Every finding on record at Westport Place Health Campus

Number of residents sampled: Number of residents cited: Review of facility policy titled, Medication Administration - General Guidelines, revised 11/2018, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy revealed, B. Administration included, 13) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of facility policy titled, Guidelines for Self-Administration of Medications, last reviewed 12/16/2025, indicated, The purpose of this policy is: To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is a part of their plan of care. The policy revealed the Procedure included, Residents requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the [the facility's parent company's name] Self-Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication. 1. Review of Resident Face Sheet indicated the facility admitted Resident #10 on 01/28/2022. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of gastro-esophageal reflux disease (GERD) without esophagitis. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/2026, revealed the facility assessed Resident #10 with a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of Resident #10's Care Plan included a problem area initiated 03/17/2023, that indicated the resident was malnourished or was at risk for malnutrition. Interventions directed staff to provide diet, supplements, medications, and adaptive equipment as ordered (initiated 03/17/2023). Continued review revealed the resident's Care Plan did not include information about the resident self-administering medications or leaving medications at the resident's bedside. An observation on 02/09/2026 at 2:04 PM revealed Resident #10 had three antacids at their bedside. During an interview at that time, the resident stated they wanted to self-administer their medications as needed and to keep them at the bedside and did not recall who the nurse was who gave them the medication. An observation on 02/10/2026 at 9:07 AM revealed a cup of antacids on Resident #10's bedside table. An observation on 02/12/2026 at 10:05 AM revealed Resident #10 sitting in their recliner with a medication cup with three antacids in it on the over-the-bed table in front of them. Review of Resident #10's physician Order History, for the timeframe from 01/14/2026 to 02/14/2026, revealed an order, dated 02/27/2022, for calcium carbonate (an antacid) chewable tablets 500 milligrams (mg) orally four times a day as needed (PRN). The Order History revealed no order to self-administer the medication or leave the medication at the resident's bedside. During an interview on 02/12/2026 at 11:10 AM, Registered Nurse (RN) #7 stated medications should not be left at the bedside. Upon entering Resident #10's room, RN #7 confirmed that the resident had a medication cup with three antacids in it on the over-the-bed table. He stated the antacids were there when he gave the resident their medications that morning. He stated he did not think about removing them when he saw them, but he should have. RN #7 went to the nurses' station and confirmed that Resident #10 did not have an order to leave them at the bedside, and he was unable to locate a self-administration assessment for the resident. During an interview on 02/13/2026 at 1:21 PM, Licensed Practical Nurse (LPN) #2 stated that if a resident wanted to self-administer a medication, the resident would have to sign a consent. She stated she always stayed with the resident until they took all their medications and did not leave medications at the bedside. She stated she did know Resident #10 had antacids at the bedside before but did not know if they had been assessed and thought that it was okay. She stated that she thought Resident #10 was capable of self-administering the antacids. She stated she did not think they needed an order, just consent from the resident. She stated that if she found medications in a room, she would remove them and educate the resident. 2. Review of a Resident Face Sheet indicated the facility admitted Resident #69 on 02/05/2026. According to Resident Face Sheet, the resident had a medical history that included diagnoses of non-pressure chronic ulcers of the right and left calf with necrosis of the muscle, and age-related osteoporosis. Review of Resident #69's Care Plan revealed problem statement initiated 02/12/2026, that indicated the resident demonstrated forgetfulness and benefitted from cueing. The Care Plan revealed that it did not include information about the resident self-administering medications or leaving medications at the bedside. Review of Resident #69's [the facility's parent company name]-Self-Administration of Medications assessment, dated 02/06/2026, indicated the resident did not want to self-administer medications. The assessment indicated that the resident would not be self-administering medications. An observation on 02/09/2026 at 10:33 AM revealed Resident #69 had multiple bottles of medications in their windowsill, including collagen peptides (a dietary supplement), Florastor (an antidiarrheal probiotic), zinc (a mineral), and bone support (dietary supplement for bone health). There was also a bottle of loratadine (an antihistamine) and fluticasone (a nasal steroid) on the dresser. An observation on 02/10/2026 at 8:30 AM, 12:32 PM, and 2:03 PM revealed the bottles of medications in the windowsill and dresser remained. During an interview at the time of the observation, Resident #69 stated they tried to remember to take the medications but did not always. Resident #69 stated they did not recall having any type of assessment, but the staff never told them that they could not have the medication. An observation on 02/11/2026 at 9:31 AM revealed all the bottles of medications were removed from the windowsill and dresser but there was a bottle of fluticasone on the nightstand. An observation on 02/12/2026 at 10:00 AM revealed a bottle of fluticasone on the nightstand. Resident #69's Physician Order History, for the timeframe from 01/14/2026 through 02/14/2026, revealed an order, dated 02/05/2026, for fluticasone propionate 50 micrograms (mcg) per actuation, one spray in each nostril twice a day. The Order History revealed no orders for the other medications found in the resident's room. The Order History revealed no orders for the resident to keep medications at the bedside or to self-administer medications. During an interview on 02/12/2026 at 11:07 AM, Registered Nurse (RN) #12 stated medications should not be left at residents' bedside. He stated if a resident wanted to self-administer their own medications, they needed to be assessed, and it would have to be approved by the Interdisciplinary Team (IDT), and they would need a physician order. He stated they also needed a physician order to keep the medication at the bedside. RN #12 stated that Resident #69 did not have an order to keep medications at the bedside or to self-administer their medications. He also stated that Resident #69's self-administration assessment indicated the resident did not want to self-administer medications. During an interview on 02/13/2026 at 3:44 PM, the Infection Control Nurse (ICN) stated that if a resident was alert and oriented and wanted to self-administer their medications, they completed an assessment first, and if the resident was assessed to be able to administer their own medications, they called the physician to get an order to self-administer and leave at the bedside. She stated that the nurse would document the use of the medication. During an interview on 02/13/2026 at 4:36 PM, the Director of Nursing Services (DNS) stated a resident could self-administer their own medications if an assessment was completed to determine if they were able to, then they notified the physician and got an order. She stated that the medications could be left at the bedside with an order from the physician.

