Every finding on record at White Oak Manor - Columbia

Based on observations, staff interviews, and a review of the facility's dietary policies, the facility failed to ensure proper sanitation of kitchen equipment and maintain overall cleanliness in the main kitchen. Additionally, the facility did not adhere to appropriate labeling and dating protocols for food items. These deficiencies could potentially pose a risk to the health and safety of the residents consuming food prepared in the kitchen. Findings include:Review of the facility's policy titled Storage of Food and Supplies last revised on 12/05/17, specifies that Time-Temperature Control for Safety (TCS) foods must be stored in the refrigerator to prevent cross-contamination. Meat, poultry, and fish products should be stored in a specific order: poultry at the bottom, followed by meat, fish, and then ready-to-eat items. The policy further mandates that all items must be labeled with a use-by date and contents if not readily identifiable. Additionally, any food removed from its original packaging should be labeled with identifying information, including the product name, the date the original package was opened, and the discard date. Staple items such as flour, sugar, cornmeal, and dried pasta should be stored in secure, designated bins, and the scoops used for these products should not come into contact with the food.During an initial walk-through of the kitchen, conducted on 09/23/25 at 9:50 AM with the Dietary Manager (DM), revealed the following: The two-door reach-in freezer in the main kitchen had a filthy appearance, with sticky residue throughout the bottom upon opening the doors. Plastic bins containing frozen meats were stuck to the freezer floor. One 2-gallon ziplock bag of Dice Chicken Mix, dated 09/22/25, was found inside the freezer but was not in its original packaging and lacked a use-by date. Several 20-quart plastic containers, located in Dry Storage, contained pasta products that were not in their original packaging and lacked use-by dates, including Spaghetti Noodles (opened 07/16/25), Macaroni Noodles (opened 09/12/25), and Egg Noodles (opened 09/21/25). Additionally, an unlabeled ingredient storage bin near the door contained a white substance with black spots, and a scoop was left inside the bin. The exterior of the ice machine had dried residue visible on the front and side. The interior of the ice machine, including the black lining, was also dusty. The dishwasher had dried residue on its exterior and was visibly dirty. Two metal racks housing clean cookware revealed a stainless-steel skillet that was rusted and covered with black residue, while two stainless-steel pots had similarly rusted bottoms with peeling black residue. A rectangular stainless steel food pan had grease build-up and brown/black residue on its bottom. The air conditioning unit located by the window had a panel with an accumulation of dust. The wall surrounding the three-compartment sink was visibly dirty, with yellow and brown dried substances. Above the sink, the window's metal panels were covered in dirt and appeared rusted with black spots. The ceiling tiles above the hood showed visible signs of damage and discoloration. The tiles, which were originally white, had turned an orange color. Several pieces of kitchen equipment were in poor condition. The conveyor toaster had dirty knobs, visible black rust, and brown residue on the bottom panel. The flat-top stove had dried grease and black residue on its front and side panels. The lid of the stove contained a brown substance and food crumbs. The burner stove had its side panel covered in dried grease, while the entire backsplash was coated with white and brown residue. The double-deck conventional ovens showed light brown buildup on the top oven and black buildup near the bottom doors. The handles of the bottom oven were covered in yellow residue.The locked freezer, located outside the building, contained various food items without proper labeling or dating. Items found included a 4-pound brown bag of waffle fries, opened and without a label or use-by date; a plastic bag of approximately twenty egg patties, with no label or use-by date; a plastic bag of approximately twenty-five pieces of brown cookie dough, with no label or use-by date; a plastic bag of approximately twenty-five pieces of white cookie dough, with no label or use-by date; a plastic bag of approximately fifteen rolls, with no label