Every finding on record at Webster Healthcare Center

Based on record review and staff interview the facility failed to revise individualized care plans related to activities. This failed practice was found true for (1) one of (1) residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier: #8. Facility census: 57. Findings Include: a) Resident #8 A record review on 02/25/26 at 11:15 AM, revealed an activity care plan for Resident #8 that reads as follows:Focus:(Resident #8 name) does not attend scheduled group activities. He prefers to remain in room for activities and 1-1 visits. He is dependent on staff for cognitive stimulation and activities. Revision date of 01/21/26Goals: (Resident #8 name) will participate in activities of choice through review date. (Resident #8 name) will show engagement in activities of interest through review date. (Resident #8 name) will accept/participate in 1:1 activities.Interventions: Encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations and religious activities. Initiated 09/11/24 Ensure all snacks/beverages comply with all diet/fluid restrictions Initiated 09/11/24. Interview and determine (Resident #8 name) activity preference Initiated 09/11/24 Introduce to other residents with similar interest. Initiated 09/11/24 Invite (Resident #8 name) to scheduled activities. Initiated 09/11/24 Provide 1:1 in room visits if unable to attend out of room events. Initiated 12/26/24 Provide a schedule of activities available. Initiated 11/05/24. Provide activity material of interest, i.e. library books , word puzzles, magazines. Initiated 09/11/24No care plan interventions have been revised or added since 12/26/24.Resident #8's care plan does not align with is most current Activity Preference Interview dated 08/01/25 which indicates he enjoys church related activities, country music, watching the news, and fishing.Resident #8's section F, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/25 indicates under F0500, that it is not important for him to do things with groups of people.During an interview on 02/26/2026 at 10;08 AM, The Activity Director confirmed that Resident #8's activity care plan interventions had not been revised since 12/26/24.

Based on observation, record review, and staff interview the facility failed to provide an ongoing resident-centered activities program to meet the needs, interest and preferences of each resident. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier: #8. Facility census: 57. Findings include: a) Resident #8 Observations on 02/24/26 at 1:15 PM, and 4:00 PM, revealed Resident #8 lying in his bed, looking toward the ceiling. No stimulation on in his room. An observation on 02/25/26 at 11:00 AM, revealed Resident #8 was lying in his bed. No stimulation on in his room. A record review on 02/25/26 at 11:15 AM, showed a Brief Interview for Mental Status (BIMS) score for Resident #8 of a (5) five. Further record review revealed an Activity care plan for Resident #8 that reads as follows:Focus:(Resident #8 name) does not attend scheduled group activities. He prefers to remain in room for activities and 1-1 visits. He is dependent on staff for cognitive stimulation and activities. Revision date of 01/21/26 Goals: (Resident #8 name) will participate in activities of choice through review date. (Resident #8 name) will show engagement in activities of interest through review date. (Resident #8 name) will accept/participate in 1:1 activities. Interventions: Encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations and religious activities. Initiated 09/11/24 Ensure all snacks/beverages comply with all diet/fluid restrictions Initiated 09/11/24. Interview and determine (Resident #8 name) activity preference Initiated 09/11/24 Introduce to other residents with similar interest. Initiated 09/11/24 Invite (Resident #8 name) to scheduled activities. Initiated 09/11/24 Provide 1:1 in room visits if unable to attend out of room events. Initiated 12/26/24 Provide a schedule of activities available. Initiated 11/05/24. Provide activity material of interest, i.e. library books , word puzzles, magazines. Initiated 09/11/24 Resident #8's care plan does not align with his most current Activity Preference Interview dated 08/01/25 which indicated he enjoyed church related activities, country music, watching the news, and fishing. Resident #8's section F, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/25 indicates under F0500, that it is not important for him to do things with groups of people. Further review of Resident #8's activity participation from 12/2025 to present, shows that Resident #8 is not participating in group activities. His individual activities are marked as nature watching or relaxation daily, which do not align with his interest noted on his Activity Preference Interview. During an interview on 02/25/26 at 1:22 PM, The State Agency (SA) asked The Activity Director (AD) for the 1:1 list for the facility. The AD replied, Everyone in our building gets one to one visits. We visit with all of them everyday. SA asked if she could tell me what those one on one visits consist of for Resident #8. The AD replied, We go in and talk to him and see if he needs anything. A specific list of meaningful 1:1 visits directed toward Resident #8's interest could not be provided.

Based on resident interview, staff interview and record review the facility failed to provide timely vision appointments for a resident with a known vision impairment. This failed practice was found true for (1) one of (1) one residents reviewed for vision/hearing services during the Long-Term Care Survey Process. Resident identifier #13. Facility census: 57. Findings Include:a) Resident #13During the initial interview on 02/24/26 at 2:10 PM, Resident #13 stated, I have a cataract on my left eye. When I close my right eye it is like my left eye is covered in bacon grease all over it. I have been here for (4) four years and have seen an eye doctor for about (2) two year. I have told them that I need to go, but I don't have an appointment or anything.A record review on 02/25/26 at 9:30 AM, revealed that Resident #13's last vision consultation was on 05/06/24. The vision consult confirmed the Cataract of the left eye and reads to return in 12 to 15 months for follow-up.No other vision consultations could be providedDuring an interview on 02/25/26 at 11:31 AM, The Director of Nursing (DON) stated, Our vision service came in June of last year. We missed her, we did not have her on the roster. I now have her scheduled to see them in March.