Based on observation, interview, and record review, the facility failed to ensure staff provided respiratory care consistent with resident care policies related to cleaning and storage of equipment for 3 of 4 residents sampled for respiratory therapy out of a total sample of 17 residents (Residents (R) 30, 48, and 69). Observations revealed used respiratory equipment not cleaned and/or stored appropriately after use. The findings include:1. Review of facility policy, Respiratory Equipment, last reviewed 12/16/2026, revealed the Overview indicated, To provide infection control guidelines to help prevent infections associated with respiratory therapy equipment and to prevent transmission of infections to residents and staff. The policy also indicated, 2. Oxygen Administration included, j. Keep oxygen cannula and tubing used PRN [pro re nata; as needed] in a plastic bag when not in use. The policy revealed, Medication Nebulizers/Continuous Aerosol included, c. After completion of therapy, which included, i. Remove nebulizer container, ii. Rinse container with fresh tap water, iii. Allow to dry on clean paper towel or gauze sponge, and iv. Reconnect to administration 'set up.' The policy continued, e. Wipe mouthpiece with damp paper towel or gauze sponge. f. Store circuit in plastic bag, marked with date and resident's name, between uses. During an interview on 02/11/2026 at 2:20 PM, the Director of Nursing Services (DNS) stated that there was no specific policy for use of CPAP machines. Review of facility document Resident Face Sheet revealed the facility admitted Resident #69 on 02/05/2026. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of asthma. Review of Resident #69's Care Plan included a problem area initiated 02/11/2026, that indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory disease. Interventions initiated 02/11/2026 directed staff to provide respiratory therapy per orders and provide medications as ordered. Review of Resident #69's physician's Order History, for the timeframe from 01/14/2026 through 02/14/2026, revealed an active order, dated 02/05/2026, for ipratropium-albuterol (a bronchodilator combination) solution for nebulization 0.5 milligrams (mg)-3 mg/3 milliliters (mL) one vial inhaled every four hours PRN for wheezing and shortness of air. An observation on 02/09/2026 at 10:33 AM revealed a nebulizer machine on Resident #69's nightstand with dried debris in the mask and fluid in the medication cannister. There was no bag to store the equipment in. Observations on 02/10/2026 at 8:30 AM and 12:32 PM revealed the nebulizer machine on Resident #69's nightstand with the mask and medication cannister in the top drawer with dried debris in the mask. The equipment was not stored in a bag. During an observation and interview on 02/10/2026 at 2:03 PM, Resident #69 stated they used the nebulizer machine when they were short of breath. The resident stated the staff laid the mask on top of the machine or in the drawer, and they had not seen staff rinse it out. The medication cannister and mask were lying on top of the nightstand and were not stored in a bag. There was fluid in the medication cannister. Review of Resident #69's Medication Administration History revealed staff documented the resident received an ipratropium-albuterol nebulizer treatment on 02/10/2026 at 8:12 PM. An observation on 02/11/2026 at 9:31 AM revealed Resident #69's nebulizer machine was on the nightstand with the tubing attached, with the mask and medication cannister lying on top of the nightstand. There was dried debris in the mask and liquid in the medication cannister, and it was not stored in a bag. An observation on 02/12/2026 at 10:00 AM revealed Resident #69's nebulizer machine on Resident #69's nightstand with the tubing attached, with the mask and medication cannister lying on top of the nightstand, with dried debris in the mask and a scant amount of liquid in the medication cannister. The mask and medication cannister were not stored in a bag. During an interview on 02/12/2026 at 11:07 AM, Registered Nurse (RN)#12 entered Resident #69's room and confirmed that the nebulizer mask was dirty and not stored in a bag. He opened the top drawer of the nightstand and there was a bag to store the equipment in. He stated the mask should be wiped out after use and the medication cannister rinsed, dried, and stored in the bag. RN #12 put Resident #69's name, room number and date on the bag and then set it next to the machine. He then removed the mask and tubing and threw them away and stated that he was going to get new equipment. During an interview on 02/13/2026 at 1:21 PM, Licensed Practical Nurse (LPN) #2 stated that after a nebulizer treatment, the mask should be wiped out and put in a plastic bag, and the medication cannister should be rinsed and allowed to air-dry then put in the bag. During a telephone interview on 02/13/2026 at 10:14 AM, RN #13 stated they were supposed to put the nebulizer mask in a bag after use. She stated that she had administered Resident #69 a nebulizer treatment on 02/10/2026, and once it was done, she placed the mask in the top drawer of the nightstand because the resident did not have a bag in their room at that time. She stated she meant to get one and put it in the room, but she got busy and forgot. 2. Review of Resident Face Sheet revealed the facility admitted Resident #48 on 03/31/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (CHF) and chronic pulmonary embolism. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2025, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident received oxygen therapy during the assessment timeframe. Review of Resident #48's Care Plan included a problem area initiated 04/07/2025, that indicated the resident had a potential for cardiovascular distress and complications related to CHF. Interventions directed staff to administer oxygen therapy per physician orders (initiated 04/07/2025). Review of Resident #48's physician's Order History, for the timeframe from 01/14/2026 through 02/14/2026, revealed an active order, dated 03/31/2025, for supplemental oxygen at 2 liters continuous per nasal cannula. The Order History indicated that the order was changed to PRN on 02/11/2026. An observation on 02/09/2026 at 9:54 AM revealed an oxygen concentrator in Resident #48's room with the oxygen tubing lying on the floor. A portable oxygen tank was under and behind a chair in the room, with the tubing and nasal cannula touching the floor. At 11:49 AM, the oxygen tubing was wadded up on top of the concentrator. An observation on 02/10/2026 at 8:29 AM revealed the oxygen concentrator in Resident #48's room was on, and the tubing was hanging over the open drawer of the nightstand, with the cannula touching the side of the nightstand. The portable oxygen tank remained on its side under and behind the chair, with the cannula and the tubing touching the floor. An observation on 02/11/2026 at 9:30 AM revealed the oxygen concentrator in Resident #48's room was on. The tubing was not plugged in but was wadded up on top of the machine. The portable oxygen tank remained on its side under and behind the chair, with the cannula and the tubing touching the floor. An observation on 02/11/2026 at 10:01 AM revealed the oxygen concentrator in Resident #48's room was off, and the tubing was lying across the resident's bed. The portable oxygen tank remained on its side under and behind the chair, with the cannula and the tubing touching the floor. During an interview on 02/12/2026 at 11:09 AM, Registered Nurse (RN) #12 stated that when oxygen tubing was not in use, it should be stored in a plastic bag. Upon entering Resident #48's room, RN #12 noticed the portable tank lying under and behind the chair. He set it up, removed the tubing, and threw it away. He stated the tubing on the bed should be stored in a plastic bag, and he was going to have to get a bag to store the equipment in. He removed the tubing from the concentrator and threw it away and stated he was going to replace it. During an interview on 02/13/2026 at 1:21 PM, Licensed Practical Nurse (LPN) #2 stated oxygen tubing should be stored in a bag when not in use, and if it fell on the floor, it should be thrown away and replaced. During an interview on 02/13/2026 at 3:44 PM, the Infection Control Nurse (ICN) stated that oxygen tubing should be stored in a bag when not in use. He stated the bag was dated and had the resident's name on it. He stated that if it touched the floor, then it should be replaced. He stated that the nebulizer mask and medication cannister should be rinsed out and stored in a plastic bag after use. During an interview on 02/13/2026 at 4:36 PM, the Director of Nursing Services (DNS) stated oxygen tubing should be stored in a bag when not in use, and if it fell on the floor, it should be thrown away and a new one obtained. She stated that per the facility policy, nebulizer equipment should be washed with soap and water, air-dried, and stored in a bag. During an interview on 02/13/2026 at 4:36 PM, the Executive Director stated staff should follow the facility policy related to respiratory equipment. 3. Review of facility document Resident Face Sheet indicated the facility admitted Resident #30 on 01/30/2026 with diagnoses including obstructive sleep apnea. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date of 02/02/2026, indicated the facility assessed Resident #30 with a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #30 received non-invasive mechanical ventilator respiratory treatments while a resident. Review of Resident 30's Care Plan, included a problem statement initiated 02/03/2026, that indicated the resident had the potential for shortness of breath (SOB) while lying flat related to obstructive sleep apnea (OSA). Interventions directed staff to administer oxygen per the physician's order and as needed (started 02/03/2026). Resident 30's Care Plan, included a problem statement initiated 02/03/2026, that indicated the resident required the use of home continuous positive airway pressure (CPAP) due to OSA. Interventions directed staff to provide CPAP treatments per the physician's orders (started 02/03/2026). An observation on 02/09/2026 at 3:36 PM of Resident #30's room revealed a CPAP mask on the top of a side table, not stored in a receptacle bag. An observation on 02/10/2026 at 10:43 AM of Resident #30's room revealed the CPAP mask on the top of the side table, not stored in a receptacle bag. During an interview on 02/11/2026 at 12:58 PM, Licensed Practical Nurse (LPN) #10 stated that Resident 30's CPAP mask should be stored in a respiratory bag when not in use. During an interview on 02/11/2026 at 1:21 PM, the acting Director of Nursing Services (DNS) stated licensed nurses were responsible for CPAP device care, including storing masks in clean plastic bags. During a concurrent observation and interview on 02/11/2026 at 1:40 PM, the DNS confirmed that upon entering Resident #30's room, the CPAP mask was observed on the top of the resident's side table, not stored in a plastic bag.