or use-by date; and a plastic bag of approximately twenty-five quesadillas, with no label or use-by date.On 09/23/25 at approximately 10:55 AM, an interview with the Dietary Manager (DM) revealed that everyone is responsible for ensuring that items are free from expiration and that items removed from their original packaging must be labeled with both open and use-by dates. She acknowledged the conditions of the kitchen, stating that the kitchen is old and staffing is limited on both the first and second shifts. She further explained that as far as deep cleaning is concerned, there is no set schedule that the dietary staff follows for these tasks. She stated that she has spoken to the Director of Housekeeping to assist with cleaning the floors and to the Maintenance Department about pressure washing the entire kitchen but stated that these actions have not yet been completed.During follow-up observations on 09/24/25 at 9:03 AM and again at 10:23 AM revealed the same conditions, with no visible improvements.On 09/24/25 at 10:25 AM, an interview with the Certified Dietary Manager (CDM), who is also a Dietetic Technician Registered (DTR), confirmed that she is on-site daily and is overseen by the regional consultant dietitian. She clarified that she is responsible for the clinical portion, while the Dietary Manager oversees the dietary operations, including the kitchen. Regarding the findings, she stated that she was aware of the kitchen's conditions and the state of the cookware. However, she was unsure about the ordering process related to cookware and the frequency of its replacement. She did mention that new cookware was ordered on 09/23/25, as a result of findings reported by the DM. Regarding cleaning practices, the CDM explained that equipment is wiped down after every meal. She also indicated that she has verbally requested assistance from housekeeping and maintenance for a deep clean, although they have an electronic system called TELS for submitting requests. She acknowledged that while ceiling tiles are replaced upon request, she does not consistently use the electronic system as required for maintenance and cleaning requests.During an interview with the [NAME] on 09/24/25 at 10:30 AM, revealed that there is no scheduled deep cleaning in the kitchen. The staff only wipes down the equipment following each use. Regarding the breakdown of equipment for cleaning, the [NAME] stated that this is not done.During an observation on 09/24/25 at 11:30 AM, revealed that the stainless-steel servicing line table had white residue throughout the entire front panel.A review of the Atlantic Cleaning Solutions, LLC kitchen exhaust inspection and service report dated 07/23/25, revealed that the overall grease accumulation was noted as mild. Prior to that, the same findings were recorded during the inspection on 01/07/2025. No services in between. During an interview conducted on 09/24/25 at 3:43 PM, the Facility Administrator (FA) revealed that the DM oversees the kitchen and is responsible for ordering supplies. The manager has the authority to order from the food vendor, which also supplies cookware. She stated she was made aware of the recent findings and noted that the main kitchen underwent a mock survey the previous week, in which she participated. During that mock survey, issues such as ingredient bins and scoops, as well as the cleanliness of equipment, including the dishwasher, were identified. Regarding cookware, it was noted that the specific pots and pans in question were not observed during the mock survey, and new cookware was ordered on 09/23/25. The Facility Administrator reported being unaware of the findings related to the outside freezer. She stated that there is no staff shortage in the dietary department, and there is no excuse for it. The Administrator reported that, for a period of time, there was confusion and disagreement among staff regarding responsibilities in the kitchen, specifically related to deep cleaning and equipment breakdown tasks. As a result, HR held a meeting with the entire Dietary Department to review and clarify the duties and job descriptions for all shifts and positions within the department. She stated that there is no formal policy related to cleaning schedules. However, the expectations for dietary staff include implementing a consistent deep cleaning schedule and ensuring that all items are properly labeled and dated once removed from their original packaging.