Based on record review and staff interview the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for a resident with Dementia This failed practice was found true for (1) one of (5) five residents reviewed for Dementia care during the Long-Term Care Survey Process. Resident identifier #8. Facility Census 57. Findings include: a) Resident #8 A record review on 02/25/26 at 2:30 PM, revealed a diagnosis of Dementia for Resident #8 dated 12/19/24. Further record review of Resident #8's care plan, revealed that no care plan was created for the diagnosis of Dementia. During an interview on 02/26/2026 at 10:02 AM, The Unit Manager Registered Nurse (UMRN) who develops nursing care plans stated, I reviewed his care plan. I would think it would trigger, but no I do not see it anywhere. UMRN confirmed that the Dementia care plan was not developed with measurable person centered goals for Resident #8.

Based on observation, record review and staff interview the facility failed to provide an activity program to meet the needs and interest of the residents. This failed practice was found true for (2) two of (5) five residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers: #39 and #1. Facility census: 59. Findings include: a) Resident #39 During the initial tour of the facility, on 09/03/24 at 1:00 PM, it was found that Resident #39 had her knees in her recliner with her head between her knees. No stimulation was noted in the room. It was also found that the door was shut due to Resident #39 having Covid-19 and being on isolation precautions. A record review, on 09/04/24 at 10:30 AM, of Resident #39's Activity Participation Records (APR) for the months of 06/24, 07/24, 08/24, and 09/24 revealed that Resident #39 had no group participation recorded. Further record review revealed an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/24, under section F0500, question E is marked that it is important for Resident # 39 to participate in group activities. The record review also revealed an Activity Preference Interview dated 07/08/24, Section C, number 6 reads that Resident #39 likes for the television to be on and that is a current interest. No Television noted in the room throughout the survey process. A review of Resident #39's Activity Care plan reads as follows: Focus: (Resident #39 named) is dependent on staff for activities, cognitive stimulation, social interaction due to Cognitive deficits Goal: Patient will actively participate during in-room visits (3) three times a week through next review Interventions: Assist/escort patient to activity functions. Encourage patient to attend group activities. Invite patient to scheduled activities and provide reminders of activities as needed. Patient enjoys listening to music. Preferred type of music is Country. Provide 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. Provide an activities calendar. Notify patient of any changes to the calendar of activities. During an interview on 09/04/24 at 2:30, The Activity Director (AD) stated, We typically drop off the daily schedule to residents and put it in as a one-to-one visit. We haven't been in Resident #39's room since she had covid. I am not sure If I have ever seen her in group activities. b) Resident #1 During the initial observation of Resident #1's room on 09/03/24 at 1:30 PM revealed Resident #1 lying in bed hollering out, Help me several times. No stimulation noted in Resident #1's room. An observation on 09/04/24 at 10:00 AM revealed Resident #1 in her room lying in bed staring at the ceiling. No stimulation noted in Resident #1's room. A record review on 09/04/24 at 1:00 PM of Resident #1's APR'S showed no group activity participation for the months of 06/2024, 07/2024, 08/2024 and 09/2024 to the present day. Further record review revealed an Annual Activity assessment dated [DATE], that indicates Resident #1 has a current interest in listening to music and watching TV. Record review also revealed an MDS with an ARD of 02/03/24, section F0800 M is marked that Resident #1 enjoys listening to music. Letter P is marked that the resident enjoys doing things with groups of people. During an interview on 09/04/24 at 2:30, The Activity Director (AD) stated, We typically drop off the daily schedule to residents and put it in as a one-to-one visit. She further confirmed that Resident #1 does not get up and needs more stimulation.

Based on observation, record review, and staff interview the facility failed to implement a care plan related to contracture devices. This failed practice was found true for (1) one of (4) four residents reviewed for Range of Motion (ROM) during the Long Term Care Survey Process. Resident identifier: #1. Facility Census: 59. Findings include: a) Resident #1 During the initial observservation on 09/03/24 at 1:30PM showed that Resident #1 had multiple contractures. A record review on 09/03/24 at 2:00 PM of Resident #1 diagnoses reads as follows: Contracture, right knee Contracture, left knee Contracture, left hip Contracture , left ankle Contracture, right ankle Further Record review revealed a Care plan that reads as follows: Focus Area: (Resident #1) has limited physical mobility r/t: weakness and remote history of right kneeinjury that did not heal properly with severe arthritis that resulted in contracture. She also has a left knee contracture, left hip contracture, bilateral ankle contractures and contractures of toes bilaterally. She usually keeps her hands tightly clenched. She is at risk for additional contractures. Goal: Resident will receive the needed assistance with mobility and ADLs through the review date. Intervention: Therapy carrots to bilateral hands at all times to prevent hand contractures. May remove for bathing, skin checks and skin care and then reapply. Notify the physician with any concerns. A review of Resident #1's orders read as follows: Carrot to Bilateral hands at all times every shift to prevent contractures Remove Q-shift for skin checks; Notify physician with any concerns. Tube-sleeves to bilateral arms at all times. (every shift) During an observation, on 09/03/24 at 2:15PM, revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an observation, on 09/04/24 at 9:15 AM, revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an interview, on 09/04/24 at 10:33 AM, the Director of Nursing confirmed that the carrot or the are tubes were not in place.

Based on observation, record review and staff interview the facility failed to follow physician's orders related to contracture devices. This failed practice was found true for (1) one of (4) four residents reviewed for Range of Motion (ROM) during the Long Term Care Survey Process. Resident identifier #1. Facility census 59. Finding Include: a) Resident #1 During the initial observservation on 09/03/24 at 1:30PM showed that Resident #1 had multiple contractures. A record review on 09/03/24 at 2:00 PM of Resident #1 diagnosis reads as follows: Contracture, right knee Contracture, left knee Contracture, left hip Contracture , left ankle Contracture, right ankle Further record review of Resident #1's orders read as follows: Carrot to Bilateral hands at all times every shift to prevent contractures Remove Q-shift for skin checks; Notify physician with any concerns. Tube-sleeves to bilateral arms at all times. every shift During an observation on 09/03/2024 at 2:15PM revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an observation on 09/04/24 at 9:15 AM, revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an interview on 09/04/24 at 10:33 AM, The Director of Nursing confirmed that the carrot or the are tubes were not in place as ordered.

Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan in the area of contractures. This was true for one (1) of two (2) residents reviewed for the care area of position and mobility. Resident identifier: #15. Facility census: 56. Findings included: a) Resident #15 Review of Resident #15's medical records showed the resident had diagnoses of left hand and left wrist contractures. Review of Resident #15's comprehensive care plan showed the following focus, [Resident's name] has impaired mobility r/t [related to]: weakness and poor balance. She has left hand stiffness and is at risk for contracture. The focus had been initiated on 02/20/2017 and last revised on 11/05/2019. During an interview on 12/13/22 at 10:49 AM, the Registered Nurse Assessment Coordinator (RNAC) confirmed Resident #15 had diagnoses of left hand and left wrist contractures. The RNAC also confirmed Resident #15's comprehensive care plan had not been updated when the resident developed contractures. No further information was provided through the completion of the survey.

Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The doors to four (4) rooms containing potentially hazardous materials were not locked. This deficient practice had the potential to affect any residents in the facility who wander and were able to access the rooms. Resident identifiers: #42, #4. Facility census: 56. Findings included: a) Accident Hazards On 12/12/22 at 11:21 AM, the soiled linen closet was noted to be unlocked and was accessed by the surveyor. There was a keypad on the door to use to unlock the door when it was locked. There was also a biohazard sign on the door. The soiled linen closet contained a refrigerator for blood and urine samples. Also, the room contained a sharps container containing used razor blades. The sharps container was on the counter and not affixed to the wall. This allowed the sharps container to potentially be removed from the room by any residents who might enter the room. The Director of Nursing (DON) confirmed the door was unlocked but should have been locked. The DON stated the door should have locked automatically when closed and demonstrated that the door locked when closed with the proper amount of force. On 12/12/22 at 11:30 AM, the janitor closet in the A hallway was noted to be unlocked and was accessed by the surveyor. There was a keypad on the door to use to unlock the door when it was locked. The room contained the cleaning compound Clorox Healthcare Fuzion Cleaner Disinfectant. The DON confirmed the door was unlocked but should have been locked. The DON stated the door should have locked automatically when closed, and demonstrated that the door locked when closed with the proper amount of force. On 12/12/22 at 11:37 AM, the janitor closet in the dining room hallway was noted to be unlocked and was accessed by the surveyor. The activity department and a resident lounge were also located in this hallway. There was a keypad on the door to use to unlock the door when it was locked. The room contained the cleaning compounds Clorox Healthcare Fuzion Cleaner Disinfectant, Virex Plus One-Step Disinfectant Cleaner and Deodorant, Clorox Commercial Solutions Green Works Glass and Surface Cleaner, Comet Cleaner with Bleach, and Good Sense RTU Odor Counteractant. Activities Assistant #52 verified the janitor closet was unlocked. On 12/12/22 at 11:40 AM, the soiled laundry room was noted to be unlocked and was accessed by the surveyor. There was a keypad on the door to use to unlock the door when it was locked. There was also a biohazard sign on the door and a sign stating authorized personnel only. The room contained the cleaning compounds Clorox Healthcare Fuzion Cleaner Disinfectant, Shine-up Lemon Furniture Polish, and Comet Cleaner with Bleach. Environmental Assistant #81 verified the soiled laundry room was unlocked. On 12/12/22 at 11:48 AM, the DON confirmed the doors to the janitor closet in the dining room hallway and the soiled laundry room should have been locked. On 12/13/22 at 11:30 AM, the Clinical Specialist Coordinator stated Resident #42 and Resident #4 were the only residents in the facility who wandered. The Material Safety Data Sheet (MSDS) for Good Sense RTU Odor Counteractant stated to rinse with plenty of water for eye and skin contact. The MSDS for Comet Cleaner with Bleach stated the substance may cause eye irritation. For eye and skin contact, instructions were given to rinse with plenty of water and get medical attention if irritation develops and persists. For ingestion, instructions were given to drink one (1) or (2) glasses of water and get medical attention immediately if symptoms occur. The MSDS for Virex Plus One-Step Disinfectant Cleaner and Deodorant gave instructions to rinse eyes cautiously with water for at least 15 minutes for eye contact. For skin or hair contact, contaminated clothing was to be removed immediately and the skin was to be rinsed with water for at least 15 minutes. For ingestion, instructions were given to rinse the mouth and to drink a cupful of milk or water. The MSDS for Clorox Commercial Solutions Green Works Glass and Surface Cleaner stated the substance may cause slight eye irritation. For eye contact, instructions were given to rinse the eyes for 15-20 minutes and a poison control center or doctor was to be called for further treatment advice. For skin contact, instructions were given to rinse the skin with plenty of water and call the doctor if irritation persists. For ingestion, instructions were given to drink a glassful of water and call a doctor or poison control center. The MSDS for Clorox Healthcare Fuzion Cleaner Disinfectant gave instructions to rinse thoroughly with plenty of water for eye contact and to get medical attention if symptoms occur. For skin contact, instructions were given to wash skin with soap and water. For ingestion, instructions were given to rinse mouth immediately and drink plenty of water. The MSDS for Shine-up Lemon Furniture Polish gave instructions to rinse with plenty of water for eye and skin contact.

