Every finding on record at Westview Health Care Center

Based on medical record review, process improvement plan review, and staff interview, the facility failed to implement interventions to ensure residents were free from accident hazards in 1 of 3 sampled residents (#5) reviewed for accident hazards, which resulted in harm to the resident. The findings were:Based on medical record review, process improvement plan review, and staff interview, the facility failed to implement interventions to ensure residents were free from accident hazards in 1 of 3 sampled residents (#5) reviewed for accident hazards, which resulted in harm to the resident. The findings were:1. Review of the [DATE] quarterly MDS assessment showed resident #5 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment, and had diagnoses which included hemiplegia, difficulty walking, renal insufficiency, heart failure, coronary artery disease, and a history of a cerebrovascular accident (stroke). Further review showed the resident was dependent for all transfers, required substantial assistance with standing from a seated position, and his/her primary mode of mobility was a wheelchair. Review of the care plan dated [DATE] showed the resident was a high fall risk. Revision on [DATE] showed interventions which included .Mat on floor for safety. Additionally, medical record review showed the resident had sustained a fall on [DATE], and was sent to the hospital on [DATE] at 7:09 PM, where s/he was diagnosed with fractures to the left humerus and the 9th through 12th ribs, and pneumonia. The resident was pronounced deceased on [DATE] at 4:15 PM. The following concerns were identified:a. Review of the progress note dated [DATE] and timed 3:40 PM showed .Resident was found laying face first next to bed on the floor.Resident did not have floor mat in place upon fall.Intervention for fall is to make sure resident's floor mat is placed on floor at all times when resident is laying in bed to comfort fall.b. Interview with the DON on [DATE] at 4:39 PM confirmed there was no floor mat next to the resident's bed at the time of the fall, further stating This is why we put the PIP and other interventions in place. c. Review of the resident pain level summary showed the resident experienced pain on 11 different occasions following the fall between [DATE] through [DATE]. d. Review of the emergency room physician note dated [DATE] showed the resident complained of left arm pain and shortness of breath. Further review showed he/she was diagnosed with pneumonia. e. Review of the chest x-ray report dated [DATE] and timed 7:52 PM showed.1.Pneumonia.2. displaced fracture of the proximal left humerus, correlate for recent trauma and point tenderness. f. Review of the CT angiography of the chest dated [DATE] and timed 9:36 PM showed fractures of the 9 th through 12 th ribs. 2. Review of the document titled Quality Assurance & Performance Improvement plan (PIP) dated [DATE] showed .The DON will track/trend falls and interventions, as well as review weekly audits and report findings to monthly QAPI for review and feedback for 90 days or until substantial compliance is achieved. Review of intervention audit forms provided by the NHA on [DATE] at 12:40 PM were blank. 3. Interview with the DON and NHA on [DATE] at 4:19 PM revealed there was no evidence the audits were completed. 4. Review of the document titled Fall Management last revised [DATE] provided by the DON on [DATE] at 10 AM showed .3. Implement Interventions.consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident.

Based on observation, staff interview, review of the kitchen training manual, and the 2022 FDA Food Code, the facility failed to ensure a sanitary environment in 1 of 1 food preparation area. The census was 61. The findings were: 1. Observation on 11/1/23 at 9:19 AM showed cook #1 was starting the food preparation tasks for the noon meal. The following concerns were identified: a. At 9:45 AM the cook washed her hands and donned gloves to place frozen breaded shrimp into hot oil to fry. After placing the shrimp into the oil the cook removed her gloves and without washing her hands proceeded to put away clean dishes. At 9:54 AM the cook washed her hands and donned gloves to place the second batch of shrimp into the oil; removed her gloves; transferred the first batch of shrimp into a pan to keep warm in the oven; and then began preparing the rice and the broccoli for the noon meal. Observation at 10:33 AM showed the cook washed her hands; donned gloves, and transferred frozen hamburger patties with her gloved hands to a prepared baking pan. The cook doffed her gloves and without washing her hands returned the box of frozen hamburger patties back to the freezer, and continued to tend to the shrimp. This pattern of washing her hands; donning gloves to perform a task; doffing her gloves; and starting a new task without washing her hands, was repeated several times throughout the food preparation process. 2. Observation on 11/1/23 at 10:15 AM showed dietary aide #1 donned gloves; scratched his armpit; entered the dietary manager's office; obtained supplies from the walk-in refrigerator and various utensils and food items from different areas of the kitchen. The aide was observed draining a can of pineapple over a colander in the sink which resulted in the pineapple juice soiling his gloves. Without changing his gloves the dietary aide entered the dry storage room and obtained a bag of marshmallows; poured the drained pineapple into a large container; checked the mixer; entered the walk-in refrigerator to obtain a jar of maraschino cherries; and opened a can of peaches over a colander in the sink with the juice once again soiling his gloves. With the same gloved hands the dietary aide removed the paddle from the mixing bowl of whipped cream and took it to the dishwashing room; retrieved a spatula, cutting board, and a knife; opened the bag of marshmallows and using his gloved hands transferred a portion of the marshmallows to the mixing bowl. The dietary aide then opened the container of maraschino cherries and using the same gloved hands reached into the container to remove some cherries and cut them up. The dietary aide was observed to add more marshmallows and cherries to the mixing bowl with his gloved hands until he doffed his gloves at 10:37 AM. 3. Observation at 10:13 AM showed cook #1 used a knife to slice butter for the rice. After using the knife she placed it in the hand washing sink. Continued observation showed both cook #1 and dietary aide #1 used the sink to wash their hands. At 10:42 AM cook #1 rinsed the knife in the hand washing sink and placed it back onto the counter for reuse. 4. Interview on 11/1/23 at 11:02 AM with cook #1 confirmed she had washed her hands in the sink with the knife. Further, the cook stated she was trained to place the knives in the hand washing sink because they cannot go in the dishwasher. 5. Interview on 11/1/23 at 10:46 AM with the dietary manager confirmed hand washing should occur before gloves were donned, after the gloves had been removed, and gloves should be changed between tasks. In addition, the dietary manager stated knives should be hand washed in the 3 compartment sink. 6. Review of the Food and Nutrition Services In-Service Training Manual Chapter 1: Food Safety and Infection Control document received from the facility on 11/1/23 showed .Important: Gloves are not a substitute for hand washing. Before you put on gloves: Gather all food items needed for the task at hand. Wash your hands. Wash hands each time new gloves are used. Change gloves: When they tear or become soiled or contaminated. Before changing tasks. After no more than four hours of continual use. After handling cooked or ready-to-eat food. After handling raw food. After touching any unsanitary or unclean item or surface such as an oven door, refrigerator handle, scoop or spoodle handle, the bottom of a plate or pan, or the outside of a bread bag. Note: Wash your hands each time you change into new gloves . 7. According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 8. According to the 2022 FDA Food Code showed 6-301.13 Hand washing Aids and Devices, Use Restrictions. A sink used for FOOD preparation or UTENSIL washing, or a service sink or curbed cleaning facility used for the disposal of mop water or similar wastes, may not be provided with the hand washing aids and devices required for a HAND WASHING SINK as specified under SS 6-301.11 and 6-301.12 and 5-501.16(C). 9. According to the 2022 FDA Food Code showed 4-603.15 Washing, Procedures for Alternative Manual Warewashing Equipment. If washing in sink compartments or a WAREWASHING machine is impractical such as when the EQUIPMENT is fixed or the UTENSILS are too large, washing shall be done by using alternative manual WAREWASHING EQUIPMENT as specified in 4-301.12(C) in accordance with the following procedures: (A) EQUIPMENT shall be disassembled as necessary to allow access of the detergent solution to all parts; (B) EQUIPMENT components and UTENSILS shall be scraped or rough cleaned to remove FOOD particle accumulation; and (C) EQUIPMENT and UTENSILS shall be washed as specified under 4-603.14(A) .4-603.16 Rinsing Procedures. Washed UTENSILS and EQUIPMENT shall be rinsed so that abrasives are removed and cleaning chemicals are removed or diluted through the use of water or a detergent-sanitizer solution by using one of the following procedures: (A) Use of a distinct, separate water rinse after washing and before SANITIZING if using: (1) A 3-compartment sink, (2) Alternative manual WAREWASHING EQUIPMENT equivalent to a 3-compartment sink as specified in 4-301.12(C), or (3) A 3-step washing, rinsing, and SANITIZING procedure in a WAREWASHING system for CIP (clean in place) EQUIPMENT; (B) Use of a detergent-SANITIZER as specified under S 4-501.115 if using: (1) Alternative WAREWASHING EQUIPMENT as specified in 4-301.12(C) that is APPROVED for use with a detergent-SANITIZER, or (2) A WAREWASHING system for CIP EQUIPMENT; (C) Use of a nondistinct water rinse that is integrated in the hot water SANITIZATION immersion step of a 2-compartment sink operation .