Based on review of facility policy, observation, interview, and record review, the facility failed to provide appropriate supervision for Resident (R)4, during medication administration, resulting in R4 not swallowing 2 of his medictions, for 1 or 1 resident reviewed.Findings include:Review of the facility's undated policy titled Oral Medication Administration Procedure indicated: 12. Administer medication and remain with resident while medication is swallowed. a. Never leave a medication in a resident's room without orders for self-administration. b. If resident is in bed, head of bed should be elevated prior to administration of medication.Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia following cerebral infarction, constipation, acquired absense of left leg above knee, acquired abscence of right leg above knee, sacral pain, Type 2 Diabetes Mellitus with diabetic neuropathy, hypocalcemia, chronic obstructive pulmonary disease, and generalized anxiety disorder.Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating R4's cognition was intact.Review of R4's Care Plan revealed, [R4] is at risk for nutritional decline/weight loss and aspiration due to mechanically altered diet and dx of dysphagia . Start Date:09/18/2025. The approach directed staff to, Administer vitamins as orderd by provider. Monitor for adverse medication side effects (reference drug handbook as needed) and report any adverse medication effects to provider created: 04/25/2025. Further review of the Care Plan revealed, Resident has a mild cognitive deficit r/t dementia, senile degeneration of brain, and Alzheimer's disease. Start Date: 11/19/2021. Review of R4's Medication Administration Record (MAR) for the month of September 2025 revealed, acetaminophen [OTC] tablet; 500 mg; Amount to Administer; 2 tab; . Further review revealed, gabapentin capsule; 100 mg .During an observation on 09/23/25 at 10:40 AM, R4 was observed in a semi-supine position in bed, with their head slightly leaning to the left side. On R4's chest was one white oblong pill and hanging out of the left corner of R4's mouth was one white capsule. During an interview on 09/23/25 at approximately 10:46 AM, Social Worker Assistant 1 acknowledged R4 was asleep with a white oblong pill on the chest and a white pill in the left corner of the mouth.During an interview on 09/23/25 at approximately 10:50 AM, Licensed Practical Nurse (LPN)1 revealed she administered R4's medications at 8:16 AM and R4 appeared to have swallowed the medications with water. LPN1 acknowledges she saw a white oblong pill on R4's chest and a white pill in the left corner of R4's mouth. LPN1 states the pill on the chest of R4 was a 500 mg (milligram) Tylenol and the pill in the left corner of R4's mouth looked like a gabapentin capsule. LPN1 awakened R4 and asked if he had been pocketing medications and proceeded to administer medication with water. LPN1 asked the resident to open his mouth after medication administration to ensure the resident had swallowed the medication. LPN1 reports this is the first time the resident pocketed pills. LPN1 states her expectations are for the resident to take medications, and she will inspect the resident's mouth inside and out post medication administration to ensure no pocketing and that the resident has swallowed the medications. LPN1 states she will inform the unit manager of the incident and place the incident on the 24-hour report.During an interview on 09/24/25 at approximately 11:02 AM, LPN2 who is also the Unit Manager stated we will document on MAR (Medication Administration Record) and put the reason why the resident pockets medications. Expectations are to ensure the resident is swallowing medications, crush medications that are able to be crushed, and administer with applesauce to ensure the resident swallows meds.During an interview on 09/24/25 at approximately 10:53 AM, the Director of Nursing (DON) revealed that the procedure and expectations for medication administration are for the nurse to identify the medication before administering medication, ensure the resident swallows medications, and let the provider know if the resident had difficulty swallowing medication. The resident is on a regular mechanical soft diet. The DON revealed acute changes with residents are discussed every shift, and if there is an ongoing issue, it will be placed on the resident's profile sheet. The DON states the resident administration with R4 has not been an issue before this time. Reports that if R4 continues to have swallowing issues, she will have Speech Therapy to assess the resident after Veteran's Administaration (VA) approval.