Based on observation, record review, and staff interview, the facility failed to ensure residents were provided with assistive devices at meals as ordered. Resident #45 was not provided with a straw as ordered by the physician. This was true for one (1) of eight (8) residents reviewed for the care area of nutrition. Resident identifier: #45. Facility census: 56. Findings included: a) Resident #45 Review of Resident #45's physician's orders showed an order for a minced and moist texture consistent carbohydrates diet. The order stated the resident was to have a cup with a lid and straw. On 12/13/22 at 1:06 PM, Resident #45 was observed eating in the dining room. He had three (3) cups containing beverages. The cups had lids, but the resident did not have a straw. The resident's tray ticket indicated the resident was to have a two (2) handled cup but did not specify the resident was to have a straw. The Certified Dietary Manager confirmed Resident #45 did not have a straw as ordered by the physician. No further information was provided through the completion of the survey.

Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's orders [REDACTED]. This practice affected one (1) of three (3) Resident's reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #36, Facility Census: 59 Findings included: A review of the facility's policy titled Respiratory Care with the effective date 11/18/19 with revision date 02/17/20 revealed the following: Resident in need of respiratory care and services will receive such careand services in accordance with professional standards of practice, physician or non-practitioner orders, the resident's care plan, and the resident preferences. Provide medications and/or oxygen as ordered by the prescriber. a) Resident #36 An observation of resident # 36 on 03/11/20 at 9:10 AM, revealed the Resident was sitting up in a chair receiving oxygen at one and a half (1.5) liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the Resident's physician order [REDACTED]. A second observation of Resident #36, on 03/11/20 at 10:49 AM, revealed the Resident was receiving oxygen at one and a half (1.5) liters via nasal cannula from an oxygen concentrator. An interview with the Director of Nursing (DON) #45 on 03/11/20 at 10:53 PM, verified the Resident was receiving oxygen at one and a half (1.5) Liter Per Minute (LPM). The DON confirmed that Resident #36 was ordered oxygen at two (2) Liters via nasal cannula at bedtime only. The DON verified the oxygen level was wrong. The DON #45 changed Resident #36's oxygen to two (2) LPM on the concentrator.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Proper hand hygiene was not performed during pressure ulcer care for one (1) of one (1) residents with pressure ulcer care observed. Resident identifier: #33. Facility census: 59. Findings included: a) Resident #33 On 03/11/20 at 2:31 PM, observation of Resident #33's sacral pressure ulcer care by Licensed Practical Nurse (LPN) #67 was observed. Clinical Care Specialist (CCS) #44 was also present, assisting with positioning the resident. LPN #44 donned gloves and removed the dressing covering Resident #33's sacral pressure ulcer. She changed her gloves after removing the dressing but did not perform hand hygiene. LPN #44 then cleaned the pressure ulcer wound using gauze. She again changed her gloves but did not perform hand hygiene. LPN #44 then used her gloved hands to place collagen powder into the sacral pressure ulcer. She placed the new dressing on the wound. LPN #44 then removed her gloves and performed hand hygiene by washing her hands using the sink in the resident's room. Following the procedure, CCS #44 was informed LPN #67 did not perform appropriate hand hygiene during Resident #33's pressure ulcer dressing change. She stated she would perform education regarding indications for hand hygiene.

Based on medical record review and staff interview, the facility failed to notify the physician when a resident experienced a change in condition. A resident was newly assessed with [REDACTED]. The physician was not notified timely of the change in condition. This was evident for one (1) of fifteen (15) sampled residents. Resident identifier: #13. Facility census: 59. Findings include: a) Resident #13 Review of the medical record on 03/19/19 found this resident was assessed with [REDACTED]. Review of section S of the most recent minimum data sets (MDS's) found the following assessments of joint contractures: * The quarterly MDS with assessment reference date (ARD) 07/02/19 assessed this resident as having no contractures. * The quarterly MDS with ARD 10/01/19 assessed this resident as having no contractures. * The quarterly MDS with ARD 12/26/19 assessed this resident as having a contracture of the right hand, contracture of the right elbow, and contracture of the right ankle. Review of the medical record found it was silent for notifying the physician of the development of the these contractures, or for requesting new or different treatment modalities. An interview was conducted with occupational therapy assistant #70 (OTA #70) on 03/19/19 at 12:40 PM. After first reviewing therapy notes, she said this resident had no occupational therapy (OT) or physical therapy (PT) in (YEAR). She said PT evaluated her on 03/04/19 because she was wanting to use her feet to propel. She said PT is now working with her on that issue, as well as working with her on bed mobility. Upon inquiry as to whether the therapy department received a referral following the 12/26/18 MDS assessment related to her contractures, she replied in the negative. She said the physician ordered a therapy evaluation on 03/04/19. She added that OT would most likely begin working with her when PT finishes services. Review of the medical record found physician's orders [REDACTED]. * PT evaluation * PT Orthotic Fitting/Training to promote indicated immobilization/improve function and prevent further functional limitation * PT Wheelchair Management for assessment, fitting, and/or training for utilization of a wheelchair for mobility * PT Therapeutic Activities for bed mobility/transfer training/lifting, carrying, reaching, pushing, grasping, and overhead activities * PT Therapeutic Exercise to increase lower extremity strength/range of motion/trunk stability to improve activities of daily living performance and functional mobility. An interview was conducted with the MDS registered nurse #37 (RN #37) on 03/19/19 at 2:00 PM. She said she completed the range of motion assessment for the 12/26/19 MDS, and determined this resident had contractures of the right elbow, right ankle, and right hand at that time. She said previously those joints were stiff and she did not assess them as contractures. Upon inquiry, she said the (MONTH) and (MONTH) MDS's were accurate in that she had no contractures at those times. A second interview was conducted with OTA #70 at 2:25 PM on 03/19/19. She confirmed the dates of past therapy services as follows: * 12/15/16 through 02/12/17 OT worked with this resident on range of motion to the right upper extremity, and PT worked with her low extremities. * 05/25/17 through 07/23/17 OT provided bilateral upper extremity range of motion, splinting, and continuing passive range of motion to the right hand, and PT worked with her lower extremities. * 07/01/17 through 08/09/17 OT did splinting and right arm passive range of motion, and PT worked with her lower extremities. OTA #70 said OT has not had this resident in services since (YEAR). She said to the best of her knowledge nursing did not make a therapy referral following the 12/26/19 MDS assessment. She said this resident had a therapy evaluation on 03/04/19 and is currently receiving PT services. On 03/19/19 an interview was conducted with the director of nursing (DON) and RN #37 at 3:00 PM. RN #37 said she was unsure at the time of the 12/26/18 MDS as to whether the left hand had a contracture. She said she asked an OTA to accompany her to assess the left hand, and they determined that there was no contracture of the left hand at that time. Upon inquiry, RN #37 said she did not notify the physician of the contractures of the right hand, right elbow, and right ankle after the 12/26/18 MDS assessment, and that a referral was not made to the therapy department. The DON did not dispute that the physician was not notified of the newly developed contractures of the right hand, right elbow, and right ankle. During an interview with the administrator on 03/20/19 at 10 AM, the facts were presented of the newly assessed contractures right hand, right elbow, right ankle per the 12/26/18 MDS, and that the MDS nurse and DON could provide no evidence that the physician was notified of the change in condition at that time. No further evidence was provided prior to exit.