Based on resident, resident representative, and staff interviews, medical record review, and review of facility policy, the facility failed to notify the appropriate entities for 2 of 6 (#22, #28) sample residents reviewed for notification of changes. The findings were: 1. During an interview with resident #22 on 7/10/23 at 3:35 PM the resident stated 2 night shift staff threw the resident in a wheelchair and slapped his/her left cheek causing a little stinging to the cheek. The resident stated s/he reported it to the head lady and the facility did not tell the family representative about the event. a. Interview with the resident's representative on 7/10/23 at 3:41 PM revealed the resident notified him/her of the event however, s/he never heard anything from the facility about the event. b. Interview with nurse aide (NA) #3 on 7/11/23 at 3:20 PM revealed resident #22 did tell her in June 2023 about being thrown around, and NA #3 told the nurse but didn't remember who the nurse was. c. Interview with the DON on 7/10/23 at 1:30 PM revealed the facility did not have any reports and was unaware of the event. Further review failed to show the resident had been assessed or monitored. 2. Interview with the resident #28 on 7/11/23 at 2:30 PM revealed the resident had been slapped by a staff member on the shoulder after he pinched her bottom. a. Interview with staff #3 on 7/11/23 at 3:20 PM confirmed she had slapped the resident on the shoulder as a reaction on 6/25/23 after this resident pinched her bottom. The staff member herself notified the nurse on duty at that time. b. Interview with resident #28 representative on 7/11/23 at 5 PM revealed he had not been notified by the facility the resident was slapped by a staff member. c. Interview with the DON on 7/11/23 at 4:20 PM showed the facility did not start an investigation, notify the doctor, state agencies or the family because the NA slapped the resident with an open hand and did not cause an injury. Further review failed to show a thorough investigation, and no assessments or monitoring in the resident's record. d. Review of the facility policy titled Protection of Residents: Reducing the Threat of Abuse & Neglect last revised 1/21/19 showed; 2. All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/ or facility representative. 3. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g.,bruising and skin tears) will be immediately reported to the administrator and/or director of nursing. 4. when an incident of resident abuse is suspected, the incident must be reported to the supervisor regardless of the time lapse since the incident occurred. The supervisor notifies the director of nursing and the executive director of the alleged incident. 6. the charge nurse will complete and sign the Incident Report and notify the physician and the resident's representative of the occurrence.8. The charge nurse will immediately assess the resident and offer medical attention, if necessary. Findings of the assessment and any treatment provided will be documented in the resident's medical record 11 . Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited 12. Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations.

Based on resident and staff interviews, medical record review, and review of facility policy, the facility failed to report a reasonable suspicion of a crime against a resident for 1 of 2 (#28) sample residents reviewed for abuse allegations. The findings were: Review of the quarterly minimum data set (MDS) assessment the 6/5/23 for resident #28 showed the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment and diagnoses which included diabetes mellitus, hypertension, and post traumatic stress disorder. Interview with the resident on 7/11/23 at 2:30 PM revealed the resident had been slapped by a staff member on the shoulder after s/he pinched the staff member's bottom. The following concerns were identified: 1. Interview with NA (non-certified nursing assistant) #3 on 7/11/23 at 3:20 PM confirmed s/he had slapped the resident on the shoulder on 6/23/25 as a reaction after this resident pinched his/her bottom. The staff member notified the nurse on duty at that time. a. Interview with the DON on 7/11/23 at 4:20 PM confirmed the facility did not start a risk management report, or report the incident to the state agency. The DON verbalized the resident was slapped by a staff member with an open hand which did not cause an injury. b. Review of the Wyoming Department of Healthcare Licensing and Survey incident data base showed no incidents of staff-to-resident abuse had been reported by the facility from 1/1/23 to 7/5/23. c. Review of the facility list of incident reports from 1/1/23 to 7/10/23 failed to show any reports created for resident #28 on 6/23/23. d. Interview with the Executive Director and Director of Nursing on 7/12/23 at 1:35 PM confirmed the incident was not reported to the state survey agency as required because the resident admitted to pinching the staff member's bottom and no injury occurred. d. Review of the facility policy titled Protection of Residents: Reducing the Threat of Abuse & Neglect last revised 1/21/19 showed; 3. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g.,bruising and skin tears) will be immediately reported to the administrator and/or director of nursing .12. Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations.

Based on medical record review, staff interview, and policy review the facility failed to ensure a written notice of transfer was provided as required for 3 of 4 sample residents (#9, #23, #54) reviewed for facility-initiated transfer. The findings were: 1. Review of current physician orders showed resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. Review of the resident's order history showed two separate physician orders, written on 5/30/22 and 9/1/22, to transfer the resident to the hospital for evaluation. b. Review of the medical record showed no evidence the resident, representative, family members, or the ombudsman were provided a written notice of either transfer to the hospital. 2. Review of the medical record for resident #23 showed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns where identified: a. Review of the progress notes showed the resident was hospitalized on [DATE] following a fall causing right hip pain. Further review of the medical record failed to show evidence a written notice of transfer was provided to the resident's representative. 3. Review of the progress notes showed resident #54 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of the nursing progress notes showed the resident was transferred to the emergency department on 9/14/22 with an irregular heart rate. b. Review of the medical record failed to show a written notice of transfer was provided to the resident and the resident representative. c. Interview on 9/22/22 at 9:03 AM with the administrator confirmed the resident and the resident representative were not provided with a notice of transfer. 4. Interview with the DON on 9/21/22 at 5:44 PM confirmed written notices of transfer had not been provided to the residents or resident representatives. 5. Review of the facility policy Bedhold/Reservation of Room, effective 5/2/19, showed Procedure . 2. Before the resident transfers to a hospital or the resident goes on therapeutic leave, the facility will provide written information for the resident or responsible party that specifies: .In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or responsible party are provided with written notification within 24 hours of the transfer.