Based on observation, record review and interviews the facility failed to ensure medication error rates were less than five percent (5%). Observations during medication administration revealed three medication errors during administration of 27 medication events resulting in a medication error rate of 11.11%. The findings include:Review of facility policy, Medication Administration - General Guidelines, revised 01/2018, indicated the Procedures included, 4) Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. The policy continued, a. Check #1: Select the Medication - label, container and contents are checked for integrity and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights when putting the medication away. The policy also indicated, D. Documentation included, 6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, (e.g. [exempli gratia, for example], the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), it is documented on MAR or in the EHR [electronic health record]. An explanatory note is also entered. 1. Review of facility document, Resident Face Sheet, indicated the facility admitted Resident #59 on 12/02/2021. According to the Resident Face Sheet, the resident had diagnoses including irritable bowel syndrome and constipation. Review of the facility quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2025, revealed the facility assessed Resident #59 with a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Review of Resident #59's physician Order History for the timeframe from 01/01/2026 to 02/14/2026, included an active order, dated 12/15/2025, for polyethylene glycol (a laxative) 17 grams mixed in 8 ounces of liquid orally once a day. During a medication administration observation on 02/11/2026 at 8:11 AM, Certified Resident Medication Assistant (CRMA) #3 prepared and administered medication to Resident #59. However, CRMA #3 omitted administering the polyethylene glycol to the resident. During an interview on 02/11/2026 at 2:34 PM, CRMA #3 stated that he did not give Resident #59 their polyethylene glycol because the resident had diarrhea. He stated that he should have documented why it was not given. 2. Review of Basaglar [a type of insulin] KwikPen Instruction for Use specified, Prime before each injection. Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. The instructions continued, Step 6, To prime your Pen, turn the Dose Knob to select 2 units. The instructions continued, Step 7, Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. The instructions revealed, Step 8, Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the needle and repeat the priming steps. Review of a Resident Face Sheet indicated the facility admitted Resident #39 on 12/28/2018. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of diabetes mellitus and constipation. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, revealed the facility assessed Resident #39 with a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Review of Resident #39's physician Order History, for the timeframe from 01/01/2026 through 02/14/2026, included an active order, dated 12/17/2025, for Basaglar KwikPen insulin 100 units/milliliter (ml) 40 units subcutaneous once a day. The Order History also included an active order, dated 11/24/2025, for polyethylene glycol (a laxative) 17 grams by mouth twice a day. During a medication administration observation on 02/11/2026 at 8:39 AM, Licensed Practical Nurse (LPN) #2 prepared and administered medication to Resident #39. LPN #39 omitted administering the polyethylene glycol to the resident and failed to prime the Basaglar KwikPen insulin pen needle prior to turning the dose knob to 40 units. During an interview on 02/11/2026 at 12:20 PM, LPN #2 stated that she forgot to give the polyethylene glycol to Resident #39. She stated she was nervous, but she should have double and triple checked the orders to ensure she administered everything that was ordered to be given at that time. LPN #2 stated she had never been educated to prime an insulin pen needle. During an interview on 02/13/2026 at 3:44 PM, the Infection Control Nurse (ICN) stated that when administering medications, staff should follow the five rights. She stated they should move the medication cart in front of the room to verify the room number and the resident with a picture, then they should double check the medication with the MAR to ensure the right medication, right dose, right time, and right route for the right resident. He stated they should check the orders against the pharmacy packet. He stated they had to have a reason if a medication was not given, and it must be documented. He stated that insulin pen needles should be primed with two units. During an interview on 02/13/2026 at 4:36 PM, the acting Director of Nursing Services (DNS) stated staff should follow the five rights of medication administration, the right resident, medication, dose, route, and time. The DNS stated that insulin pen needles should be primed with two units or until the insulin was seen coming out of the needle. During an interview on 02/13/2026 at 4:36 PM, the Executive Director (ED) stated the staff

Based on observation, interview, record review, and review of facility's policies. The facility failed to follow infection control precautions for three of four sampled residents with peripherally inserted central catheters used for intravenous medication administration for Resident (R) 41, R197 and R6. Observation on 04/29/2025 at 09:23 AM revealed R197 had a peripheral inserted central catheter in right upper arm without a protective cap placed on end of catheter hub (the entry port distal of the catheter that connects to tubing or a syringe to deliver medication intravenously) leaving hub exposed. Observation on 04/29/2025 at 09:43 AM revealed R6 had a peripheral inserted central catheter in left upper arm without a protective cap placed on end of catheter hub, leaving hub exposed. Observation on 04/29/2025 at 09:45 AM revealed R41 had a peripheral inserted central catheter in left upper arm without a protective cap placed on end of catheter hub, leaving hub exposed. The findings include: Review of the facility's policy titled, Catheter Insertion and Care revision date, 12/15, stated under general guidelines, step 7. Apply a sterile end cap to the end of primary tubing when it is disconnected from catheter. The facility's policy does not mention placing a protective cap at the end of peripheral inserted central catheter hub. Review of R41's Physician Orders, located in electronic health record, revealed an order to place caps at the end of peripheral inserted central catheter. Review of R6's Physician Orders, located in electronic health record, revealed an order to place caps at the end of peripheral inserted central catheter. Review of R197's Physician Orders, located in electronic health record, revealed an order to place caps at the end of peripheral inserted central catheter. During an interview with Director of Nursing, acting Infection Preventionist, on 04/30/2025 at 04:10 PM, she stated she was unsure and would follow up to why one of four residents had a cap on the hub of her peripheral inserted central catheter and the others did not. She followed up with Clinical Services and she stated that all peripheral inserted catheters had to have caps at the end of their catheter hubs. During an interview with Registered Nurse (RN) 2 on 05/01/2025 at 04:44 PM, he stated after administering an intravenous medication into a peripherally inserted central catheter he would clean the catheter hub again with alcohol and place a cap at the end. During an interview with Assistant Director of Nursing, on 05/01/2025 at 04:55 PM, she stated that nurses should be cleaning the peripheral inserted central catheters with alcohol after disconnection of tubing or a syringe and placing a cap on the end of catheter's hub. She stated that a potential outcome could be introducing infection to the resident if not placing cap to catheter hub. During an interview with RN3 on 05/01/2025 at 05:12 PM, he stated that after he disconnects intravenous tubing or a syringe, he cleans the end of the catheter hub with alcohol, then flushes and then recaps the end of hub. He stated, there is a hole there and that can introduce bacteria if you do not recap. During an interview with the Administrator, on 05/01/2025 at 05:37 PM, she stated that she is not a nurse, but she expects staff to follow facility policies.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to ensure a medication error rate of less than 5% for two (2) of three (3) sampled residents (Residents #142 and #143) observed during medication administration. Two (2) errors in medication administration observed during thirty-two (32) medication administration opportunities resulted in a medication error rate of 6.25%. The findings include: A review of the facility policy, Medication Administration General Guidelines, revised 11/2018, revealed if staff could not locate a medication with a current, active order in the medication cart/drawer, then staff searched other areas of the medication cart, medication room, and facility (e.g., other units), if possible. If staff fail to locate the medication after further investigation, staff contacted the pharmacy or removed the medication from the emergency drug supply. Additionally, the policy allowed residents to self-administer medications when specifically authorized by the attending physician, and in accordance with procedures for self-administration of medications. 