Based on observation, record review, interview, and facility document and policy review, the facility failed to provide adequate supervision to prevent falls, failed to consider all causal factors related to falls, and failed to update a resident-centered care plan with appropriate interventions to prevent further falls for 1 (Resident (R)3) of 4 sampled residents reviewed for falls. Specifically, R3, a resident with a history of multiple falls, sustained falls on 08/18/2024, 09/03/2024, and 01/16/2025, and the facility failed to consider all causal factors related to these falls in an effort to develop and implement appropriate fall prevention interventions. Subsequently, on 02/07/2025, the resident sustained a fall that resulted in an injury. In addition, the facility failed to ensure staff performed an appropriate transfer from the floor to the bed following the fall on 02/07/2025. After hospital evaluation, R3 was diagnosed with a right humeral neck fracture. R3 sustained an additional fall on 02/23/2025. Findings included: An undated facility policy titled, Falls Management Program indicated, INTRODUCTION: To attempt to provide an environment as free from accidental hazards as possible and provide adequate supervision and assistive devices to attempt to reduce the risk for occurrences. The policy revealed, The Fall Management Program has been developed to assist facilities in identifying strategies to minimize the risk of falls for residents and still maintain the highest practicable level of functioning and mobility through comprehensive analysis of physical, mental and psychosocial conditions and the development and implementation of individualized plan of care. The section of the policy titled, DOCUMENTATION specified, -Fall Investigation *This form is to be completed upon occurrence of any fall *Documentation should include date, time and exact location of fall; prior history of falls; reason/circumstances surrounding the fall; review of care plan and update of interventions; review need for placement in Fall Management Program, review of medication, diagnosis, assistive and protective devices, environmental factors, mental status and action taken to reduce risk of a fall. The section of the policy titled DOCUMENTATION also specified, -Care Plan *When developing a plan of care to reduce the incidence of falls, staff need to review the factors that can contribute to, or directly cause, these types of incidents. In addition, the policy specified, -Following a fall an Occurrence Report, Witness Statement and Fall Investigation are completed. - Any resident who experiences a fall is reviewed by the Safety / QI [Quality Improvement] Committee for recommendations of possible changes in interventions and communicated to the facility care team. The policy included a NURSING FALL PROTOCOL, revised 12/22/2022, that specified nursing responsibilities for resident falls included, -Investigate cause of the fall, using witness if it was witnessed -Educate resident and staff on interventions needed -Occurrence Report, including witness statement, -Complete Fall Investigation, -Refer to Physical / Occupational Therapy for evaluation and possible additional equipment or preventive devices as appropriate, -Refer to Safety / QI Committee for review. A Resident Face Sheet revealed the facility admitted R3 on 03/11/2019 and most recently admitted the resident on 02/01/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of paranoid schizophrenia, insomnia, lack of coordination, unsteadiness on feet, muscle weakness, Alzheimer's disease with early onset, Parkinson's disease, and repeated falls. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/11/2024, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required partial/moderate assistance with putting on and taking off footwear and required supervision or touching assistance when transitioning from a sitting to standing position, with toilet transfers, and with walking distances of 10 feet, 50 feet with two turns, and 150 feet. Per the MDS, the resident had sustained two falls without injury and one fall with injury (not major) since admission or reentry to the facility or their prior MDS assessment. An annual MDS, with an ARD of 09/10/2024, revealed R3 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required partial/moderate assistance with putting on and taking off footwear and required supervision or touching assistance when transitioning from a sitting to standing position, with toilet transfers, and with walking distances of 10 feet, 50 feet with two turns, and 150 feet. Per the MDS, the resident had sustained two falls without injury since admission or reentry to the facility or their prior MDS assessment. An Event Summary List for the timeframe from 08/01/2024 through 04/16/2025 revealed R3 sustained falls on 08/18/2024, 09/03/2024, 01/16/2025, 02/07/2025, and 02/23/2025. R3's Care Plan History included a problem statement, with a start date of 08/16/2018, that indicated the resident was at risk for falls due to general weakness; a history of falls/falls with major injury; potential medication side effects; episodes of incontinence and pain; cognition that waxed and waned with episodes of confusion or agitation; and diagnoses of Parkinson's disease, Alzheimer's dementia, schizophrenia, and anemia. Interventions in place prior to the above-listed falls directed staff to ensure the resident used a wheelchair for long distance locomotion (started 11/20/2018); conduct safety checks during rounds and as needed (started 11/20/2018); ensure the resident's room and hall were free from clutter, spills, or other tripping hazards (started 11/20/2018); administer Parkinson's medications as ordered and monitor for and report any adverse side effects (started 03/11/2019); physical therapy (PT) to evaluate and treat as needed (started 07/05/2021); encourage the resident to use their call light for assistance (started 10/01/2021); assist the resident to