Based on medical record review, staff interview, and review of facility policy, the facility failed to provide written information on the bed-hold policy for 3 of 4 sample resident (#9, #23, #54) reviewed for facility-initiated transfers. The findings were: 1. Review of current physician orders showed resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. Review of the resident's order history showed two separate physician orders, written on 5/30/22 and 9/1/22, to transfer the resident to the hospital for evaluation. b. Review of the medical record showed no evidence the resident or the resident's representative were provided a bed hold policy for either transfer to the hospital. 2. Review of the medical record for resident #23 showed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concern where identified: a. Review of the progress notes showed the resident was hospitalized on [DATE] following a fall causing right hip pain. Further review of the medical record failed to show evidence the facility issued a written notice of the bed-hold policy to the resident or resident's representative. 3. Review of the progress notes showed resident #54 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of the nursing progress notes showed the resident was transferred to the emergency department on 9/14/22 with an irregular heart rate. b. Review of the medical record showed no evidence the bed hold policy was provided to the resident and the resident representative. c. Interview on 9/22/22 at 9:03 AM with the administrator confirmed the resident and the resident representative were not provided with a bed hold policy. 4. Interview with the DON on 9/21/22 at 5:44 PM confirmed the facility had not issued a bed hold policy to the residents or resident representatives. 5. Review of the facility policy Bedhold/Reservation of Room, effective 5/2/19, showed Procedure . 2. Before the resident transfers to a hospital or the resident goes on therapeutic leave, the facility will provide written information for the resident or responsible party that specifies: . The duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility .The reserve bed payment policy in the state plan, if any .The facility policies regarding bed-hold .In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or responsible party are provided with written notification within 24 hours of the transfer.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure safe food handling practices were implemented and maintained during inspection of 1 of 1 food preparation and storage areas. The following concerns were identified: 1. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed an upright reach-in freezer with a temperature log for September 2022 posted on the front of the unit. Further review of the log showed AM temperatures were not documented on 9/3/22, 9/9/22, 9/10/22, 9/15/22, or 9/16/22, and PM temperatures were not documented on 9/6/22, 9/7/22, 9/14/22, or 9/18/22. Continued review showed every documented temperature was above 0 degrees Fahrenheit. 2. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed a temperature log for September 2022 posted for documentation of temperatures for the walk-in freezer. Further review of the log showed AM temperatures were not documented on 9/3/22, 9/9/22, 9/10/22, 9/15/22, or 9/16/22, and PM temperatures were not documented on 9/6/22, 9/7/22, 9/13/22, 9/14/22, or 9/18/22. Continued review showed all documented temperatures were above 0 degrees Fahrenheit. 3. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed an upright reach-in refrigerator with a temperature log for September 2022 posted on the front of the unit. Further review of the log showed AM temperatures were not documented on 9/3/22, 9/9/22, 9/10/22, 9/12/22, 9/15/22, or 9/16/22, and PM temperatures were not documented on 9/6/22, 9/7/22, 9/14/22, or 9/18/22. Continued review showed a documented temperature of 45 degrees Fahrenheit. 4. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed a walk-in refrigerator with a temperature log for September 2022 posted on the front of the unit. Further review of the log showed AM temperatures were not documented on 9/3/22, 9/9/22, 9/10/22, 9/15/22, or 9/16/22, and PM temperatures were not documented on 9/6/22, 9/7/22, 9/14/22, or 9/18/22. 5. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed a thick build-up of grease on the surfaces of the stove burners and griddle. Further observation showed the burners of the stove had a large build-up of burnt-on food and grease, and the area underneath the burners had a large amount of burnt crumbs and debris. 6. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed the conveyor toaster had a build-up of burnt food and grease on the face, conveyor, and interior surfaces of the appliance. 7. Observation of the kitchen, food preparation areas, and food storage areas on 9/19/22 at 3:24 PM showed the range hood above the stove and a food preparation cart with a large amount of dust and debris along the interior surfaces of the hood. 8. Interview with the dietary manager on 9/21/22 at 1:13 PM confirmed the temperature logs were all lacking multiple temperature checks. She stated a new employee was working those shifts, and she wasn't sure if the new employee was aware of all her responsibilities yet. The dietary manager further confirmed the range hood, stove, and conveyor toaster all were needing cleaned. She stated she was in the process of implementing a new weekly cleaning schedule to address cleanings as a team on a regular basis. 9. Review of undated facility policy Food in Storage Areas showed guidelines for refrigeration as Keep temperatures between 34oF and 38oF. Record temperatures a minimum of twice daily. Further review showed freezer guidelines as Keep at 0oF or below or per state regulation. 10. According to Food Code 2017, U.S. Public Health Service: 3-501.16 (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less.

Based on observation, staff interview, and review of professional standards of practice for feeding tubes, the facility failed to ensure professional standards of practice were followed for 1 of 1 observation of medication administration via a feeding tube (resident #13). The findings were: 1. Observation on 9/21/22 at 1 PM showed LPN #2 administered medications to resident #13, who had a feeding tube. Continued observation showed the resident lying flat in bed. The following concerns were identified: a. Interview with the LPN on 9/21/22 at 1 PM confirmed the patient was lying flat in bed, and the head of the bed should have been elevated while administering medication through the feeding tube to prevent aspiration. b. Review of Lippincott Nursing Procedures, Seventh Edition showed .Keep the head of the patient's bed elevated at a 30-to 45-degree angle at all times during the enteral tube feeding administration and for 30 to 60 minutes after the feeding has been completed or stopped for any reason .

Based on observation, staff interview and policy and procedure review, the facility failed to ensure medications and supplies for patient use were not expired in 1 of 2 medication rooms (central medication room) observed. Additionally, the facility failed to ensure medications and supplies were kept secure for 1 of 1 random observations of medication rooms (Saddle Ridge Unit medication room). The findings were: 1. Observation on [DATE] at 1:36 PM of the central medication room showed the following items were expired: a. 5 Buff NA [MEDICATION(S)] 3.2% vacutainers (for blood collection) with an expiration date [DATE]. b. 3 Universal [CONDITION(S)] Transport for viruses, chlamydia, & mycoplasmas & urea plasmas swab & collection containers with an expiration date [DATE]. c. 1 bottle of Tums [MEDICATION(S)] Smoothies Berry Fusion with an expiration date ,d+[DATE]. d. 1 1 ounce tube of [MEDICATION(S)] hydrocortisone cream 1% with an expiration date ,d+[DATE]. e. 1 4 mm Integra Miltex Disposable Dermal Curette with an expiration date [DATE]. f. [NAME] Skin Protectant Ointment with vitamins A&D 5 G tubes: 3 with an expiration date ,d+[DATE], 2 with an expiration date ,d+[DATE], 2 with an expiration date ,d+[DATE], 1 with an expiration date ,d+[DATE], and 2 with an expiration date ,d+[DATE]. g. 1 packet of [NAME] Lubricating Jelly with an expiration date [DATE]. h. 1 Cutimed Sorbact WCL 4 inch by 5 inch (wound dressing) with an expiration date ,d+[DATE]. i. 5 Xeroform Occlusive Gauze Patch 4 inch by 4 inch (wound dressing) with an expiration date [DATE]. j. 1 [MEDICATION(S)] AG 4 inch by 4 inch (wound dressing) with an expiration date ,d+[DATE]. k. Interview with LPN #2 confirmed the items in the medication room were for patient use. l. Review of the facility policy 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date [DATE], showed .4. Facility should ensure that medications and biological that: (1) have an expired date on the label; 92) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier . 2. Observation of the Saddle Ridge Unit medication room on [DATE] at 2:55 PM showed the door was open, unattended and no staff was in the area. a. The nurse returned at 3:00 PM, interview at that time with RN #1 confirmed the door to the medication room was left open and it should be kept closed and locked. b. Review of the facility policy 5.3 Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, with a revision date [DATE], showed .3.3 Facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors .

Based on observation, staff interview, policy and procedure review, and review of manufacturer's instructions, the facility failed to perform hand hygiene as required during one random observation during dining services. In addition, the facility failed to ensure glucometers were disinfected as required for 1 of 2 random observations of glucometer disinfection. The following concerns were identified: 1. Observation on 9/19/22 at 4:45 PM showed LA #1 serving drinks to residents during the dinner service. It was noted he was not wearing gloves at that time. Continued observation showed pushing the beverage cart around to residents, and making contact with the residents and their items. No observations of hand hygiene were observed between resident contacts. Continued observation showed the LA inserted his right hand down the back of his own pants three times to tuck his shirt in. No hand hygiene was observed after these actions. 2. Observation on 9/19/22 at 5:01 PM showed LA #1 serving drinks from the beverage cart. After preparing a cup of hot chocolate, he plunged his right arm up to his elbow down into a trash bag that was hanging from the side of the cart, which was approximately one quarter of the way full of garbage. He then used his right hand to handle the hot water pitcher and spoon to stir the beverage, then used his right hand to deliver the beverage to the resident. No hand hygiene was observed after these actions. 3. Interview with LA #1 on 9/19/22 at 5:03 PM revealed he typically serves beverages to the residents during the lunch and dinner services. Further, he didn't think about needing to wash his hands after tucking his shirt in, putting his arm in the trash, or in between contact with residents and their items. 4. Observation on 9/20/22 at 4:35 PM with LPN #1 showed she used a Oxyvir TB wipe on a glucometer. She wiped the glucometer and set it down. The surface of the glucometer was dry within 40 seconds. Interview with the LPN at that time revealed she was not aware of the necessary wet contact time to achieve disinfection of the glucometer. Review of the directions for use on the container showed the surface must remain wet for 1 minute. 5. Review of facility policy Standard Precautions, last reviewed 12/31/20, showed Standard precautions include: (1) Hand hygiene . Perform hand hygiene: . a. Before and after all resident contact; . c. Contact with blood, body fluids, or visibly contaminated surfaces; . (5) Safe handling of equipment or items that are likely contaminated with infectious body fluids . (6) Cleaning and disinfecting or sterilizing of potentially contaminated surfaces and equipment between resident use .