1. Observations during morning medication pass, on 03/02/2022 at 8:20 AM, with Licensed Practical Nurse (LPN) #3, revealed LPN #3 administered six (6) medications to Resident #142, which did not include [MEDICATION(S)] nasal spray. LPN #3 was asked specifically if there were any medications that had already been given prior to the observation, any medications that would have been given at a different time than that observation, or any medications that were omitted during that observation. LPN #3 stated she administered all the medication ordered for the resident at that time frame; none had already been administered, and none were remaining to administer. A review of Resident #142's March 2022 active Physician's Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication reconciliation review completed by comparing the resident's Physician's Orders to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication that was observed as administered was [MEDICATION(S)] nasal spray. Interview, on 03/02/2022 at 11:10 AM, with LPN #3 revealed she did not administer the [MEDICATION(S)] to the resident, although she charted the administration. LPN #3 stated the resident self-administered the medication and stored the medication in his/her room. Additionally, LPN #3 reviewed the resident's Electronic Health Record (EHR) and stated there was no self-administration assessment documented for the resident. Interview with Resident #142, on 03/02/2022 at 11:20 AM, revealed LPN #3 gave the [MEDICATION(S)] to Resident #142 to keep at bedside. The resident stated that he/she told LPN #3, Just give me the bottle and I'll do it myself. The resident pulled the [MEDICATION(S)] out of an unlocked drawer at the bedside. Interview, on 03/02/2022 at 11:32 AM, with the Executive Director (ED), revealed staff should complete a self-administration assessment before staff left medication at the bedside. Interview, on 03/03/2022 at 10:05 AM, with the Director of Health Services (DHS) revealed staff should complete a self-administration assessment prior to giving the medication to the resident to self-administer. 2. Observation during morning medication pass, on 03/02/2022 at 8:36 AM, revealed LPN #3 administered eleven (11) medications to Resident #143, which did not include [MEDICATION(S)] (used to treat hypertension or [CONDITION(S)]) or [MEDICATION(S)] suspension (used to treat or prevent fungal infection). LPN #3 was asked specifically if there were any medications already administered prior to the observation, any medications to be administered later, or any medications omitted during that medication pass. LPN #3 stated she provided all the medications, except she held the [MEDICATION(S)], due to the resident's low blood pressure, but everything else was given to the resident. Review of Resident #143's March 2022 active Physician's Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication reconciliation review completed by comparing the resident's Physician Orders to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications not observed being administered during that date and time were the [MEDICATION(S)], held due to Resident Condition and the [MEDICATION(S)] suspension due to Drug/Item Unavailable. Interview, on 03/02/2022 at 11:10 AM, with LPN #3 revealed the [MEDICATION(S)] suspension was not available from the pharmacy. Continued interview with LPN #3 revealed she was unable to locate the medication in the cart. Interview, on 03/02/2022 at 11:32 AM, with the Executive Director (ED) revealed the nurse should contact the pharmacy or use the emergency medication kit when a medication was not available. The ED stated that if a medication was not given, the doctor should be notified. Interview, on 03/03/2022 at 10:13 AM, with the Director of Health Services (DHS) revealed the nurse should call the doctor to notify them of any missing medication and also call the pharmacy to have something sent over immediately.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure one (1) of three (3) ice machines were kept clean and sanitary to prevent foodborne illnesses. This failed practice had the potential to affect all residents and staff. The findings include: A review of the facility policy, Kitchen Equipment Preventative Maintenance, revised 02/08/2018, revealed, staff inspected kitchen equipment monthly, unless otherwise directed. Additionally, staff checked the cleanliness of the ice tray and maintained the ice machine per manufacturer's recommendations. Observation, on 02/28/2022 at 2:30 PM, revealed a soda fountain machine with a push-button activated ice dispenser fitted inside a mounted grey plate that was approximately five (5) inches by three (3) inches with approximately a 1/4-inch space between the ice dispenser. Continued observation revealed the gray plate contained caked black, brown, and pink moist substances which had the potential to drip down and into containers. Interview, on 03/02/2022 at 3:25 PM, with the Director of Food Services (DFS) revealed the soda nozzles and juice maker were on a cleaning schedule, but the ice chute on the soda machine was not on a cleaning schedule. The DFS stated they had only used the soda machine for approximately six (6) months. The DFS stated the ice chute on the soda machine was not on a cleaning schedule because he was new to the facility, and he did not think to have the ice chute cleaned. Further interview revealed the equipment should be on a monthly cleaning schedule like the other ice machine. Interview, on 03/02/2022 at 4:11 PM, with the Executive Director (ED) revealed the facility had a cleaning schedule for the ice machines, but not for the soda fountains with an ice dispenser. The ED stated it was her expectation the ice dispenser be cleaned as frequently as the other ice machines, on a quarterly basis. She stated it was the responsibility of the DFS or the Director of Plant Operation's (DPO) to ensure the cleanliness of the ice machine, and both were aware of the equipment. The ED indicated a potential negative outcome of an unclean ice machine was that someone could become sick. Interview, on 03/03/2022 at 10:23 AM, with the Director of Health Services (DHS) revealed her expectation was the ice dispenser be cleaned regularly, and the observation of the black and pink substances was unacceptable. The DHS further stated she did not know the cleaning schedule. She stated the soda fountain with ice dispenser was used by both staff and residents, and a potential negative outcome of an unclean ice dispenser was that it could cause food borne illnesses.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the facility assessed residents for self-administration of medication for one (1) of three (3) sampled residents (Resident #142). The findings include: A review of facility policy, Guidelines for Self-Administration of Medications, revised 05/22/2018, revealed residents who requested to self-medicate or with self-medication as a part of the plan of care were assessed for the ability. Staff presented the assessment results to the physician for evaluation and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident and a nurse maintained a key. The facility admitted Resident #142, on 02/24/2022 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Comprehensive Care Plan, with a created date of 02/28/2022, did not indicate the facility assessed the resident to self-administer medications. Review of the resident's active physician's orders indicated the resident an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation, on 03/02/2022 at 8:20 AM, of the morning medication pass with Licensed Practical Nurse (LPN) #3 revealed the LPN administered six (6) medications to Resident #142, however, LPN #3 did not administer [MEDICATION(S)] Nasal Spray. Interview, on 03/02/2022 at 8:25 AM, with LPN #3, revealed she administered all the ordered morning medications to Resident #142. Review of Resident #142's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3. Continued review revealed the resident no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview, on 03/02/2022 at 11:10 AM, with LPN #3 revealed she had not administered [MEDICATION(S)] Nasal Spray to the resident because the resident kept the medication in his/her room for self-administration. The LPN continued to state she was unable to locate a Self-Administration Assessment in the resident's Electronic Health Record (EHR). LPN #3 stated she assumed the resident already had the assessment completed by other staff. Observation of Resident #142, on 03/02/2022 at 11:20 AM, revealed the resident removed the [MEDICATION(S)] Nasal Spray out of an unlocked drawer at his/her bedside. Interview, on 03/02/2022 at 11:20 AM, with Resident #142 revealed LPN #3 provided him/her with the [MEDICATION(S)] Nasal Spray to keep at his/her bedside. The resident continued to state he/she asked the LPN to leave the medication at his/her bedside. Interview, on 03/02/2022 at 11:32 AM, with the Executive Director (ED) revealed staff should complete a self-administration assessment before a medication was left at the bedside. Interview, on 03/03/2022 at 10:05 AM, with the Director of Health Services (DHS) revealed a self-administration assessment should be completed prior to giving the medication to the resident to self-administer.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medication carts were secured when not in use for one (1) of three (3) medication carts. Observation revealed an unlocked, unattended medication cart on the 200 Hall. The findings include: Review of the facility's policy, Medication Administration General Guidelines, revised 11/2018, revealed during administration of medications the medication cart was kept closed and locked when out of sight of the facility medication administration personnel. Additionally, staff stored no medications on top of the cart and the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation, on 03/02/2022 at 7:59 AM, revealed an unlocked, and un-attended medication cart located on the 200 Hall. Staff placed the cart in front of the Nurses Station. Continued observation revealed the top drawer of the medication cart could be opened, and there was a clear, unlabeled, medication cup observed which contained numerous medications. At 8:06 AM, LPN (Licensed Practical Nurse) #2 approached the Medication Cart. Interview with LPN # 2, on 03/02/2022 at 8:06 AM, revealed he/she was responsible for the medication cart, and stated the cart should be locked when not in use. The LPN revealed the medication visible in the medication cup was for Resident #40; however, the LPN was called to assist another staff member and left the medication in the cart. Interview on, 03/02/2022 at 12:50 PM with the Executive Director (ED) revealed staff should lock medication carts when not in use. Interview, on 03/03/2022 at 10:21 AM, with the Director of Health Services (DHS) revealed the medication carts should be locked when not in use.