Based on observation, review of the United States Food and Drug Administration Food Code, review of refrigeration temperature charts, and staff interview, the facility failed to store foods under conditions to prevent the outbreak of foodborne illnesses. The facility did not act on refrigeration unit temperatures each time they were measured and documented at unsafe temperatures to ensure food was stored in a safe manner. This had the potential to affect all residents who were served food from the dietary department. Facility Census: 53. Findings include: a) During the initial tour, on 09/29/14 at 1:30 p.m., observation with Employee #81, the Dietary Services Supervisor (DSS), revealed the reach-in cooler contained an extremely large amount of food. The DSS said the walk-in cooler was turned off because they were waiting on a repairman. b) Upon inquiry regarding how the temperatures for the refrigerators and the freezer were monitored, the DSS said staff made entries two (2) times a day on the refrigeration temperature chart. Employee #81 explained the heading "opening" on the refrigeration temperature chart referred to temperatures taken between 5:00 a.m. and 6:00 a.m. She said the heading "closing" referred to temperatures taken between 7:00 p.m. and 8:00 p.m. c) Review of the facility's refrigeration and freezer temperature monitoring records, on 10/02/14 at 3:35 p.m., revealed the refrigerator temperatures were noted above 40 degrees F, and the freezer temperature was noted above 0 degrees F on numerous occasions in July, August, and September 2014: July 2014 1) The reach-in cooler "opening" temperature was noted above 40 degrees F four (4) times, and the "closing" temperature was noted 16 times above 40 degrees F. -- The "opening" temperature was 42 degrees F on 07/21/14, 07/22/14, and 07/24/14. The "opening" temperature was 44 degrees F on 07/15/14. -- The "closing" temperatures were 42 degrees F on 07/08/14, 07/09/14, 07/10/14, 07/20/14, 07/24/14, 07/27/14, and 07/28/14. They were 44 degrees F on 07/03/14 and 07/11/14 and 46 degrees F on 07/02/14, 07/23/14, 07/25/14, 07/26/14, and 07/29/14. On 07/21/14 and 07/22/14 "closing" temperature was 48 degrees F. 2) The walk-in refrigerator "closing" temperature was noted four (4) times above 40 degrees F. -- The "closing" temperature was 42 degrees F on 07/15/14 and 07/17/14. It was 49 degrees F on 07/14/14 and 07/16/14 at "closing". 3) The walk-in freezer "opening" temperature was noted nine (9) times above 0 degrees F, and the "closing" temperature was noted 28 times above 0 degrees F. -- The "opening" temperature was two (2) degrees F on 07/04/14, 07/14/14, 07/15/14, 07/17/14, 07/18/14, and 07/23/14. It was four (4) degrees F was on 07/16/14, 07/22/14, and 07/24/14 at "opening". -- At "closing", the temperature was four (4) degrees F on 07/05/14, 07/07/14, 07/08/14, and 07/12/14. It was eight (8) degrees F on 07/01/14 and 07/13/14. It was 10 degrees F on 07/10/14, 07/11/14, 07/18/14, 07/19/14, 07/20/14, 07/24/14, 07/28/14, and 07/30/14. On 07/09/14, 07/14/14, 07/15/14, 07/16/14, and 07/17/14, the temperature was 12 degrees F. It was 14 degrees F on 07/27/14 and 07/31/14. It was 15 degrees F on 07/03/14 and 16 degrees F on 07/02/14. On 07/21/14 and 07/26/14 the freezer temperature was 20 degrees F. It was 22 degrees F on 07/25/14 and 07/29/14. On 07/22/14 the temperature at closing was 30 degrees F. August 2014 1) The reach-in cooler "opening" temperature was noted two (2) times above 40 degrees F, and the "closing" temperature was noted 18 times above 40 degrees F. -- On 08/29/14 and 08/30/14 at opening the temperature was forty four (44) degrees F. -- The "closing" temperature was 41 degrees F on 08/16/14 and 08/17/14. It was 42 degrees F on 08/04/14, 08/09/14, 08/13/14, 08/14/14, 08/15/14, 08/20/14, 08/25/14, and 08/26/14. On 08/07/14, 08/19/14, 08/27/14, and 08/28/14 it was 44 degrees F. On 08/01/14, 08/10/14, 08/21/14, and 08/22/14 it was 46 degrees F. 2) The walk-in refrigerator "opening" temperature was noted two (2) times above 40 degrees F, and the "closing" temperature was noted one (1) time above 40 degrees F. -- At "opening" on 08/29/14 and 08/30/14 the temperature was 42 degrees F. -- The "closing" temperature on 08/27/14 was 43 degrees F. 3) The walk-in freezer "opening" temperature was noted twelve (12) times above 0 degrees F, and the "closing" temperature was noted 31 times above 0 degrees F. -- The "opening" temperature on 08/13/14, 08/14/14, 08/24/14, 08/25/14, 08/26/14, 08/29/14, and on 08/30/14 it was two (2) degrees F. It was four (4) degrees F on 08/09/14, 08/19/14, and 08/20/14. On 08/11/14, it was 16 degrees F. -- At "closing", the walk-in freezer was above 0 degrees F every day in August. On 08/24/14 it was six (6) degrees F. On 08/13/14, 08/14/14, and 08/19/14 the temperature was eight (8) degrees F. It was nine (9) degrees F on 08/16/14 and 08/17/14. On 08/02/14, 08/03/14, 08/05/14, 08/08/14, 08/09/14, 08/10/14, 08/11/14, 08/12/14, 08/15/14, 08/18/14, 08/22/14, 08/23/14, 08/26/14, 08/27/14, 08/28/14, and 08/29/14, the temperature was ten (10) degrees F. On 08/25/14 it was 11 degrees F and was 12 degrees F on 08/06/14, 08/07/14, 08/03/14, and 08/31/14. It was 16 degrees F on 08/20/14 and 08/21/14 and 18 degrees F on 08/01/14. The freezer was 20 degrees F. on 08/01/14. September 2014 1) The reach-in cooler "opening" temperature was noted one (1) time above 40 degrees F, and the "closing" temperature was noted 17 times above 40 degrees F. -- On 09/12/14 the temperature was 42 degrees F at "opening". -- The "closing" temperature was 42 degrees F on 09/01/14, 09/03/14, 09/05/14, 09/07/14, 09/08/14, 09/13/14, 09/18/14, 09/19/14, and 09/24/14. On 09/27/14, it was 43 degrees F. The temperature was 44 degrees F on 09/02/14 and 09/06/14. On 09/09/14, 09/12/14, and 09/26/14 it was 46 degrees F and 48 degrees F on 09/21/14 and 09/25/14. 2) The walk-in refrigerator opening temperature was noted 12 times above 40 degrees F, and the "closing" temperature was noted 19 times above 40 degrees F. -- At "opening" on 09/01/14, 09/03/14, 09/07/14, 09/08/14, 09/10/14, 09/11/14, 09/12/14, 09/16/14, and 09/25/14 the temperature was 42 degrees F. It was 44 degrees F on 09/13/14, 09/14/14, and 09/15/14. -- The "closing" temperature was 41 degrees F on 09/21/14 and 42 degrees F on 09/04/14, 09/07/14, 09/10/14, 09/11/14, and 09/13/14. It was 43 degrees F on 09/01/14, 09/02/14, 09/03/14, 09/05/14, 09/06/14, 09/12/14, 09/14/14, and 09/25/14. On 09/09/14, 09/16/14, and 09/26/14 it was 44 degrees F. The temperature was 45 degrees F on 09/15/14 and 47 degrees F on 09/24/14. 3) The walk-in freezer "opening" temperature was noted 11 times above 0 degrees F, and the "closing" temperature was noted 23 times above 0 degrees F. -- At "opening" the walk-in freezer was two (2) degrees F on 09/01/14, 09/04/14, 09/05/14, 09/12/14, 09/16/14, 09/17/14, 09/26/14, and 09/27/14. It was four (4) degrees F on 09/13/14 and 09/28/14. On 09/29/14 it was 12 degrees F. -- The "closing" temperature was four (4) degrees F on 09/07/14 and 09/08/14. On 09/25/14 it was six (6) degrees F and eight (8) degrees F on 09/13/14 and 09/17/14. It was nine (9) degrees F on 09/19/14 and 09/24/14 and 10 degrees F on 09/12/14, 09/16/14, 09/20/14, 09/27/14, and 09/28/14. On 09/04/14, 09/05/14, 09/10/14, 09/11/14, and 09/26/14 the temperature was 12 degrees F. It was 16 degrees F on 09/01/14, 09/02/14, 09/03/14, 09/06/14, and 09/18/14 and 20 degrees F on 09/09/14. d) On 10/02/14 at 3:35 p.m. an interview was conducted with the DSS, Employee #23, Environmental Supervisor Employee #31, and the Executive Director. They were unable to provide evidence anyone reported, evaluated, and/or intervened each time the units' temperatures were out of required ranges. The facility's "Refrigeration Temperature Chart" had a note on the bottom which stated, "NOTIFY SUPERVISOR IMMEDIATELY IF COOLER IS ABOVE 40 DEGREES OR FREEZER ABOVE 0 DEGREES." The facility provided evidence the reach-in cooler was evaluated by a refrigeration specialist only one (1) time, on 09/17/14. The walk-in refrigerator was evaluated by a refrigeration specialist only three (3) times, on 08/05/14, 09/17/14 and 09/27/14. The freezer was evaluated by a refrigeration specialist only one (1) time, on 08/05/14. e) According to the United States Food and Drug Administration Food Code, the required refrigerator temperature to keep foods safe for human consumption is at or below 40 degrees Fahrenheit (F), and frozen foods must be kept at or below zero (0) degrees F. The facility's refrigeration units were not maintained at these safe temperatures on numerous occasions. .