Based on resident and staff interview, review of the staffing schedule, and policy review, the facility failed to provide sufficient staff for 3 of 3 resident care units (Saddle Ridge, Long Hall, Short Hall). The census was 60. The findings were: 1. Group interview with 11 residents on 9/14/21 at 2 PM revealed residents felt they had to wait an extended amount of time to receive assistance during the night shift. Resident #33 stated s/he had to wait for assistance for 1 ½ hours when the facility had 1 CNA working night shift. 2. Interview with resident #3 on 9/14/21 at 11:14 AM revealed the facility did not have enough staff to assist residents and it caused him/her to wait extended periods to get help. Further interview revealed the facility only staffed 1 CNA for 2 halls, usually in the evening and night. 3. Interview with resident #49 on 9/14/21 at 10:09 AM revealed the resident did not feel the facility had enough CNAs to provide resident care. 4. Interview with LPN #3 on 9/15/21 at 8:07 AM revealed the facility was constantly running short handed on staff, and did not always have the minimum staff needed to provide resident care. 5. Interview with the staff development coordinator on 9/16/21 at 8:17 AM confirmed the facility had 60 residents and the facility was usually staffing 3 CNAs for the night shift. Further interview revealed the facility tried to staff for resident needs. 6. Review of the nursing staff schedule for August 2021 showed the facility utilized 2 CNAs for the night shift on 19 of 31 days. Review of the nursing staff schedule for September 2021 showed the facility utilized 2 CNAs for the night shift on 10 of 15 days and utilized 1 CNA for the night shift on 3 of 15 days. 7. Review of the policy titled Administrative General Policies last revised 3/9/21 showed .The facility utilizes the Facility Assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met .

Based on observation, staff interview, and policy and procedure review the facility failed to ensure medications were labeled with an open date and medications available for use were not expired in 3 of 5 medication storage's (Saddle Ridge medication cart, Saddle Ridge medication room, Long Hall medication cart). The findings were: 1. Observation on [DATE] at 7:42 AM of the Saddle Ridge medication cart showed 1 Novolog ,d+[DATE] suspension 100 unit per milliliter (ml) flex pen was not dated. Further, observation showed 2 [MEDICATION(S)] 100 units per ml kwik pens were not dated. Interview with RN #2 at that time confirmed the injection pens were not dated and should have been, and also confirmed the medications were available for resident use. 2. Observation on [DATE] at 8:50 AM of the Saddle Ridge medication room showed 2 bags of [MEDICATION(S)] 50 milligram (mg) per 260 ml bag normal saline solution which had an expiration date of [DATE], and 1 bag of 0.9% [MEDICATION(S)] 250 ml solution which had an expiration date of [DATE]. In addition, there were 8 [MEDICATION(S)] 2 ml vials which had expiration dates of ,d+[DATE]. Interview at that time with RN #3 confirmed the medications were for available for resident use and were expired. 3. Observation on [DATE] at 9:15 AM of the Long Hall medication cart showed 2 [MEDICATION(S)] flextouch insulin pens with no written open date. Interview at that time with LPN #3 confirmed the medications were available for resident use and were not dated. 4. Review of the policy titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised on [DATE] showed .5. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law .

Based on staff interview, medical record review, review of State Survey Agency incident report logs, and policy and procedure review, the facility failed to report allegations of abuse to the State Survey Agency for 1 of 2 residents (#30) reviewed for abuse. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had a brief interview of mental status (BIMS) score of 6 out 15, which indicated the resident was severely cognitively impaired. The following concerns were identified: a. Interview with CNA #3 on 9/15/21 at 4:35 PM revealed the CNA had observed RN #1 attempting to give the resident medications on a camera monitor at the nurse's station. The resident attempted to refuse the medications and the CNA observed the RN kneel on the resident's arm and put the medications in the resident's mouth. The CNA and LPN #1 went to the resident's room after the observation on the camera monitor and upon entering the room, observed the resident spit out the medication. The CNA stated RN #1 grabbed the resident's hand and forced the resident to take the medication. Further interview revealed the CNA and LPN #1 reported the incident to the DON. b. Interview with LPN #1 on 9/16/21 at 10:08 AM revealed she and CNA #3 observed, on a camera at the nurse's station, resident #30 swatting at RN #1. The RN grabbed the resident's arm, placed it on the bed, and knelt on the residents arm with her knee. The LPN and CNA went to the resident's room following the observation. The LPN revealed upon entry in the resident's room, she observed the RN put a spoon full of medications in the resident's mouth, forced water into the resident's mouth with a syringe, and placed a wipe over the resident's mouth. The LPN stated the resident was trying to yell out and she heard gurgling when the resident tried to speak. Further interview revealed the LPN reported the incident to the MDS coordinator and stated the incident occurred at the end of July. c. Review of the State Survey Agency incident report logs failed to show this allegation was reported to the agency as required. d. Interview with the MDS coordinator on 9/16/21 at 10:20 AM revealed she was notified of the incident between resident #30 and RN #1. She did not remember the date the incident was reported to her and confirmed she did not report the allegation further. e. Interview with the DON on 9/16/21 at 8:35 AM revealed she was notified of the incident between resident #30 and RN #1 during an investigation into another incident involving the RN, and further revealed LPN #1 reported she was in the room with RN #1 when the RN leaned on the resident's arm, forced the resident to take medications and water, and covered the resident's mouth with a tissue to prevent the resident from spitting out the medications. The DON was unsure when the alleged incident occurred. 2. Review of the policy titled Protection of Residents: Reducing the threat of Abuse & Neglect last revised on 4/15/19 showed .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .

Based on staff interview, medical record review, and policy and procedure review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 2residents (#30) reviewed for abuse. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had a brief interview of mental status (BIMS) score of 6 out 15, which indicated the resident was severely cognitively impaired. The following concerns were identified: a. Interview with CNA #3 on 9/15/21 at 4:35 PM revealed the CNA had observed RN #1 attempting to give the resident medications on a camera monitor at the nurse's station. The resident attempted to refuse the medications and the CNA observed the RN kneel on the resident's arm and put the medications in the resident's mouth. The CNA and another nurse went to the resident's room after the observation on the camera monitor and, after entering the room, observed the resident spit out the medication. The CNA stated the RN grabbed the resident's hand and forced the resident to take the medication. Further interview revealed the CNA and LPN #1 reported the incident to the DON. b. Interview with LPN #1 on 9/16/21 at 10:08 AM revealed her and CNA #3 observed, on a camera at the nurse's station, resident #30 swatting at RN #1. The RN grabbed the resident's arm, placed it on the bed, and knelt on the resident's arm with her knee. The LPN and CNA went to the resident's room following the observation. The LPN revealed upon entry in the resident's room, she observed as RN #1 put a spoon full of medications in the resident's mouth, forced water into the resident's mouth with a syringe, and placed a wipe over the resident's mouth. The LPN stated the resident was trying to yell out and she heard gurgling when the resident tried to speak. Further interview revealed the LPN reported the incident to the MDS coordinator and stated the incident occurred at the end of July. c. Interview with the DON on 9/16/21 at 8:35 AM revealed she was notified of the incident between resident #30 and RN #1 during an investigation into another incident involving RN #1. Also confirmed an investigation was not conducted. 2. Review of the policy titled Protection of Residents: Reducing the threat of Abuse & Neglect last revised on 4/15/19 showed .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: .Have evidence that all alleged violations are thoroughly investigated .

Based on medical record review, policy and procedure review, and staff interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 19 residents (#5) with care plans reviewed for development. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident was coded as wandering occurred daily. The following concerns were identified: a. Review of the resident's risk assessment dated [DATE] showed resident is at risk for elopement. b. Review of a progress note dated [DATE] showed the interdisciplinary team (IDT) documented the resident would rummage quite often and roam around looking for his/her deceased spouse. c. Review of the care plan last revised on [DATE], showed elopement and wandering were not addressed. d. Interview with LPN #3 on [DATE] at 9:25 AM revealed staff did not review care plans often and she was sure the care plan did not show anything about elopement precautions. 2. Review of the policy and procedure titled Baseline Care Plan provided by the facility on [DATE] showed .The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .

Based on medical record review, staff interview, review of policy and procedure, and review of a clinical drug resource, the facility failed to ensure unnecessary [CONDITION(S)] medications were not used for 2 of 5 sample residents (#18, #30) reviewed for medication regimen. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #18 had a brief interview for mental status (BIMS) score of 2 out 15, which indicated severe cognitive impairment and had diagnoses which included non-Alzheimer's dementia. Further review showed the resident had physical behavioral symptoms and verbal behavioral symptoms directed toward other 4 to 6 days during the look back period, but less than daily. Review of the physician orders for September 2021 showed the resident received [MEDICATION(S)] (antipsychotic) 1 milligram (mg) by mouth every 12 hours related to unspecified dementia with behaviors, [MEDICATION(S)] (antidepressant) 50 mg by mouth once per day for depression, and [MEDICATION(S)] (sedative/hypnotic) 0.5 mg by mouth at bedtime for dementia. The following concerns were identified: a. Review of the antidepressant medication care plan last revised on 8/16/21 showed medication side effects were identified; however, there were no specific target symptoms for the use of the medication identified. b. Review of the anti-anxiety medication care plan last revised on 8/16/21 showed medication side effects were identified; however, there were no specific target symptoms for the use of the medication identified. c. Review of the [CONDITION(S)] medication care plan last revised on 8/16/21 showed medication side effects were identified; however, there were no specific target symptoms for the use of the medication identified. d. Review of the Behavior Monitoring form provided by the facility on 9/16/21 showed the psychoactive medication sections and target behaviors for the medications were not completed. e. According to Beizer, Semla, and Higbee in Geriatric Dosage Handbook, 12th edition, 2007, on page 1389: .[MEDICATION(S)] .[MEDICATION(S)] is not approved for the treatment of dementia-related [CONDITION(S)] . f. Interview with the social services director on 9/16/21 at 9:26 AM revealed the resident had target symptoms which included exit seeking, verbal and physical aggression, impulsivity, and packing belongings to leave the facility. Further interview confirmed target symptoms were not identified for each medication the resident used. 2. Review of the admission MDS assessment dated [DATE] showed resident #30 had diagnoses which included [CONDITION(S)], other fracture, non-Alzheimer's dementia, and asthma. Further review showed the resident had a brief interview of mental status (BIMS) score of 6 out 15, which indicated the resident was severely cognitively impaired. Review of the physician orders for September 2021 showed the resident received [MEDICATION(S)] (antipsychotic) 50 mg by mouth at bedtime for dementia and Trazadone (antidepressant) 50 mg at bedtime for [CONDITION(S)]. The following concerns were identified: a. Review of the [CONDITION(S)] medication care plan last revised on 5/27/21showed medication side effects were identified; however, there were no specific target symptoms for the use of the medication identified. b. Review of the antidepressant medication care plan last revised on 5/27/21 showed medication side effects were identified; however, there were no specific target symptoms for the use of the medication identified. c. Review of the Behavior Monitoring form provided by the facility on 9/16/21 showed the psychoactive medication sections and target behaviors for the medications were not completed. e. According to Beizer, Semla, and Higbee in Geriatric Dosage Handbook, 12th edition, 2007, on page 1330: .[MEDICATION(S)] .Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at an increased risk of death compared to placebo. [MEDICATION(S)] is not approved for this indication . d. Interview with the social services director on 9/16/21 at 9:38 AM revealed the resident received Trazadone to help the resident sleep and the [MEDICATION(S)] was for depression. Social service director interview revealed the resident displayed symptoms of crying, self-pity, vocalization of concerns about spouse and marital status, irritability, and verbal abuse. Further interview confirmed target symptoms were not identified for each medication the resident used. 3. Review of the policy titled [CONDITION(S)] Medication Use last revised on 11/28/16 showed .Facility staff should take a holistic approach to behavior management that involves thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions .[CONDITION(S)] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving [CONDITION(S)] medication for organic mental syndrome with agitated or psychotic behavior(s) .Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and resident's response to staff interventions .

Based on medical record review, staff interview, review of policy and procedures, and review of incident reports, the facility failed to ensure residents were protected from unwanted sexual touching for 1 of 5 residents (#1) reviewed for abuse. The findings were: Review of the 6/16/21 facility reported incident (#2021-1809) involving residents #1 and #2 showed resident #2 inappropriately touched resident #1 under the shirt on the breasts while in the dining room. Resident #2, who was mobile in his/her wheelchair, was removed from the area by staff who observed the incident and took the resident to the activity room. The staff member notified the nurse of the the incident and the location of resident #2 in the activity room. Resident #1 remained in the dining room eating. The incident report showed the time of the occurrence was 5:15 PM. Continued review showed resident #2 returned to the dining room and again touched resident #1 on the breasts. There was no time entered for when the second incident occurred. The report showed the facility administrator reported the incident to the survey agency on 6/16/21 at 6:28 PM. The report further showed both residents were severely demented and were unable to recall the events. [Resident #1] continued to eat during these events and was not injured nor did [s/he] exhibit any signs or symptoms of fear or withdrawal. Review of the 6/11/21 quarterly MDS assessment showed resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further showed no behaviors, and severe cognitive impairment with a BIMS score of 0/15. Review of the 5/1/21 quarterly MDS assessment showed resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Walking and locomotion off the unit did not occur. The assessment further showed the resident had no behaviors, and had severe cognitive impairment with a BIMS score of 0/15. Review of the care plan for resident #2, updated on 6/30/21, showed it included 1 to 1 staff supervision of the resident when up in his/her wheelchair to prevent any further behaviors of inappropriate touching. The following concerns were identified: a. Interview with CNA #1 on 6/30/21 at 4:30 PM confirmed she observed the incident in the dining room and took resident #2 to the activity room and reported to LPN #1. She stated she then returned to the dining room and was assisting another resident with eating when she saw resident #2 again in the room with his/her hands up resident #1's shirt. She intervened and moved the resident back to his/her room, notified the nurse and the resident was transferred from the wheelchair into the recliner. The CNA stated both residents were confused and this was not usual behavior for resident #2. She was unaware of any previous incidents involving the resident touching others inappropriately. She stated resident #2 continued to stay at the table and eat, and did not appear to be affected. b. Interview with LPN #1 on 6/30/21 at 4:40 PM confirmed the CNA had informed her of the incident and made her aware resident #2 was in the activity room. The nurse stated she saw the resident start to wheel out of the room; however, she didn't think [s/he] would do it again. She verified she was not aware the resident had gone back to the dining room. When she was informed of the second incident, the resident was transferred from the wheelchair to the recliner in his/her room and she notified the DON. She was not sure how much time elapsed between incidents. c. Review of the progress note dated 6/16/21 at 9:47 PM for resident #1 showed LPN #1 noted the incident and documented the inappropriate touching had occurred twice. The note showed resident #1 continued eating and .did not appear to be affected negatively. DON [director of nursing] notified. The note did not include any assessment or details related to the resident's physical or psychological state. Further review of the medical record failed to show any physical assessment was completed of the resident following the incident. d. Review of the medical record for resident #2 showed a progress note dated 6/16/21 at 9:39 PM where LPN #1 noted the resident's involvement in the incident. The note did not include any assessment or details related to the resident's physical or psychological state. Further review of the medical record failed to show any assessment was completed for this resident following the incident. e. Interview with the nursing home administrator on 6/30/21 at 5:03 PM confirmed she was uncertain of how much time elapsed between the two incidents in the dining room. She stated they occurred back to back. She further verified she was notified by the DON and made the initial report to the state agency that evening regarding the resident to resident sexual abuse investigation. The interventions put into place to protect residents was the initial removal of the resident from the dining room and the one to one staff supervision after the 2nd incident occurred. This intervention became part of the resident's care plan to be implemented when s/he was up in the wheelchair. The administrator further verified the investigation showed it was an unusual event and the resident had no previous inappropriate behaviors with others. She confirmed there was no specific monitoring done after the incident, and resident #2 was determined to be unaffected. She stated if nursing assessments were completed after the incident they would be included in the medical records. She would check with her DON who was unavailable at that time. Interview with the administrator on 7/7/21 at 9:08 AM verified there were no nursing assessments completed for either resident related to the 6/16/21 incidents. f. Review of the Protection of Residents: Reducing the Treat of Abuse & Neglect policy and procedure last reviewed on 4/15/19 showed the topic Investigation and Protection included .9. If the accused abuser is another resident, the residents must be separated while investigating the incident. Interventions must be implemented to assure safety of all residents. In addition, the topic Reporting and Response included .8. The charge nurse will immediately assess the resident and offer medical attention, if necessary. Findings of the assessment and any treatment provided will be documented in the resident's medical record.