Based on observations, record review and staff interviews, the facility failed to place caution signage on residents' doors, that exhibited signs and symptoms of COVID-19. The facility also failed to communicate effectively to ensure environmental staff was made aware, of residents' rooms that needed to be deep cleaned. This was for three (3) of four (4) residents (Resident #s 1, 2 and 3). The failures occurred during a COVID-19 pandemic. The findings include: During an observation on 06/11/2020 at 1:24 p.m., accompanied by the Director of Nursing (DON), the DON confirmed Resident #s 1, 2 and 3 exhibited signs and symptoms of COVID-19, and were pending laboratory results. The residents' doors were observed closed and the DON stated, the residents were sent to the hospital. There was no signage observed on the doors to alert one not to enter the rooms, or see the nurse for further instructions. The DON stated that she expected signage to have been placed on the doors, due to it could not be determined if the rooms had been cleaned by environmental services, since the residents were sent to the hospital. There was no staff or residents observed to enter the rooms. During an interview on 06/11/2020 at 3:00 p.m., the Environmental Services Director, after review of housekeeping staff cleaning tasks for the day, and discussions with the housekeeping staff, was unable to ascertain the aforementioned residents' rooms were deep cleaned, or if staff were made aware of the necessity. During an interview on 06/11/2020 at 4:16 p.m., the Infection Control Nurse (ICN) confirmed that if a resident exhibited signs and symptoms of COVID-19, signage should be placed on the door, not to enter the room, or instructions to use the necessary precautions, prior to entering the room. She stated that the nurse on the floor was responsible for initiating the signage on the residents' doors. The ICN also stated residents sent out to the hospital for signs and symptoms of COVID-19, rooms were expected to be deep cleaned. She clarified that just sanitizing the room was not acceptable. Review of the facility records provided by the Executive Director, confirmed Resident #s 1 and 3 tested positive for COVID-19, and Resident #2 COVID results were pending. Review of the Room Cleaning - Isolation rooms protocol, revised on 03/16/2020, revealed, .When cleaning isolation rooms extra measures are taken to minimize cross contamination to other resident rooms. Clean isolation rooms at the end of the day .All isolation rooms are to have clear labeling that identifies the room as an isolation room .

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were given the opportunity to exercise their right to vote for one (1) of twelve (12) sampled residents (Resident #1) and three (3) of nine (9) unsampled residents (Unsampled Residents A, B, and C). The findings include: Review of the facility's policy, Resident Rights, not dated, revealed the residents living in the facility had the right to exercise their voting rights as a citizen or resident of the United States. The facility allowed the residents an opportunity to vote and participate in public elections. Interviews with residents during the Resident Council Meeting, on 10/18/16 at 4:00 PM, revealed residents were not aware they could vote in the upcoming election and would like the opportunity to do so. Interview with Unsampled Resident A, on 10/19/16 at 9:21 AM, revealed staff had not asked him/her if he/she wanted to vote. Unsampled Resident A stated he/she wanted the opportunity to vote, but thought he/she could not vote because he/she could not ambulate independently. Unsampled Resident A stated he/she had always voted when he/she lived at home. Interview with Unsampled Resident B, on 10/19/16 at 11:07 AM, revealed he/she wanted the opportunity to exercise his/her voting rights in the upcoming election and did not know the facility would have arranged for him/her to vote. According to Unsampled Resident B, he/she had always voted prior to residing at the facility. Interview with Resident #2, on 10/19/16 at 11:11 AM, revealed the resident wanted the opportunity to vote but did not know how he/she could vote in the facility. Interview with Unsampled Resident C, on 10/19/16 at 11:45 AM, revealed staff had not informed him/her that he/she could vote. Unsampled Resident C stated he/she had never voted before but wanted the opportunity to vote because every vote counted. Interview with the Life Enrichment Director (LED), on 10/19/16 at 11:25 AM, revealed she had received a packet of applications for Absentee Ballots from the County Clerk's office and posted the applications on the bulletin board in the hall outside her office. The LED stated she had not given all the residents an Absentee Ballot application nor had she directly asked all the residents if they wanted to vote. The LED stated the bulletin board directed residents to request an application for an Absentee Ballot from her if they wanted to vote and gave the residents a deadline date of 09/02/16. According to the LED, if a resident was not ambulatory, the resident's family member had to request the application for an Absentee Ballot. She stated the resident's initial Minimum Data Set (MDS) assessment obtained the residents' voting preferences and if they wanted to vote, she ensured the residents received an application. The LED also stated after the initial MDS, the voting questions were not generated on subsequent MDS assessments and staff did not ask the residents if they wanted to exercise their right to vote. Continued interview with the LED revealed she needed to enhance the voting process that was in place because it had not worked well for the residents. She stated failure to allow residents to vote was a violation of their resident rights. Interview with the Administrator, on 10/19/16 at 2:10 PM, revealed all residents in the facility had the right to vote and the facility ensured each resident had the opportunity to exercise their right to vote. The Administrator stated the Activities Director was responsible for ensuring the residents had the opportunity to exercise their voting right. Further interview with the Administrator, on 10/20/16 at 1:17 PM, revealed a glitch in the facility's computer system that prompted staff to ask residents if they wanted to vote. According to the Administrator, the voting questions only populated for the rehabilitation residents and not the long-term care residents.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to maintain effective infection control practices for one (1) of thirteen (13) sampled residents, Resident #1. Registered Nurse (RN) #1 failed to perform hand hygiene between glove changes during pericare and failed to change gloves after they were contaminated. The findings include: Review of the facility's policy, Guideline for Handwashing/Hand Hygiene, revised 05/11/16, revealed hand hygiene was the single most important practice for preventing the transmission of infections and was required by all personnel in the health care setting. Hand hygiene was defined as either handwashing or the use of alcohol based gels. Hand hygiene was required after removing gloves. Review of the facility's policy, Perineal Care for the Incontinent, revised 05/10/16, revealed health care workers should pay particular attention to infection control techniques when performing pericare to not introduce contamination that may lead to urinary tract infection. Review of facility's medical record for Resident #1, revealed the facility admitted the resident on 05/13/16 with [DIAGNOSES REDACTED]. Observation of Resident #1's skin assessment, on 10/18/16 at 10:30 AM, revealed RN #1 started the skin assessment on the resident's upper body, and then assisted Certified Nursing Assistant (CNA) #1 with repositioning the resident. RN #1 removed her gloves, and without washing her hands or using hand-sanitizing gel, donned new gloves and continued with the skin assessment of the lower body. RN #1 noted the resident had an incident of bowel incontinence. While RN #1 was cleansing the resident's buttocks, she ran out of wipes. RN #1 removed her gloves and donned clean gloves, without washing her hands or using sanitizing gel, while CNA #1 retrieved a new box of gloves. RN #1 then finished cleansing the resident's buttocks. While wearing the same pair of gloves, RN #1 handed a clean wipe to CNA #1 and CNA #1 cleansed the resident's front genital area. RN #1 fastened the resident's clean brief while wearing the same gloves she had on while cleansing the resident's perineal area. Interview with CNA #1, on 10/20/16 at 2:00 PM, revealed hand sanitizer use or hand washing should occur between glove changes. Glove changes should occur any time after touching potentially soiled areas. CNA #1 was uncertain if RN#1 had used hand sanitizer between glove changes. CNA #1 was uncertain if RN #1 had changed her gloves before she handed CNA #1 the clean wipe. CNA #1 stated RN #1 should have used hand sanitizer between glove changes because of the risk for contamination. Interview with RN #1, on 10/20/16 at 2:28 PM, revealed she did not have hand sanitizer available during Resident #1's brief change. She stated she handed CNA #1 the clean wipe with her left hand that was not soiled. She stated her gloves were not visible soiled when she fastened the resident's brief. She stated it was not her usual role to provide pericare for the residents. Interview with the Director of Nursing, on 10/18/16 at 3:45 PM, revealed she expected staff to always wash or sanitize their hands between glove changes. She stated not performing proper hand hygiene could cause cross contamination.