Based on record review, staff interview, reportable allegations of abuse/neglect review, and policy review, the facility failed to ensure an allegation of abuse was identified, thoroughly investigated reported to the appropriate state agencies. In addition it was determined the facility failed to implement measures to prevent the potential for further abuse. The facility received an allegation of abuse involving Resident #36. This allegation was not thoroughly investigated and reported to the appropriate state agencies. This was found for one (1) of four (4) residents reviewed during a complaint investigation. Resident identifier: #36. Facility census 56. Findings include: a) Resident #36. On 03/18/14 at 2:30 p.m., during an interview with Employee #74 (administrator) and the director of nursing (DON) (Employee #73), they were asked if any staff member had ever reported an allegation concerning Employee #21 digitally removing bowel movement from Resident #36. The administrator said an employee had come to her with this concern, but she did not report this issue as an allegation of abuse. She handled it as a complaint. Employee #73 said she did not become aware of this allegation of abuse until a meeting was held with staff regarding their concerns. When she was asked for the meeting notes/minutes, she did not provide the date this allegation had occurred on, nor meeting notes/minutes as of the time of exit. She also said she did not document anything concerning the investigation. When she was asked for evidence an investigation, the staff began trying to document what they could remember of the allegation that occurred in October 2013. The facility had no evidence to show they had recognized this allegation of abuse, thoroughly investigated the allegation of abuse or put any measures in place to prevent the abuse from reoccurring. An interview, conducted on 03/19/14 at 11:00 a.m., with an anonymous staff member revealed the staff member had witnessed a nursing assistant going beyond their scope of practice. The anonymous staff member (ASM) said they had seen a nursing assistant go beyond their scope of practice in October 2013. The ASM said they observed Employee #21(nurse aide) in Resident #36's bathroom. Employee #21 digitally (used finger) to remove bowel movement from Resident #36. The resident moaned and swatted at Employee #21 and tried to push the employee's hand away. The ASM said he/she reported this to Employee #54 (LPN). The ASM said he/she also believed Employee #54 reported this allegation of abuse to the director of nursing (Employee #73). On 03/19/14 at 11:20 a.m., during an interview with Employee #54 (licensed practical nurse), the employee was questioned whether she had reported Employee #21 digitally removing bowel movement from Resident #36. Employee #54 said she had reported this to the director of nursing. At 2:00 p.m. on 03/19/14, the social worker (Employee #24) (social worker) was given information about the allegation of abuse involving Resident #36. He was asked if this would be considered abuse. He said "Yes." He also said the facility would report and investigate an allegation of abuse if they had knowledge of the incident. He went on to say he was unaware of the allegation involving Resident #36. In another interview with Employee #54 and the ASM, on 03/19/14 at 2:20 p.m., they were asked when they reported the allegation to the director of nursing. They said they reported the allegation to the director of nursing before the staff meeting set up by the administrator. A review of the facility's policy on 03/19/14 at 2:35 p.m., revealed anyone who witnessed any incident of suspected abuse, neglect, involuntary seclusion or misappropriation of resident property was to immediately report this to his or her immediate supervisor. The policy stated after a supervisor received a report of an allegation of abuse or neglect they were to follow all state specific requirements for reporting. .