Based on resident and staff interview and policy and procedure review, the facility failed to ensure resident funds were available for 3 of 4 sample residents (#8, #18, #20) who maintained a personal funds account with the facility. The findings were: 1. Interview with resident #8 on 8/6/19 at 9:18 AM revealed residents were unable to get money from their personal funds accounts on the weekends when the business office was closed because nobody is here on the weekends. 2. Interview with resident #18 on 8/6/19 at 2:28 PM revealed residents got money from the business office, but the business office did not work on the weekends. Further, it was revealed if residents needed money on the weekends they must plan ahead and get their money during business office hours. 3. Interview with resident #20 on 8/6/19 at 8:27 AM revealed the resident had a personal funds account at the facility and s/he was not able to get money on the weekends. 4. Interview with the business office manager on 8/8/19 at 8:59 AM revealed residents were not able to get money for the weekends unless it was requested during business office hours. 5. Review of the LCCA Resident Trust Policy and Procedure dated 3/10/16 showed .4. Provide residents with access to his or her funds within a reasonable amount of time. a. Requests for $50.00 or less ($100.00 or less for medicare residents) should be honored within the same day. b. Requests for more than $50 ($100.00 or more for Medicare residents) should be honored within three (3) banking days .Facility Banking Hours .Some states require that residents have access to cash on a twenty-four (24) hours a day, seven (7) days a week basis. In these states, this requirement shall be met while maintaining all other procedures with regard to cash distribution and documentation. In addition, the business office shall verify on a daily basis that cash kept for after-hours access is properly secured and accounted for .

Based on review of employee personnel files and staff interview, the facility failed to ensure the State nurse aide abuse registry was checked prior to resident contact for 3 of 5 sample CNAs (#2, #3, #4) reviewed. The findings were: 1. Review of the employee files for CNAs #2, #3, and #4 revealed that a search of the State nurse aide abuse registry was not documented and abuse/neglect findings were not available for CNA #2, hire date of 7/10/19; CNA #3, hire date of 6/20/19; and CNA #4 hire date of 3/7/19. 2. Interview with the human resource director on 8/7/19 at 9:11 AM revealed she was unaware of this requirement. 3. Interview with the ED on 8/7/19 at 9:32 AM confirmed the State CNA abuse registry needed to be checked prior to the CNA having contact with residents.

Based observation, staff interview, review of food temperature logs, review of manufacturer's product description, and review of the U.S. Public Health Service Food Code, the facility failed to ensure food temperatures were taken prior to service in 1 of 2 food service areas (main kitchen). In addition the facility failed to ensure proper dating of health shakes in 1 of 2 food storage areas (Saddle Ridge dining room). The census was 67. The findings were: Related to food temperatures: 1. Observation on 8/7/19 at 11:28 AM showed dietary aide #1 prepared mechanically-altered food which included meatballs with marinara sauce, cooked carrots, and instant mashed potatoes for residents that required a mechanically-altered diet. The dietary aide failed to take the temperature of these foods upon placing them on the steam table prior to service. Interview with the dietary aide at that time confirmed he had not taken the temperature of the mechanically-altered food because the temperature usually stayed the same after it had been altered. 2. Review of the food temperature logs showed 4 of 111 meals reviewed from 7/1/19 through 8/6/19 did not have the temperature of the food logged. 3. Interview with the certified dietary manager (CDM) on 8/7/19 at 11:45 AM revealed she reviewed the logs and knew which staff members did not record the temperatures, but did not document what she had done to correct the error. 4. Interview with the dietitian on 8/7/19 at 5:08 PM revealed she was aware of the incomplete log sheets and felt more education was needed. Related to the dating of food products: 1. Observation on 8/5/19 at 2:58 PM showed 6 health shakes were located in the Saddle Ridge dining room refrigerator. The thawed health shakes were not labeled with an open date or an expiration date. 2. Interview with LPN #1 and the DON on 8/5/19 at 3:39 PM confirmed the health shakes were not dated, and they were unable to state what the expiration date was. 3. Interview with the DON on 8/5/19 at 4 PM revealed dietary should have put a sticker with the expiration date on the health shakes when they were removed from the freezer. The DON discarded the health shakes at that time. 4. Review of the health shake product description showed the supplement was to be stored frozen, thawed under refrigeration, and could be refrigerated up to 14 days once thawed. 5. Interview with the CDM on 8/7/19 at 3:15 PM revealed it was her expectation the temperature of the food be taken and recorded when the food was placed on the steam table. In addition, the health shakes were to be labeled with the expiration date after being removed from the freezer. 6. According to Food Code (YEAR), U.S. Public Health Service: 3-501.16 (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5ºC (41ºF) or less.

Based on observation, staff interview, medical record review, review of the facility incident investigations, and policy and procedure review, the facility failed to ensure residents were free of neglect for 1 of 3 sample residents (#43) with a fall which resulted in injury. This failure resulted in actual harm to resident #43. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #43 had [DIAGNOSES REDACTED]. Further review showed the resident was independent with walking in room and corridor, required extensive assistance of 1 staff member for locomotion, dressing, toilet use, and personal hygiene, and extensive assistance of 2 or more staff members for bed mobility and transfers. The following concerns were identified: a. Observation on 12/12/18 at 2:43 PM showed the resident had a bruise located on his/her right hip which was yellow and green around the perimeter and purple in the center. Interview with NA #1 at that time revealed the resident had a fall approximately 2 weeks ago and had declined since that time. b. Interview with RN #1 on 12/12/18 at 2:50 PM revealed she was not at the facility when the fall happened. Interview with the RN at 6:15 PM revealed there was no report of any fall that occurred, an incident form was not completed, but the evidence showed there was a fall that caused the fracture. c. Observation on 12/12/18 at 4:25 PM showed 2 staff members assisted the resident to transfer from bed to wheelchair. The staff members placed a gait belt around the resident's trunk and assisted him/her to stand. During the transfer, the resident did not place weight on his/her right leg. Further, there was no evidence of pain noted. d. Interview with CNA #1 on 12/13/18 at 8:14 AM revealed she was told there had been a fall; however, no fall was documented. e. Review of the Monthly Flow Report from 11/1/18 to 11/30/18 showed the resident was documented as independent for bed mobility 65 out of 91 entries, for transfers 62 out of 90 entries, for walk in room [ROOM NUMBER] out of 90 entries, for walk in hallway 59 out of 90 entries, for locomotion on unit 33 out of 90 entries, for locomotion off the unit 30 out of 90 entries, for toileting 30 out of 118 entries, and for personal hygiene 24 out of 90 entries. Review of the Monthly Flow Report From 11/30/18 to 12/12/18 showed the resident was not marked as independent for any activities of daily living entries. Further, the resident was marked extensive assistance, total assistance, or activity did not occur for bed mobility, transfers, walk in room, walk in hallway, locomotion on unit, locomotion off unit, toileting, and personal hygiene for all entries made during that time period. f. Review of a progress note entry dated 12/4/18 and timed 10:52 AM showed Res (resident) noted decline. Res ext (extensive) assist of 1-2 (1 to 2 staff members) with cares. Not communicating. Res pocketing food per report. Res is using w/c (wheelchair) for mobility. Will evaluated(sic) how (s/he) can take meds (medications) when (s/he) gets up at (his/her) usual time here shortly. g. Review of a physician's Nursing Home Progress Note dated 12/4/18 and timed 5:53 PM showed .(resident's name) is seen today in routine home rounds. (His/her) daughter really has some concerns about (his/her) decline . h. Review of a skin assessment dated [DATE] and untimed showed the resident had a bruise identified on his/her right thigh. i. Review of a progress note entry dated 12/7/18 and timed 5:40 PM showed While getting the resident up for evening meal staff noticed that (his/her) right hip was significantly swollen. Upon nursing assessment the hip was notably swollen, had a large healing bruise to (his/her) right femur/hip area. Bruise measured 7 cmx3 cm (sic) center of the bruise is light purple and the outside is yellowish/green. Hip was abducted (moved away from the body midline) and adducted (moved toward the body midline) and resident showed no s/s (signs/symptoms) of pain, and denied pain. When lying flat right leg appears shorter than left leg. When standing resident would not put any weight on the right leg (s/he) would pick it up off the floor leaving(his/her) toes touching the floor. Spoke with DON and the decision was made that it would be beneficial to have the resident examined at the hospital . j. Review of an EMS (emergency medical services) note dated 12/7/18 and timed 5:26 PM showed .RN reports the pt. (patient) has been unwilling to bear weight or ambulate, and has been guarding (his/her) right hip. She reports that (s/he) has a bruise and some swelling on (his/her) right hip. She reports that (s/he) has had no falls and no other trauma. She states that she is unsure how the patient got the bruise. She states that (s/he) was normally ambulatory a couple of weeks ago .pt. appears to be favoring (his/her) left side, and is unwilling to bear weight on right leg. Right leg appears shorter and externally rotated. Large bruise noted to lateral right thigh with various colors and appears to be at least several days old . k. Review of a facility investigation reported to the State Survey Agency on 12/8/18 at 11:45 AM showed the administrator was informed the resident was found to have a fracture and bruise to his/her right hip on 12/7/18 at 9:55 PM. Further review showed the facility interviewed a RN who revealed on 11/30/18 the resident was trying to sit down or stand up from the w/c and the nurse positioned herself behind the resident and lowered (him/her) to the floor. Further review showed this incident could have possibly lead to (his/her) injuries. The RN admitted she failed to report and follow policy . l. Review of the Progress Note entries for (MONTH) (YEAR) and (MONTH) (YEAR) showed there were no entries made between 11/8/18 and 12/4/18. m. Interview with the DON and administrator on 12/13/18 at 8:40 AM revealed if the nurse had followed the facility's policy the resident would have been placed on follow up with routine monitoring. This may have resulted in sooner injury identification, and it was the facility's expectation for staff to document all changes in a resident's condition. The decline in ADLs also should have resulted in resident monitoring related to a change in condition. Further, it was revealed administration should have been notified of the bruise on 12/6/18 when the skin check was performed and an investigation would have been initiated at that time; however, the investigation was not initiated until the hospital notified the administrator on 12/7/18 that the resident had a bruise and fracture that were several days old. n. Review of a policy titled Change in a Resident's Condition last revised 3/2010 showed 1. All changes in the resident's condition will be recorded in the resident's medical record. Such changes or conditions include, but are not limited to: Any accident/incident involving the resident. Any change in the resident's mental, physical, or emotional status .

