 was observed in her room in bed awake without the television or radio on for entertainment. Resident #45 did not attend the Hymns and Devotion activity at 10:00 a.m. On 9/14/16 at 10:57 a.m., the Activity Director said they tracked each activity and marked down which resident attended each activity. Review of Resident #45's admission activity evaluation completed on 12/17/15 by the Activity Director, said Resident #45 had multiple current interests which included spiritual/religious activities, cards, games, crafts, parties/social events, music and groups/organizations events. He said he wrote activity progress notes dated 6/20/16 and 8/25/16 which said Resident #45 enjoyed hymns and devotions, musical programs and intergenerational group activities. After the activity director viewed the activity attendance sheets for September and August 2016 he said Resident #45 did not attend any of the activity programs in September and only 6 activity programs in the month of August. He said he didn't know why Resident #45 only attended 6 activities in 2 months. He confirmed there was no documentation in the record noting the activity department had identified and addressed Resident #45 not attending the schedule activity programs which met her interest and enhanced her mental and psychological well-being. 2. On 9/13/16 at 2:50 p.m., Resident #16 said she was a social person and liked to attend activities like bingo. She said she didn't remember the last time she had attended any of the activities in the facility and/or the last time any of the staff members have invited her to attend any of the activity programs. On 9/13/16 at 3:15 p.m., Activity Assistant Staff A confirmed Resident #16 did not attend the cookie social activity and did not remember inviting her to attend the activity. Review of Resident #16's admission activity evaluation dated 7/12/16 completed by the Activity Director, said Resident #16 had multiple current interests which included games, crafts, parties/social events, spiritual/religious activates, music and groups/organizations events. He said since Resident #16's admission to the facility on [DATE] he had not written any activity progress notes. After the Activity Director reviewed the activity attendance sheets for August and September 2016, he said Resident #16 only attended 3 activity programs in the month of August. Resident #16 did not attend any of the activity programs in September. He said he didn't know why Resident #16 only attended 3 activity programs in 2 months. He confirmed there was no documentation in the record noting the activity department had identified and addressed Resident #16 not attending the scheduled activity programs which met her interest and enhanced her mental and psychological well-being.

Based on observation, interview and record review, the facility failed to follow the interventions for 1 (Resident #41) of 7 care plans reviewed. The failure to follow the listed interventions had the potential to lead to skin breakdown and leave the resident sitting in urine soaked briefs for an unnecessary extended period of time. The findings included: On 9/13/2016 at 9:00 a.m., Resident #41 was observed sitting in her wheelchair outside of the family room door. At 10:50 a.m., Resident #41 remained outside the family room door. At 11:25 a.m., Resident #41 continued sitting outside the family room door. On 9/13/16 at 12:45 p.m., Certified Nursing Assistant (CNA) Staff G was observed performing incontinence care with Resident #41. Staff G said the resident was frequently incontinent. Staff G said at 10:00 a.m. she performed peri care and changed Resident #41, then brought her to the family room to watch television. On 9/14/16 at 9:30 a.m., Resident #41 was observed sitting in her wheelchair in the family room. At 10:00 a.m., the Activity Director took Resident #41 to the music and hymn activity in the main dining room. At 11:10 a.m., Resident #41 was returned to the hallway outside of the family room. At 11:45 a.m., Resident #41 was observed in the main dining room for lunch. At 12:45 p.m., Resident #41 was returned to the hallway outside the family room where she remained until 1:30 p.m. On 9/14/16 at 1:30 p.m., CNA Staff C approached Resident #41 and asked her if she wanted to go to bed because she looked tired. Staff C pushed her down the hallway, and left her sitting in the hallway outside of Resident #41's room. Staff C did not return to Resident #41 until 2:05 p.m. At 2:15 p.m., during an observation of incontinence care, Staff C confirmed Resident #41's buttocks were slightly pink and her brief was heavily saturated with urine. Staff C said she had gotten Resident #41 up at 11:15 a.m. today. She said she had not checked on her since then. Staff C said she checked Resident #41 every 2 hours to see if she was wet. Review on 9/14/16 of Resident #41's care plan documented the resident required care for incontinence of bladder with a goal to be free from skin breakdown. The interventions listed included incontinence care needed to maintain dryness and cleanliness, apply skin barrier and apply incontinence pads and briefs.

Based on observation, interview and review of the survey book, the facility failed to post the results of the last annual recertification survey including the facility's plan of correction for residents and visitors. The findings included: 1. On 9/12/16 at 9:26 a.m., during a tour of the facility, a notice for the location of survey results was observed behind a glass cabinet across from the nurses station. The notice said the survey results could be found in the library and the nursing station. The book labeled Survey Results was observed on the desk of the nurses station and did not contain the results of the last annual survey conducted on 8/27/15. There was no plan of correction posted from the deficiencies received at this survey. There were no survey results found in the library area. On 9/14/16 at 9:32 a.m., the Director of Nursing confirmed there were no results from the last annual survey that included the facility's plan of correction in the book at the nursing station and no survey results were located in the library.

Based on record review, observation, and interviews, the facility failed to post for residents and visitors the number of nursing staff on duty at the start of the shift and actual hours worked. The findings included: On 9/12/16 at 8:50 a.m., during a tour of the facility, the facility's posted nursing staff data was observed. The posting did not include the actual hours worked. On 9/13/16 at 8:54 a.m., the posted nursing data was dated 9/12/16 and had not been updated. On 9/14/16 at 8:52 a.m., the posted nursing data was dated for 9/13/16 and had not been updated. The Director of Nursing (DON) said the staff member responsible (Staff B) did not arrive until 8:00 a.m. The DON confirmed the day nursing shift started at 7:00 a.m. The postings for the last 18 months were reviewed. There were no actual hours worked noted on any of the postings reviewed. On 9/14/16 at 9:00 a.m., the DON confirmed the staffing data did not contain the actual hours worked and were not posted at the start of each shift.

Based on observation and staff interviews, the facility failed to secure medications during medication pass and failed to store medications in a sanitary manner. The findings included: 1. On 8/25/15, there were 2 observations of the 100 hall medication not secured on the medication cart. At 10:21 a.m., the medication cart was observed outside of room [ROOM NUMBER], and the Licensed Practical Nurse (LPN) was administering medication. The LPN went into the resident's room, closed the door, and the medication cart was left unlocked. At 10:29 a.m., the nurse returned to the medication cart and prepared additional medication and revisited the same resident's room without locking the cart. The nurse's back was to the door and the medication cart remained unlocked. In each incident the nurse did not have a clear view of the unsecured medication cart. 2. On 8/26/15 at 1:15 p.m., a review of the medication chart in Cherry lane was conducted. The medication cart was observed to be dirty, a white powdery and sticky substance was observed on several drawers where medication was stored. Several bottles of medications were dirty and sticky. The electronic pill crusher had built-up residue throughout the top barrel and a large chunk of a pill that looked to be approximately one quarter of a tablet was found. At this time Staff A confirmed these observations and stated all nurses who worked this medication cart are responsible to ensure this cart stayed clean. She said she would clean these items.