the bathroom after breakfast (started 10/08/2023); utilize a defined perimeter mattress on the resident's bed due to attempts to stand from the bed by self and unable to do so (started on 01/29/2024); assist the resident with early morning care and get up as tolerated (started 03/23/2024); assist the resident with toileting before bedtime as tolerated (started 05/06/2024); ensure the resident had non-skid socks on at all times/in bed as tolerated (started 05/15/2024); toilet the resident before lunch as tolerated (started 06/01/2024); use non-slip material on the resident's mattress (started 07/10/2024); and ensure when the resident was in bed that the resident's wheelchair was at the resident's bedside with brakes locked with shoes in the wheelchair for easy access (started 07/25/2024). R3's Care Plan History also included a problem statement, started on 05/24/2024, that indicated the resident was noncompliant with calling for staff assistance and waiting for staff assistance related to fluctuating cognitive status; poor safety awareness; and diagnoses of Alzheimer's dementia, schizophrenia, and Parkinson's disease. During an interview on 04/18/2025 at 3:45 PM, the Director of Nursing (DON) stated she left all falls and fall investigations for the Assistant Director of Nursing (ADON) to handle. During an interview on 04/17/2025 at 1:49 PM, the ADON described the fall investigation process and indicated that following falls, she spoke with the resident, the resident's roommate (if applicable), and staff but did not document any notes of the details discovered during the investigation or any details obtained when speaking with individuals about the fall. The ADON stated if anything struck her as unusual, she asked more questions. The ADON further stated nursing staff turned in a fall packet after a resident fall, and the packet was reviewed during the facility's morning meeting the following day and during Friday risk assessment meetings. An Event Report, completed by the ADON on 08/19/2024, revealed R3 was found on the floor in their bathroom on 08/18/2024 at 12:40 AM without injury. Per the Event Report, immediate measures taken included assessing the resident for an acute process. The Event Report reflected a Progress Note, dated 08/18/2024 at 3:02 AM, that indicated the resident reported to staff they were trying to go to the bathroom when they fell . The Progress Note indicated staff told the resident to use their call light when they needed assistance. The Event Report also reflected the following Progress Notes: - a note dated 08/19/2024 at 10:33 AM that indicated new orders for a urinalysis and urine culture were received related to an assessment for acute processes r/t [related to] fall; and - a note 08/22/2024 at 10:44 PM that indicated the resident's laboratory results (urine culture) were received, and there were no new orders. R3's fall risk care plan revealed an intervention was added on 08/18/2024 to assess for acute processes, and the intervention was discontinued as of 08/21/2024. The fall risk care plan revealed no additional updates or revisions to prevent further falls or to ensure the resident's safety related to the fall on 08/18/2024. During an interview on 04/18/2025 at 3:05 PM, the ADON stated it was not appropriate for the nurse to educate the resident to use their call light when they needed assistance (due to the resident's cognitive function); however, the ADON stated they also evaluated the resident for an acute process. During an interview on 04/18/2025 at 3:45 PM, the DON stated she did not feel it was appropriate to educate R3 after the fall on 08/18/2024. The DON stated the interdisciplinary team also met and discussed the fall and had the resident assessed to determine if they may have had a urinary tract infection, which the DON stated she felt was an appropriate fall intervention. An Event Report, completed by the ADON on 09/09/2024, revealed R3 was found on the floor in their room on 09/03/2024 at 7:00 AM without injury. The Event Report revealed the resident had bare feet at the time of the fall, and the resident was trying to get out of bed. Per the Event Report, possible contributing factors included that the resident would not call for assistance. The Event Report indicated immediate measures taken included pillows for positioning and comfort. The Event Report reflected a Progress Note, dated 09/03/2024 at 2:52 PM, that indicated the resident was reeducated on using their call light and wearing non-skid socks. R3's fall risk care plan revealed an intervention was added on 09/03/2024 to provide extra pillows in bed for positioning. The fall risk care plan revealed no additional updates or revisions to address the contributing factor identified by the facility for the 09/03/2024 fall (resident would not call for assistance). There were also no updates or revisions to address the absence of non-skid socks as per the resident's care plan at the time of the fall. During an interview on 04/18/2025 at 3:05 PM, the ADON stated the addition of pillows after the fall on 09/03/2024 was decided upon to help the resident stay in bed. During an interview on 04/18/2025 at 3:45 PM, the DON stated that for the fall on 09/03/2024, R3 probably took their non-skid socks off while they were in bed, but it was not