Based on observation, staff interview, medical record review, review of the facility incident investigations, and policy and procedure review, the facility failed to ensure a change of condition was assessed for 1 of 4 sample residents (#43) with a fall. This failure resulted in actual harm to resident #43. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #43 had [DIAGNOSES REDACTED]. Further review showed the resident was independent with walking in room and corridor, required extensive assistance of 1 staff member for locomotion, dressing, toilet use, and personal hygiene, and extensive assistance of 2 or more staff members for bed mobility and transfers. The following concerns were identified: a. Observation on 12/12/18 at 2:43 PM showed the resident had a bruise located on his/her right hip which was yellow and green around the perimeter and purple in the center. Interview with NA #1 at that time revealed the resident had a fall approximately 2 weeks ago and had declined since that time. b. Interview with RN #1 on 12/12/18 at 2:50 PM revealed the she was not at the facility when the fall happened. Interview with the RN at 6:15 PM revealed there was no report of any fall that occurred, an incident form was not completed, but the evidence showed there was a fall that caused the fracture. c. Observation on 12/12/18 at 4:25 PM showed 2 staff members assisted the resident to transfer from bed to wheelchair. The staff members placed a gait belt around the resident's trunk and assisted him/her to stand. During the transfer, the resident did not place weight on his/her right leg. Further, there was no evidence of pain noted. d. Interview with CNA #1 on 12/13/18 at 8:14 AM revealed she was told there had been a fall; however, no fall was documented. e. Review of the Monthly Flow Report from 11/1/18 to 11/30/18 showed the resident was documented as independent for bed mobility 65 out of 91 entries, for transfers 62 out of 90 entries, for walk in room [ROOM NUMBER] out of 90 entries, for walk in hallway 59 out of 90 entries, for locomtion on unit 33 out of 90 entries, for locomotion off the unit 30 out of 90 entries, for toileting 30 out of 118 entries, and for personal hygiene 24 out of 90 entries. Review of the Monthly Flow Report From 11/30/18 to 12/12/18 showed the resident was not marked as independent for any activities of daily living entries. Further, the resident was marked extensive assistance, total assistance, or activity did not occur for bed mobility, transfers, walk in room, walk in hallway, locomotion on unit, locomotion off unit, toileting, and personal hygiene for all entries made during that time period. f. Review of a progress note entry dated 12/4/18 and timed 10:52 AM showed Res (resident) noted decline. Res ext (extensive) assist of 1-2 (1 to 2 staff members) with cares. Not communicating. Res pocketing food per report. Res is using w/c (wheelchair) for mobility. Will evaluated(sic) how (s/he) can take meds (medications) when (s/he) gets up at (his/her) usual time here shortly. g. Review of a physician's Nursing Home Progress Note dated 12/4/18 and timed 5:53 PM showed .(resident's name) is seen today in routine home rounds. (His/her) daughter really has some concerns about (his/her) decline . h. Review of a skin assessment dated [DATE] and untimed showed the resident had a bruise identified on his/her right thigh. i. Review of a progress note entry dated 12/7/18 and timed 5:40 PM showed While getting the resident up for evening meal staff noticed that (his/her) right hip was significantly swollen. Upon nursing assessment the hip was notably swollen, had a large healing bruise to (his/her) right femur/hip area. Bruise measured 7 cmx3 cm (sic) center of the bruise is light purple and the outside is yellowish/green. Hip was abducted (moved away from the body midline) and adducted (moved toward the body midline) and resident showed no s/s (signs/symptoms) of pain, and denied pain. When lying flat right leg appears shorter than left leg. When standing resident would not put any weight on the right leg (s/he) would pick it up off the floor leaving(his/her) toes touching the floor. Spoke with DON and the decision was made that it would be beneficial to have the resident examined at the hospital . j. Review of an EMS (emergency medical services) note dated 12/7/18 and timed 5:26 PM showed .RN reports the pt. (patient) has been unwilling to bear weight or ambulate, and has been guarding (his/her) right hip. She reports that (s/he) has a bruise and some swelling on (his/her) right hip. She reports that (s/he) has had no falls and no other trauma. She states that she is unsure how the patient got the bruise. She states that (s/he) was normally ambulatory a couple of weeks ago .pt. appears to be favoring (his/her) left side, and is unwilling to bear weight on right leg. Right leg appears shorter and externally rotated. Large bruise noted to lateral right thigh with various colors and appears to be at least several days old . k. Review of a facility investigation reported to HLS on 12/8/18 at 11:45 AM showed the administrator was informed the resident was found to have a fracture and bruise to his/her right hip on 12/7/18 at 9:55 PM. Further review showed the facility interviewed a RN who revealed on 11/30/18 the resident was trying to sit down or stand up from the w/c and the nurse positioned herself behind the resident and lowered (him/her) to the floor. Further review showed this incident could have possibly lead to (his/her) injuries. The RN admitted she failed to report and follow policy . The nurse was suspended pending investigation on 12/8/18. The facility notified the State Survey Agency, local law enforcement, and the resident's family. l. Review of the Progress Note entries for (MONTH) (YEAR) and (MONTH) (YEAR) showed there were no entries made between 11/8/18 and 12/4/18. m. Interview with the DON and administrator on 12/13/18 at 8:40 AM revealed if the nurse had followed the facility's policy the resident would have been placed on follow up with routine monitoring. That may have resulted in sooner injury identification, and it was the facility's expectation for staff to document all changes in a resident's condition. The decline in ADLs should have also resulted in resident monitoring related to a change in condition. Further, it was revealed administration should have been notified of the bruise on 12/6/18 when the skin check was performed and an investigation would have been initiated at that time; however, the investigation was not initiated until the hospital notified the administrator on 12/7/18 that the resident had a bruise and fracture that were several days old. n. Review of a policy titled Change in a Resident's Condition last revised 3/2010 showed 1. All changes in the resident's condition will be recorded in the resident's medical record. Such changes or conditions include, but are not limited to: Any accident/incident involving the resident. Any change in the resident's mental, physical, or emotional status .