Based on medical record review, policy review, and staff interviews, the facility failed to ensure it implemented its policy and procedures on reporting and thoroughly investigating allegations of resident abuse. The facility policy on abuse and neglect indicated it would report and thoroughly investigate allegations of abuse. The facility received an allegation of abuse involving Resident #36, but did not report this allegation to the required outside agencies. The facility also did not thoroughly investigate the allegation of abuse. Resident identifier: #36. Facility census: 56. Findings include: a) Resident #36 On 03/18/14 at 2:30 p.m., during an interview with Employee #74 (administrator) and the director of nursing (DON) (Employee #73), they were asked if any staff member had ever reported an allegation concerning Employee #21 digitally removing bowel movement from Resident #36. Employee #74 said an employee had come to her with this concern. The administrator then said she did not report this issue as an allegation of abuse. She handled it as a complaint. Employee #73 said she did not become aware of this allegation of abuse until a meeting was held with staff regarding their concerns. The DON said she did not report the allegation because she considered it a complaint. She also said she did not document anything concerning the investigation. An interview conducted on 03/19/14 at 11:00 a.m. with an anonymous staff member revealed the staff member had witnessed a nursing assistant going beyond their scope of practice. The anonymous staff member (ASM) said they had seen a nursing assistant going beyond her scope of practice in October 2013. The ASM observed Employee #21(nurse aide) in Resident #36's bathroom. Employee #21 digitally (used finger) removed bowel movement from Resident #36. The resident moaned as if in pain and swatted at Employee #21. She also tried to push the employee's hand away. The ASM said they reported this to Employee #54 (LPN). The ASM said they also believed Employee #54 reported this allegation of abuse to the director of nursing (Employee #73). On 03/19/14 at 11:20 a.m., during an interview with Employee #54 (licensed practical nurse), the employee was questioned whether they had reported Employee #21 digitally removing bowel movement from Resident #36. Employee #54 said she had reported this to the director of nursing. At 2:00 p.m. on 03/19/14, the social worker (Employee #24) was given a short scenario about the allegation involving Resident #36. He was asked if this would be considered abuse. He said "yes." He also said the facility would report and investigate that type of issue if they had knowledge of it. He went on to say he was unaware of the allegation involving Resident #36. During an interview with Employee #54 and the ASM, on 03/19/14 at 2:20 p.m., they were asked when they reported the allegation to the director of nursing. They said they reported to the director of nursing before the staff meeting set up by the administrator. A review of the facility's policy (effective 09/09/11) on 03/19/14 at 2:35 p.m., revealed anyone who witnesses any incident of suspected abuse, neglect, involuntary seclusion or misappropriation of resident property is to immediately report this to his or her immediate supervisor. The policy goes on to state after a supervisor receives a report of an allegation of abuse or neglect they are to follow all state specific requirements for reporting. The facility did not report the allegation of abuse against Employee #21. The administrator and director of nursing confirmed this issue was not reported as an allegation of abuse. .