Based on observation, interview and facility policy review it was determined that the facility failed to ensure sanitary disposal of garbage/refuse in two (2) of two (2) dumpsters. The findings include: Review of the facility's policy titled, Pest Control, which was not dated, revealed the facility should not permit garbage and trash to accumulate and garbage would be removed daily. Observation during the environmental tour, on 09/16/15 at 10:15 AM, revealed soiled gloves on the ground in front of the main dumpsters, the lid was open on the recyclable's dumpster and it was overflowing with an excess of thirteen (13) boxes on the ground around the recycle dumpster. There were scattered wet boxes in variable stages of decay. There was a rodent trap on the ground between the building and the main dumpster. Interview with the Maintenance Director, on 09/16/15 at 10:15 AM and 09/17/15 at 1:40 PM, revealed the lids to the dumpsters were to remain closed to prevent rodent infestation. He stated the main dumpster was emptied during business hours twice each week. He stated garbage often fell out the back of the dumpster as it was being emptied. The recyclable's dumpster was emptied weekly between 3:00 AM and 4:00 AM and the 3rd shift staff often parked next to the dumpster preventing the company from accessing the dumpster to empty it. He also stated some staff don't break down their boxes which filled the recyclable's dumpster faster than it would with flattened boxes. He stated he had no routine schedule for rounding on the dumpsters or to check for illegal parking. He stated with the garbage spillage and the overflowing recyclable's it was an invitation for pests. He stated that although they hadn't had any issues with rats the Pest Control company they contracted with had expressed a concern in the past that the boxes could attract squirrels as the facility was located in a heavily wooded area next to a farm. Interview with the Central Supply Manager, on 09/16/15 at 2:15 PM, revealed she was responsible for ordering and receiving medical supplies. She reported 3rd shift Certified Nursing Assistants CNA)'s and Environmental Aids were responsible to break down the boxes and dispose of them properly. She stated she was unaware boxes weren't being consistently broken down or that the dumpster was overflowing. She was also unaware the night staff was parking in front of the dumpster gate preventing the emptying of the recyclable's dumpster. She never rounded on the dumpster. She stated the dumpsters should remain closed and the area free of garbage and debris which could lead to pest infestation and a possible infection control issue. Interview with the Director of Food Services on 09/16/15 at 2:50 PM, revealed the kitchen received food deliveries twice a week, they unpacked and stocked their shelves and walk-ins and the cooks broke down the boxes and disposed of them in the recyclable's dumpster. He stated often when the recyclable dumpster was full of boxes they spilled out and often times the recycle bin was set back down on spilled boxes that staff couldn't remove. He was unaware someone was parking in front of the dumpster gate and expressed concern with the unsanitary state of the dumpster area as pests or rodents could infest the dumpster area. Interview with the Director of Environmental Services, on 09/16/15 at 4:00 PM, revealed he made three to four trips to the dumpsters each day to dump resident and facility garbage and to dispose of boxes from his weekly supply order. He stated he cleaned up any spillage that he encountered when he emptied garbage as he wanted to avoid an infestation of mice or rats. Interview with the Administrator, on 09/17/15 at 2:30 PM, revealed she had been aware of the issues with the recyclable dumpster and had been addressing it in her stand up meetings with 3rd shift staff, this occured twice a month. She had been advising staff that their car would be towed if it was discovered parked in front of the dumpster gate and that signage had been posted. She expressed her expectation that the dumpster area would be clean and sanitary and was concerned with the possibility of mice.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the Pneumonia Vaccine consent form included documentation to indicate a resident's acceptance or refusal of the pneumonia vaccine, and the signature of the witnessing staff member for one (1) of fourteen (14) sampled residents (Resident #8). The findings include: Review of the facility's policy regarding Guidelines for Influenza and Pneumococcal Immunizations, dated August 2014, revealed upon admission and annually each resident/responsible party would sign a Pneumococcal Immunization Education and Informed Consent form indicating the acceptance or refusal of a pneumonia vaccination. A copy of the completed form was to be placed in the medical record. Review of Resident #8's clinical record revealed the facility admitted the resident on 09/06/15 with [DIAGNOSES REDACTED]. Review of the Pneumococcal Immunization Education and Informed Consent form, dated 09/06/15, revealed Resident #8 signed the document giving his/her permission for the facility to administer the Pneumococcal Vaccine. However, review of Resident #8's medical record and Medication Administration Record [REDACTED]. Interview with the Interim Assistant Director of Nursing (ADON), on 09/16/15 at 3:02 PM, revealed she completed a chart audit on 09/08/15 of Resident #8's chart. She stated she could not find documentation of whether or not Resident #8 received the Pneumococcal Vaccine. The ADON stated she reported this to the floor nurse to follow up on. Interview on 09/17/15 at 8:42 AM, with the Director of Health Services (DHS), revealed when admitted to the facility a resident is educated about what vaccines are available and the resident or their responsible party consent or refuse the vaccination. In addition, the nurse was to sign and date the vaccination consent form and document a progress note indicating the vaccine was given or refused and the reason for refusal. The DHS also, stated the ADON completed chart audits on newly admitted residents on 09/08/15. During the chart audit it was identified that it was unclear whether Resident #8 received the vaccination. The DHS stated it was her expectation that all staff nurses document that an immunization was administered or not.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure food was stored and served under sanitary conditions. Fifteen (15) containers of multi-serving food products stored in the walk-in-freezer were found unsealed, open to air, and not labeled with open dates. In addition, five (5) female staff members were observed wearing hair nets with their hair not fully restrained within the nets. These practices affected all residents who received oral nutrition. The findings include: Review of the facility's policy for Frozen Food Storage, dated 2009, revealed all foods in the freezer were to be wrapped in moisture proof wrapping or placed in suitable containers to prevent freezer burn. The policy also revealed items were to be labeled and dated with open date. The facility's policy for Dietary Hair Restraint Policy and Procedures, not dated, noted all Dining Service employees would be required to wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covered body hair, that were designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Observation of the walk-in-freezer, on 12/09/14 at 8:20 AM, during the initial kitchen tour, revealed one (1) package of flat egg pasta sheets, one (1) package of talapia fish fillets, one (1) package of hamburger patties, one (1) package of biscuits, one (1) package of sausage patties, one (1) package of mixed vegetables, one (1) package of carrots, one (1) package of green beans, one (1) package of lima beans, one (1) package of bread dough, one (1) package of puff pastry dough, unsealed, open to air, and not labeled with open date. Two (2) multiple-serving pitchers of milk shakes were observed uncovered and not dated. On 12/09/14 at 8:30 AM, during the initial tour of the facility, one (1) female staff was observed leaving the Restorative Dining Area and entering the Kitchen with tendrils of hair hanging out of her hair net on the nape of her neck, the bang area, and side facial area. On 12/10/14 during the Lunch Dining observation of the Health Care Dining Room at 12:15 PM, four (4) staff members were observed leaving the dining area and entering the Kitchen on several occasions with tendrils of hair hanging out of their hair nets, on the nape of their necks, bang areas, and side facial areas. Interview with the Dietary Manager (DM), on 12/09/14 at 8:30 AM, revealed he did not label frozen foods with open dates nor did he seal the packages after opening. The DM revealed he thought the packages were too large to seal shut and that "time stops when foods are in the freezer". Further interview revealed the DM did not know what the facility's policy was on storing frozen foods. Interview with the DM, on 12/09/14 at 9:00 AM, revealed staff members should keep their hair under the hair nets and not hanging out because the hair could fall into a resident's food. Interview with the Assistant Dietary Manager (ADM), on 12/11/14 at 10:10 AM, revealed the facility was not sealing frozen packages and labeling with open dates until it was brought to their attention by the surveyor. Further interview revealed the ADM had not noticed staff with hair out of their hair nets, but realized the importance of restraining hair so that the resident's food would not be contaminated with loose hair. Interview with the Administrator, on 12/11/14 at 10:30 AM, revealed she expected frozen foods to be sealed, closed to air, and to be labeled with open dates. The food could receive freezer burn, go bad, deteriorate, or lose quality of taste. Further interview revealed if hair restraints were not properly used, hair could get into the residents' food.