Based on observations, medical record review, and staff interview, the facility failed to ensure effective measures were implemented to ensure good nutritional status for 1 of 1 sample residents (#37) reviewed for weight loss. This failure resulted in a six month significant weight loss and harm for the resident. The findings were: Review of the medical record showed resident #37 had [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance from staff to complete ADLs including eating. Review of the care plan updated 3/11/14 identified the resident as being at risk for nutrition related to fluctuating intake and history of weight loss. Interventions included offering substitutes if 50% or less of a meal was consumed and to observe the resident and report to the physician. The care plan also showed the resident had an ADL deficit related to a [DIAGNOSES REDACTED]." Review of a physician's progress note dated 2/6/14 showed the resident, "tries to eat by (her/himself), apparently does not have to be fed...Is probably progressively more demented." Review of the physician's progress note dated 3/5/14 showed no reference to the resident's weight loss or eating abilities. On 4/3/14 the physician noted the resident "will be given less medication, given (his/her) weight loss." Review of the resident's weight record for a 6 month period from 11/12/13 (116 pounds) to 5/5/14 (100 pounds) showed the resident had weight loss ranging between 1 to 4 lbs each month resulting in a significant weight loss of 13.79% for the 6 month time period. Review of a nursing note dated 4/17/14 from a resident at risk team meeting showed the resident triggered for weight loss and finger foods would be continued and the resident, "plays with food." Recommendations dated 4/16/14 from the resident at risk team showed "finger foods, provide snacks." The following concerns were identified: a. Observation of dining on 5/5/14 from 5:40 PM to 6:30 PM revealed the resident was seated at a dining table near the window in the south dining room. The resident attempted to eat without assistance and licked a dessert consistent with pudding or whipped topping out of a plastic dish. The resident also attempted to eat a casserole type dish, which included rice, with his/her fingers. The resident was observed to have food on his/her chin, hands, and down the front of the clothing protector, shirt, and pants. CNA #3 was observed providing meal set up for another resident at the same table, and did not offer assistance to resident #37. At 6:10 PM CNA #1 came to stand over resident and began feeding the resident. The CNA provided the resident with 2 bites of food from the plate, then instructed the resident to, "use your spoon", and walked away. The resident looked at the spoon; however, continued eating with his/her fingers. At 6:20 PM trays were removed from tables and staff began assisting residents out of the dining room the resident was observed licking his/her dietary place card. At 6:30 PM the resident remained seated at the table with food on his/her face, hands, clothing and scattered in the floor surrounding the chair. The resident consumed approximately 25% of the meal. b. Observation of dining on 5/7/14 at 12:15 PM showed the resident was again seated by the window in the south dining room. The resident was observed eating a brownie type dessert and mashing it between his/her fingers. The resident picked up a spoon and began mashing the dessert on the table with the spoon. The resident then picked up a butter knife and looked at the spoon and knife. The resident attempted eating pieces of steamed vegetables with his/her hands. The resident's face, hands, including under nailbeds, clothing and floor surrounding his/her chair were covered with scattered bits of food. At 12:30 PM CNA #6 went to stand over the resident and attempted to assist the resident with eating, however, the resident was resistive and turned his/her head. The CNA then walked away and went back to assisting residents at another table. The resident consumed approximately half the dessert and a few bites vegetables. Interview with CNA #6 at 12:35 PM revealed the resident didn't eat very well and was resistive and often combative to being fed. c. Review of the 8/15/13 nutrition data collection/assessment completed by the CDM showed the resident received a regular diet, weighed 116 pounds, and had an average daily consumption of 0% for breakfast, and "25/100%" for lunch, and "25/75%" for dinner. There was no information related to snack consumption recorded. Further review of the document showed the registered dietitian (RD) failed to complete the assessment portion, and there was nothing to show the resident's estimated energy, protein, or fluid needs. d. Interview with the CDM on 5/8/14 at 10:15 AM revealed the resident had been identified as being at risk for weight loss and currently had interventions including a fortified diet, finger foods, and provided snacks. The CDM verified she had not actually observed the resident eat, "in a while" and was not sure of the level of assistance the resident required. She further revealed she was unsure the last time the RD assessed the resident. e. Review of monthly intake records from 1/1/14 through 5/8/14 (128 days) showed the resident consumed 0% of breakfast 121 days, 50% or less of lunch on 93 days, and 50% or less of dinner on 92 days. Additional review of AM, PM and Bedtime recorded snacks for this 128 day period showed the resident had a snack 16 times.

Based on resident interview, staff interview, review of facility policies and procedures, and medical record review, the facility failed to ensure staff assessed, monitored, and implemented measures to prevent and treat skin breakdown for 1 (#40) of 1 sample resident who had skin breakdown. The facility's failure to provide timely assessments, interventions, and monitoring resulted in harm for resident #40. The findings were: Review of the medical record for resident #40 showed s/he was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 12/8/12 significant change MDS assessment showed the resident had no pressure ulcers at this time but was at risk according to the Braden risk skin assessments performed on 10/5/12 (score of 18) and 12/27/12 (score of 17). Review of the Braden risk skin assessment scores for 1/11/13, 1/23/13 and 1/30/13 showed scores of 14. Braden risk assessment scores of 14 indicate the resident's risk of developing a pressure ulcer was higher than in December 2012 when the previous Braden risk assessment was performed on 12/27/12. The following concerns with pressure ulcer assessment, notification, and management were identified: a. Review of the March 2013 physician's recapitulation of orders showed an order dated 7/2/12 for weekly skin checks. However, review of the weekly skin integrity data collection flow sheet showed the skin checks were performed on 12/18/12 then not again until 1/1/13, 14 days later instead of the ordered every 7 days. Further review of the weekly skin integrity data collection flow sheets showed the check was performed on 1/15/13 and then not again for another 13 days on 1/28/13. The resident developed a pressure ulcer on the right heel on 1/11/13 and one on the left heel on 1/24/13. Interview with the DON and unit manager on 3/13/13 at 4:20 PM revealed the weekly skin checks should have been performed weekly not every other week. b. Review of the 1/8/13 weekly skin integrity data collection flow sheet showed the resident's skin was intact. Review of the pressure ulcer status record dated 1/11/13, three days later, showed a pressure ulcer was first observed on the right heel on 1/11/13 which was unstageable. Further review of this document showed the physician was not notified until 1/15/13. Review of the 1/15/13 computerized nursing notes timed at 3:19 PM showed a late entry for 1/13/13 indicating the nurse documented her concern about "a spot of skin" on the outside of the resident's right heel that appeared to be an area of concern. Further review of these computerized nursing notes showed the physician, family, DON and wound nurse manager were notified of the pressure ulcer on 1/13/13. However, review of the handwritten wound nursing notes showed no documentation in regard to pressure ulcers prior to the 1/15/13 nursing notes timed at 9:30 AM. Based on inconsistencies in the documentation it was unknown whether the pressure ulcer was identified on 1/11/13 or 1/13/13. It was also unclear whether the physician was notified on 1/13/13 or 1/15/13. In addition, review of the 2/5/13 nutrition assessment, performed after the development of two pressure ulcers in January 2013, showed the resident's skin was intact which was incorrect. c. Based on review of the 1/24/13 pressure ulcer status record and the 1/24/13 timed at 7:56 AM nursing notes, the resident had developed a pressure ulcer on the left heel, also unstageable, in addition to the one on the right heel. Review of the medical record showed the first physician's orders [REDACTED]. A second pressure ulcer developed between when the physician was first notified and when the first physician orders [REDACTED]. d. Review of the pressure ulcer status records for the right heel entries on 1/11/13, 1/17/13, 1/24/13, 2/15/13, 2/21/13, 2/28/13, 3/8/13 and 3/15/13 showed the right heel caused the resident pain. Interview with the resident on 3/12/13 at 10 AM revealed the right heel was painful, especially during dressing changes and when anything touched the area. e. The inconsistencies in various clinical records made it impossible to determine the timeliness of identification and physician notification in regard to the pressure ulcers. Review of the accumulated information did show, however, the physician did not order any specific, individualized treatment until after the second pressure ulcer developed on 1/23/13. f. Review of the facility's policies and procedures regarding pressure ulcers, dated 10/7/10, showed instructions to do skin integrity assessment/checks weekly and to follow the residents' care plans and update them as necessary. Further review showed the "...facility's procedures are such that all disciplines are alerted immediately if the resident either has skin breakdown or is at risk for the development of skin breakdown. The Nursing department coordinates the response to resident needs (in the area of skin integrity) by the following means....With an array of preventative measures practices on the resident's behalf when the resident has been identified as being at risk...."