Based on medical record review and staff interview, the facility failed to notify the resident's physician when the resident's pulse fell below the parameters specified by the physician's orders [REDACTED]. The resident's pulse was below 60 on two (2) separate occasions from 06/21/13, the date of admission, through 07/05/13. There was no evidence the facility had notified the physician. This was true for one (1) of ten (10) residents reviewed for unnecessary medications during Stage II of the Quality Indicator Survey. Resident identifier: #78. Facility census 57. Findings include: a) Resident #78 Medical record review found a physician's orders [REDACTED]. was less than 60. Further review of the nurses' notes found the resident's pulse was recorded as 59 on 06/29/13 at 7:26 a.m. Documentation in the nurses notes' found, "No communication with physician concerning the patient during this shift." On 07/05/13 at 12:23 p.m., the resident's pulse was recorded as 54. Documentation in the nursing notes found, "No communication with physician concerning this patient during this shift." Employee #79, a registered nurse, was interviewed on 07/09/13 at 3:40 p.m. She was unable to find verification the physician was contacted. The administrator was made aware of the situation on 07/09/13 at approximately 4:00 p.m. No further information was provided to verify the physician was aware of the resident's pulse on 06/29/13 and 07/05/13. .

Based on observation, staff interview, and review of the manufacturer's guidelines, the facility failed to discard one (1) partially used vial of tuberculin testing serum after it had been opened for greater than thirty (30) days. This had the potential to negatively affect a test result for any resident or employee who would receive a tuberculin test from this vial. Facility census: 57. Findings include: a) On 07/08/13 at 11:30 a.m., an opened, partially used, one (1) milliliter (ml.) vial of Purified Protein Derivative (PPD), dated 06/05/13, was observed in the medication storage room refrigerator. This vial had the capacity for the administration of ten (10) [DIAGNOSES REDACTED] screening tests. Licensed nurse, Employee #60, was present when this vial was observed. She said the date on the vial that was inscribed with ink, indicated it had been opened on 06/05/13. She said she thought that vials should be discarded thirty (30) days after opening, but would check with the pharmacy to be certain. On 07/08/13 at 1:00 p.m., Employee #60 produced a fax from the pharmacy with the manufacturer's guidelines for Tuberculin-PPD Aplisol, which stated "Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency". She stated that after receiving the fax, she disposed of that vial in the sharps container per facility protocol. .

Based on observation and staff interview, the facility failed to store refrigerated foods in a manner that ensured the foods were safe for use. The facility did not keep track of use-by dates or when to discard perishable foods. Opened food items in the kitchen's refrigerator were not dated and/or disposed of when outdated. This practice had the potential to affect all residents who received food from the kitchen. Facility census: 55. Findings include: a) Kitchen Observation of the kitchen, on 03/05/12, at approximately 11:40 a.m., found a container of strawberries with no date, two (2) glasses of nectar thickened milk with no date, and a bowl of cottage cheese with no date. The facility also failed to dispose of an outdated container of juice. The juice had a use by date of 03/02/12. Observations of the items found in the refrigerator were identified with Employee #61 (dietary service assistance). Employee #75 (the executive director) was informed of the findings at approximately 11:50 a.m. on 03/05/12. .

Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to dispose of outdated insulin vials for six (6) residents, an outdated bottle of tuberculin testing serum (PPD), and outdated medications on both medication carts. This had the potential to affect more than an isolated number of residents. Resident identifiers: #57, #38, #45, #11, #16, #43 Facility census: 55. Findings include: a) Observation of the medication storage refrigerator, on 03/06/12 at noon, revealed five (5) vials of insulin that either had no date of when the vial was opened, or had an opened date inscribed on the bottle that was beyond the acceptable parameters for using the medication. The director of nursing was present during this inspection, and agreed the medications should have been destroyed according to their facility policy, which was to discard after twenty-eight (28) days of opening. 1) Resident #57 This resident. had a partially used vial of Lantus insulin in the refrigerator with no date as to when it had been opened. 2) Resident #38 A partially used vial of Lantus insulin for this resident was in the refrigerator with a date of opening inscribed on the bottle of 01/22/12. According to manufacturer's instructions, this type of insulin product may by stored in the refrigerator for only up to 28 days after opening. 3) Resident #45 This resident had a partially used vial of Lantus insulin in the refrigerator with a date of opening inscribed on the bottle of 11/20/11. 4) Resident #11 A partially used vial of Lantus insulin for this resident was in the refrigerator with no date as to when it had been opened. 5) Resident #16 This resident had a partially used vial of Lantus insulin in the refrigerator with no date as to when it had been opened. b) A Hall medication cart 1) Resident #43 Observation of the A Hall medication cart, with a licensed nurse, Employee #28, on 03/05/12 at 12:15 p.m., revealed a vial of Novolin-N insulin for this resident. It was dated as opened on 12/06/11. Employee #28 said the resident did not receive insulin coverage anymore, and agreed the vial should have been discarded. 2) Observation of the A Hall medication cart, with Employee #28, on 03/05/12 at 12:15 p.m., revealed a stock bottle of Zinc Sulfate 220 milligrams with a printed notation that it should be used by 11/2011. Also, a stock bottle of enteric coated aspirin 325 milligram tablets was inscribed with a use by date of of 11/2011. Employee #28 removed these bottles from stock, and agreed that they should have been discarded by the date inscribed on the bottles. c) B Hall medication cart Observation of the B Hall medication cart, with a licensed nurse, Employee #70, on 03/05/12 at 12:30 p.m., revealed a stock bottle of Zinc Sulfate 220 milligram tables with a use by date of 10/2011. Observation also revealed a stock bottle of Vitamin B Complex tablets with an expiration date of 12/2011. Employee #70 removed these bottles from stock, and agreed that they should have been discarded by the date inscribed on the bottles. .