appropriate for staff to reeducate the resident on using their call light and wearing non-skid socks (due to the resident's cognitive function). The DON stated the facility placed pillows for the resident's comfort following this fall. An Event Report, completed by the ADON on 01/17/2025, revealed R3 was found on the floor in their room on 01/16/2025 at 3:25 PM without injury. The Event Report revealed the resident was getting up from their wheelchair when the fall occurred. The Event Report revealed no possible contributing factors were identified by the facility. The Event Report indicated immediate measures taken included a dental evaluation during the dentist's upcoming visit. The Event Report reflected a Progress Note, dated 01/16/2025 at 3:25 PM, that indicated the resident was at the nurses' station just prior to the fall and reported they needed to get their dentures. Per the Progress Note, the resident's dentures were observed on the counter in their room within arm's reach. R3's fall risk care plan revealed an intervention was added on 01/16/2025 to have the resident's dentures assessed by the dentist for proper fit. The fall risk care plan revealed no additional updates or revisions to address the resident's fall from their wheelchair, such as non-slip material to the resident's wheelchair seat. There were also no updates or revisions to address the resident's need for assistance with their dentures and denture care in relation to this fall. An intervention was later added on 03/28/2025 to place the resident's dentures within reach when the resident was out of bed. During an interview on 04/16/2025 at 1:39 PM, Licensed Practical Nurse (LPN)11stated she was assigned to care for R3 on 01/16/2025. She recalled that on 01/16/2025, R3 was found on the floor after returning to their room to retrieve their dentures. LPN11further stated a member of the administrative nursing team implemented the intervention for a dental consultation following the fall. During a concurrent observation and interview on 04/17/2025 at 11:00 AM, the Therapy Director observed R3's wheelchair and verified the resident's wheelchair did not have any slip-resistant material. During an interview on 04/18/2025 at 9:35 AM, the Medical Director (MD) stated a dental evaluation would not prevent a fall. The MD stated he was not involved in the development of that particular intervention. During an interview on 04/18/2025 at 3:05 PM, the ADON stated that for the fall on 01/16/2025, R3 went back to their room to get their dentures, because their dentures were not in their mouth. The ADON stated that if the resident had their dentures in their mouth, the resident would not have had to go back to their room to get them and therefore would not have fallen. The ADON stated they felt the intervention to have the resident's dentures assessed was an appropriate fall intervention. The ADON further stated she was not aware of the interdisciplinary team ever discussing the implementation of non-slip material to the resident's wheelchair. During an interview on 04/18/2025 at 3:45 PM, the DON stated the interdisciplinary team felt having R3's dentures assessed for proper fit after the fall on 01/16/2025 was an appropriate intervention to prevent falls. An Event Report, completed by the ADON on 02/10/2025, revealed R3 was found on the floor in their room on 02/07/2025 at 5:00 PM. The Event Report revealed the resident was utilizing a wheelchair at the time of the event and was changing their clothes. Per the Event Report, the resident's footwear at the time of the fall consisted of plain socks, as opposed to non-skid socks as per their care plan. The Event Report revealed no possible contributing factors were identified by the facility. The Event Report indicated immediate measures taken included to assist the resident to change clothes before dinner as tolerated. The Event Report reflected a Progress Note, dated 02/08/2025 at 1:56 AM, that indicated during a neurological check, R3 was noted with no grip strength in their right hand and slight swelling to their right arm. The Progress Note further indicated that the resident was only able to raise their right arm by lifting their right arm with their left hand, and the resident was sent to the emergency room for further evaluation. Another Progress Note, dated 02/08/2025 at 7:19 AM, indicated the resident would be returning to the facility with a mildly displaced femoral neck fracture. R3's fall risk care plan revealed an intervention was added on 02/07/2025 to assist the resident with changing clothes before dinner as tolerated. There were no updates or revisions to address the absence of non-skid socks as per the resident's care plan at the time of the fall or to interventions to address the fact that the resident was utilizing their wheelchair at the time of the fall, such as non-slip material to the resident's wheelchair seat. During an interview on 04/18/2025 at 3:45 PM, the DON stated the interdisciplinary team felt assisting the resident to change clothes and get ready for bed before dinner would prevent the resident from falling. A Confidential Occurrence Statement or Interview, signed by LPN11 on 02/07/2025, indicated LPN11 was not present at the time of R3's fall but was notified by the resident's roommate. According to the