Based on observation, interview, record review and review of the facility's policy regarding Guidelines for Care Plan Development, it was determined the facility failed to develop nursing and Certified Nursing Assistant (CNA) plans of care for one (1) of sixteen (16) sampled residents, Resident #4. The facility assessed the resident as being at risk for pressure ulcers with an intervention of physician ordered bilateral heel lift boots and neither was care planned. The findings include: Review of the facility policy Guidelines for Care Plan Development revealed the resident care plans would be developed based on the resident's applicable care needs. Observation of Resident #4, on 02/11/14 at 9:20 AM, revealed the resident w as laying abed without heel lift boots applied and with a pair of heel lift boots on the resident's bedside table. Further observation of Resident #4, on 02/11/14 at 11:00 AM, 2:00 PM and 4:30 PM, revealed the resident was without the application of bilateral heel lift boots. Observation of Resident #4, on 02/12/14 at 10:15 AM, revealed the resident was sitting in a wheelchair in the common area of the unit without the application of bilateral heel lift boots. Observation of Resident #4's skin assessment on 02/12/14 at 11:00 AM revealed he/she had no pressure ulcers on his/her heels. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 01/16/14 with [DIAGNOSES REDACTED]. The facility assessed the resident as having a Brief Mental Inventory (assessment of cognition) score of five (5) on 01/30/14 indicating Resident #4 was not interviewable. Further review of Resident #4's clinical record revealed a current physician's order for lift boots to bilateral heels at all times. Review of the Minimum Data Set (collection of assessment information about the resident) dated 01/30/14 revealed the resident triggered for being at risk for developing pressure ulcers and was to have care plans in place for that risk. Review of the care plans (to be followed by the nurses and the CNAs) for Resident #4 (undated) revealed no mention of the resident being at risk for pressure ulcers and having bilateral heel lift boots ordered by the physician to be worn at all times. Interview with CNA #1, on 02/13/14 at 10:20 AM, revealed she received a verbal report on her assigned residents at the beginning of her shift and would receive verbal information from the unit nurse about a resident when necessary. She also revealed she could look at the residents' care plans in a book at the nursing station if she had a question about one of her assigned residents. CNA #1 stated there was information in a kiosk about each resident and she might find information about the residents there. CNA #1 indicated she was not aware Resident #4 needed bilateral heel lift boots although she saw them in the resident's room. She indicated she looked in the book at the nursing station and in the kiosk after she had seen the boots in Resident #4's room and there was no information there about the resident needing bilateral heel lift boots at all times. CNA #1 divulged she was assigned to Resident #4 on 02/12/14 and on 02/13/14 and she did not receive a report from the unit nurse about Resident #4 needing to have his/her heel lift boots applied at all times. Interview with Licensed Practical Nurse (LPN) #4, on 02/13/14 at 2:30 PM, revealed a resident's assessed need for being at risk for pressure ulcers with applicable interventions should be addressed on the resident's care plan for the nurses and the CNAs. She stated it was the responsibility of the Minimum Data Set (MDS) nurses to develop a resident's care plans for nurses and CNAs and to put that information into the kiosk. LPN #4 further stated the physician ordered bilateral heel lift boots would be an intervention to prevent pressure ulcers on Resident #4's heels. Interview with MDS Registered Nurse (RN) #3, on 02/13/14 at 2:45 PM, revealed the resident care plans were developed by the MDS nurses and other disciplines. She indicated the assessed need for Resident #4 of being at risk for pressure ulcers with interventions (bilateral heel lift boots) to reduce that risk should have been addressed on the nursing and CNA care plans and in the kiosk. MDS RN #3 further indicated Resident #4's skin was assessed weekly and the resident had no pressure ulcers. Interview with the Director of Nursing (DON), on 02/13/14 at 3:00 PM, revealed the assessed need for Resident #4 was being at risk for pressure ulcers and the physician ordered intervention of heel lift boots should have been on the nursing and CNA care plans and in the kiosk. She stated she did not know why Resident #4's care plans did not include the assessed risk for pressure ulcers and the application of heel lift boots as an intervention to reduce pressure on the resident's heels. The DON indicated she did not monitor the nursing and CNA care plans for accuracy.

Based on observation, interview and record review it was determined the facility failed to provide the necessary services to maintain the highest physical well-being for one (1) of sixteen (16) sampled residents, Resident #4. The staff failed to follow a physician's orders [REDACTED].#4. The findings include: The facility did not provide a policy which addressed the necessity of following physician orders. Observation of Resident #4, on 02/11/14 at 9:20 AM, revealed the resident was laying in bed without heel lift boots applied and with a pair of heel lift boots on the bedside table. Further observation of Resident #4, on 02/11/14 at 11:00 AM, 2:00 PM and 4:30 PM, revealed the resident was without the application of bilateral heel lift boots. Observation of Resident #4, on 02/12/14 at 10:15 AM, revealed the resident was sitting in a wheelchair in the common area of the unit without the application of bilateral heel lift boots. Observation of Resident #4's skin assessment, on 02/12/14 at 11:00 AM, revealed he/she had no pressure ulcers on his/her heels. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 01/16/14 with [DIAGNOSES REDACTED]. The facility assessed the resident as having a Brief Mental Inventory (assessment of cognition) score of five (5) on 01/30/14 indicating Resident #4 was not interviewable. Further review of Resident #4's clinical record revealed a current physician's orders [REDACTED]. Review of the February 2014, monthly Treatment Administration Record (TAR) for Resident #4 revealed the order for bilateral heel lift boot application and a nurses' signature for each shift up to date of survey. Interview with CNA #1, on 02/13/14 at 10:20 AM, revealed she was assigned to Resident #4 on 02/12/14 and on 02/13/14 and she did not receive a report from the off-going CNA or the unit nurse about Resident #4 needing to have bilateral heel lift boots applied at all times. CNA #1 indicated she looked in the CNA care plan book at the nursing station and in the kiosk after she had seen the boots in Resident #4's room and there was no information there about the resident needing bilateral heel lift boots at all times. She further indicated it was the responsibility of the CNAs and the nurses together to ensure the heel lift boots were applied. Interview with Licensed Practical Nurse (LPN) #4, on 02/13/14 at 2:30 PM, revealed following physician orders [REDACTED]. She stated the physician's orders [REDACTED].#4 was transcribed onto the nursing TAR and was to be signed off by the nurse on each shift. She stated the signature of the nurse on the TAR indicated he/she was ensuring the order was followed by the CNAs and nurses. LPN #4 stated she was unaware the bilateral heel lift boots were not applied for Resident #4. Interview with MDS Registered Nurse (RN) #3 on 02/13/14 at 2:45 PM revealed the nurses and CNAs care plans should have included the physician order [REDACTED].#3 further indicated not doing so was an error. Interview with the Director of Nursing (DON), on 02/13/14 at 3:00 PM, revealed it was a standard of practice for nurses to follow physician orders. She stated an order for [REDACTED].