statement, LPN11 assessed R3 for injuries and assisted R3 back to bed with the assistance of Certified Nursing Assistant (CNA)12 and CNA16. During an interview on 04/16/2025 at 1:39 PM, LPN11 stated she was assigned to care for R3 on 02/07/2025. LPN11 stated that on 02/07/2025, R3 was on the floor of their room with their legs stretched out straight towards the top of their bed. She stated the residents' right side was parallel to the bed. LPN11 stated she assessed the resident and found no injuries, then she, CNA12, and CNA16 lifted the resident into the bed. She stated the transfer from the floor to the bed was completed by CNA12 and CNA16 lifting the resident under the resident's arms and LPN11 lifting the resident's legs. During an interview on 04/17/2025 at 11:42 AM, CNA12 stated she was on duty on 02/07/2025 and was assigned to R3 when the resident was found on the floor. CNA12 explained that R3 was positioned on the floor in a seated position with their right side towards the bed, their left side parallel to the sink, and their legs outstretched towards the head of the bed. She stated the resident had removed the clothing from their lower body and was wearing plain socks or TED hose (stockings to prevent blood clots and swelling in the legs) at the time of the fall. She stated the resident had also removed their incontinence brief. CNA12 further stated that after the nurse assessed the resident, she and CNA16 lifted the resident under the resident's arms while LPN11 lifted the resident's feet, and the three of them placed the resident into bed. CNA12 stated she was under the resident's right side, CNA16 was under the resident's left side, and LPN11 held the resident's feet/legs during the transfer. CNA12 recalled that while assisting the resident into the bed, she fell over into the bed against the resident on the resident's right side. During an interview on 04/16/2025 at 1:32 PM, CNA16 stated she was not assigned to R3 on 02/07/2025 but assisted with R3's transfer from the floor to the bed. She stated R3 was disrobed from the waist down. CNA16 stated R3 was unable or refused to bear weight to assist staff with the transfer into bed. CNA16 stated she and CNA12 assisted LPN11 transfer R3 into the bed by placing their arms under each of the resident's arms, and LPN11 lifted the resident's legs. During an interview on 04/16/2025 at 4:00 PM, with both the ADON and DON present, the DON stated that when it came to lifting residents after a fall, the appropriate transfer status was based upon how well the resident could assist with that transfer. The ADON stated if the resident was not injured and was able to do 75 percent (%) of the work and bear weight, then the staff could use two people to manually lift and transfer the resident from the floor to the bed, but if the resident required more assistance, a mechanical lift should be utilized. During an interview on 04/18/2025 at 9:35 AM, the MD stated staff should not perform transfers by lifting under the arms of a resident because it increased the risk of an injury. An Initial Report, dated 02/08/2025, revealed the facility reported the fall on 02/07/2023 to the state survey agency as a bone or joint fracture due to a fall. A Five-Day Follow-Up Report, dated 02/12/2025, revealed staff had last seen R3 at approximately 4:30 PM self-propelling themself in their wheelchair toward their room after activities. The report indicated the resident was changing their clothes and slid out of their wheelchair. According to the report, to prevent future injuries, the facility implemented an intervention that directed staff to assist the resident with changing clothes before dinner as tolerated. The Five-Day Follow-Up Report revealed no documentation to indicate the facility considered new interventions related to the resident sliding out of their wheelchair or that non-skid socks were not in use at the time of the fall. In addition, there was no indication the facility identified any concerns related to the method of transfer to the bed following the resident's fall. During an interview on 04/17/2025 at 1:49 PM, the ADON stated she could not recall why the resident was found to be wearing plain socks instead of non-skid socks at the time of the fall. The ADON further stated that during the course of her investigation, she had not identified that the resident was placed into bed with the assistance of three staff members due to the resident not bearing weight, or that CNA12 had fallen into the bed with R3 during the transfer from the floor to the bed on 02/07/2025. During an interview on 04/18/2025 at 3:45 PM, the DON stated the facility had not identified any concerns with the method of transfer during their investigation into the resident's falls. An Event Report, completed by the ADON on 02/25/2025, revealed R3 was found on the floor in their bathroom on 02/23/2025 at 11:00 AM without injury. The Event Report revealed the resident was getting up from their wheelchair at the time of the fall. The Event Report revealed no possible contributing factors were identified by the facility. The Event Report indicated immediate measures taken included a therapy evaluation. The Event Report reflected a Progress Note, dated 02/23/2025 at 12:58 PM, that indicated the resident was in the bathroom in their room