Based on observations, interviews and record review, it was determined the facility failed to ensure open foods were sealed, labeled, and/or dated in one (1) of one (1) freezer and one (1) of one (1) refrigerator. The facility failed to ensure kitchen appliances were clean for two (2) of two (2) appliances (stove and deep fryer). The facility failed to ensure the cleaning schedule was followed and documented. In addition, the facility failed to ensure the kitchen staff wore beard covers for three male staff members. The findings include: Review of the kitchen Sanitation and Safety Policy, dated 2009 revealed: hair restraints shall be used by kitchen staff; and leftovers must be labeled and dated Tour of the kitchen, on 03/12/13 at 8:20 AM, revealed, a container of peaches and a container of sour cream not dated when opened. There were two (2) partial bottles of tomato juice dated 01/16/13, and 4 salads without dates in the free standing two door refrigerator. The walk-in refrigerator had a pan of sliced ham which was uncovered/ no date. In the freezer there were chicken fingers, not dated. There was a scoop lying in the flour of the flour bin. The KitchenAid mixer had a white substance on the metal bowl. The convection oven had a brown/black substance on the floor of the oven. Continued observation, at this time, revealed a brown/white coating on the back splash behind the grill. The grease in the fryer was dark and had sediment floating in the grease. Currently, the fryer oil is changed on Thursdays and the kitchen serves fried fish on Fridays' In addition, there were three (3) male kitchen staff with facial hair and were not wearing beard covers. Review of the cooks and aides cleaning schedule revealed there were no cleaning chores documented as completed for cooks since 02/14/13 and for aides since 02/17/13. Interview with the Director of Food Services, on 03/13/13 at 1:30 PM, revealed he was in the process of creating a new cleaning schedule. Because the old schedule had no checks for assigned tasks, he was unable to validate the old schedule had been followed. He stated he was not aware non-food items were not discarded after seven days. He stated the male staff with facial hair should wear beard covers. He stated he was unaware of the importance of changing the fryer oil after fish had been cooked in the oil.

Based on interview, and record review, it was determined the facility failed to complete a quarterly Resident Assessment Inventory (RAI) within the time frame allotted by federal guidelines for one (1) of fifteen (15) sampled residents, Resident #1. The Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS's) Resident Assessment Inventory (RAI) 3.0 Manual (Dated October 2011), revealed the quarterly (non-comprehensive) assessment was to be completed no later than ninety-two (92) days from the Assessment Reference Date (ARD) of a previous assessment of any type. Review of the clinical record revealed the facility admitted Resident #1 on 09/01/2012 with [DIAGNOSES REDACTED]. Resident #1's clinical record contained the admission (comprehensive) assessment dated [DATE], and the quarterly assessment dated [DATE], but the facility had not completed the quarterly Minimum Data Set (MDS) assessment due 03/05/13, nine (9) days late. Interview, on 03/14/13 at 1:30 PM, with the facility's RAI/MDS Coordinator revealed Resident #1's quarterly assessment should have been completed no later than 03/05/13. The RAI/MDS Coordinator stated she was responsible for completion of the scheduled assessment, and a regional support staff person was responsible for completion of the residents' assessments in the event she had to be absent from work. Interview, on 03/14/13 at 3:05 PM, with the Director of Health Services (DHS) revealed the facility needed additional staff to assist with the MDS assessment process to ensure timely completion of the scheduled assessments.

Based on observations, interviews and record review, it was determined the facility failed to ensure open foods were sealed, labeled, and/or dated in one (1) of one (1) freezer and one (1) of one (1) refrigerator. The facility failed to ensure kitchen appliances were clean for two (2) of two (2) appliances (stove/oven and deep fryer). The facility failed to ensure the ice scoop in one (1) of two (2) dining rooms was not stored in the ice. In addition, the facility failed to ensure the kitchen staff wore beard covers for one male staff. The findings include: Tour of the kitchen, on 07/17/12 at 8:15 AM, revealed two (2) open packages of green beans on the shelf in the refrigerator, four (4) opened gallon containers of salad dressings without dates to indicate when they were opened, and an outdated container of tuna salad. The tuna salad was prepared on 07/02/12 and had expired on 07/09/12. The freezer had an opened box of pork patties. There was no date on the box and the patties were loose in the box, and unwrapped. Continued observation, at this time, revealed a brownish/black substance on the side of the fryer, inside the convection oven doors and a clear, shiny substance on the lid of the fryer. In addition, one (1) male kitchen staff did not have his beard covered and a contaminated ice scoop was sitting in the ice bowl in the dining room. Review of the kitchen's daily cleaning schedule revealed all scheduled cleaning had been initialed as completed; however, the stove, fryer, and oven have a brownish/black substance on them. There was also a shiny, clear substance on the lid and sides of the fryer. Interview with the Assistant Director of the kitchen, on 07/18/12 at 11:40 AM, revealed some of the area's on the cleaning schedule (the fryer, stove, and oven) needed further cleaning. Interview with Cook #1, on 07/18/12 at 11:45 AM, revealed he wiped the fryer and oven with a damp rag and disinfectant daily. He could not confirm when these items had last been treated with a cleaning agent. Interview with Cook #2, on 07/18/12 at 11:50 AM, revealed he cleaned the oven and stove top weekly with an oven cleaner. Residue of the spray cleaner, a white substance, was seen on the side of the grill. He had no explanation for why the residue of the cleaner had not been removed.

Based on interview and record review, it was determined the facility failed to provide a Notice of Transfer, including the right to appeal, for two (2) of thirteen (13) sampled residents, Residents #1 and #4, prior to transfer to an acute care hospital. The findings include: The facility did not have a policy regarding Notice of Transfer or the Right to Appeal. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 07/10/12 with a [DIAGNOSES REDACTED]. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 03/23/12 with [DIAGNOSES REDACTED]. There was no evidence of a notice of transfer or the right to appeal found in either clinical record. Interview and record review, on 07/19/12 at 10:15 AM, with Licensed Practical Nurse (LPN) #2 revealed a Notice of Transfer with the right to appeal was not in the clinical record for Residents #1 or #4. On 07/19/12 at 3:30 PM, interview with the Assistant Director of Health Services (ADHS) revealed she was unsure if the facility had a Notice of Transfer with resident rights documentation provided to residents or their families. She stated the facility did not give the resident documentation of Notice of Transfer including resident rights. Interview with the Business Office Manager, on 07/19/12 at 3:45 PM, revealed she was not involved in the documentation for Notice of Transfer to residents. On 07/19/12 at 4:15 PM, interview with the Director of Health Services (DHS) revealed the resident transfer rights were discussed during the resident's admission process. The DHS stated the nursing department was not involved in providing to residents the Notice of Transfer and right to appeal. Interview, on 07/19/12 at 4:45 PM, with the Customer Service Specialist revealed the Notice of Transfer was in the resident handbook given upon initial admission. She stated she was not involved in providing residents the Notice of Transfer with right to appeal, prior to residents transfer to the hospital.