at the time of the fall and was being assisted by a staff member. The Progress Note indicated the staff member stepped out of the bathroom to obtain an item from the room, and upon returning to the bathroom, found the resident on the floor. R3's fall risk care plan revealed an intervention was added on 02/23/2025 for therapy to do safety training with the resident regarding transfers. There were no updates or revisions to address the fact that the resident was utilizing their wheelchair at the time of the fall, such as non-slip material to the resident's wheelchair seat. There were also no updates or revisions addressing the resident's needed level of supervision when being assisted by staff in the bathroom. During an interview on 04/16/2025 at 1:00 PM, the Therapy Director stated R3 was already on therapy caseload at the time of the fall on 02/23/2025. The Therapy Director stated the resident had been on caseload since 01/2025. During an interview on 04/18/2025 at 3:05 PM, the ADON stated the staff member did not necessarily leave the resident on 02/23/2025 and that although they liked staff to have everything they needed, they sometimes forgot things. The ADON stated they did not know if the staff was going to get water in a basin or if they were warming water in the sink. The ADON further stated she could not confirm or deny whether the staff member should have known what items they needed before entering the bathroom to assist the resident that morning. The ADON stated that the reason for the therapy evaluation after R3's fall on 02/23/2025 was that they needed to do more or something different for the resident. The ADON further stated she was unaware of the interdisciplinary team every discussing the use of non-slip material in the resident's wheelchair. The ADON stated non-slip material for the wheelchair should be considered if the resident slid out of their wheelchair; however, the ADON denied having knowledge of R3 ever sliding from their wheelchair (despite documentation of such for the fall on 02/07/2025). During an interview on 04/18/2025 at 3:45 PM, the DON stated the interdisciplinary team decided on a therapy evaluation following R3's fall on 02/23/2025, and therapy should have alerted the ADON that the resident was already on their caseload. During an interview on 04/17/2025 at 1:49 PM, the ADON stated the facility ran out of interventions to place for R3.

Based on observation, interviews and facility policy, the facility failed to label and date open food items. The facility further failed to discard expired food items for 1 of 1 kitchen. This has the potential to lead to food poisoning, gastrointestinal distress and or growth of harmful bacteria. Findings Include: Review of the facility policy titled, Storage of Food and Supplies with a revision date of ,d+[DATE], revealed, Food and supplies are received, stored, and monitored according to federal, state, and local guidelines. Potentially hazardous foods are stored in the refrigerator in a manner to prevent cross-contamination. When meat, poultry, and fish products require simultaneous refrigerated storage, the items are stored from bottom shelf to top in this order: poultry, meat, fish, then ready-to-eat. All items are labeled with a use-by date as well as the contents (if not readily identifiable). All opened items are securely wrapped or stored in a secure storage container and labeled to identify the product (if not readily identifiable) as well as a use-by date no greater than 72 hours after opening (unless documentation available for a longer shelf life is available). Staple products such as flour, sugar, cornmeal, dries pasta, etc. may be stored in designated, secured bins. Staple bin scoops may be stored in the product if the handle is out the product in a manner to prevent to touching of the food product. During an observation on [DATE] at 10:18 AM, revealed the following under the preparatory counter: 1 package of chicken flavor gravy mix wrapped in saran wrap was open and undated. 5 slices of bread in a clear bag was open and undated without label. 1 container of poultry seasoning without an expiration date. During an observation on [DATE] at 10:38 PM revealed the following in the walk-in freezer: 1 open undated pack of swiss cheese. 1 open undated pack of smoked provolone cheese. 1 open undated container of daisy sour cream. 1 open undated box of pasteurized eggs. 1 open undated package of [NAME] Italian sausage. During an observation on [DATE] at 10:57 AM, revealed the following in the dry storage: 1 box with six bottles of mint extract, one of the six bottles was opened with an expiration date of [DATE]. 1 eleven ounce container of parsley flakes with an expiration date of [DATE]. 1 open undated bag of [NAME] Choice mini sweet chocolate chips. 1 open undated box of US no. onions. 6 cans of no salt added diced tomatoes without expiration date. 1 can of [NAME] Brand fruit cocktail without an expiration date. 7 cans of [NAME] Choice peach fillers without an expiration date. 3 bags of yellow cake mix without an expiration date. 1 bottle of Kibmee Farms natural orange blossom honey was open and undated. 3 128 ounce jars of maraschino cherries without an expiration date. During an interview on [DATE] at 11:10 AM, the Certified Dietary Manager (CDM) revealed, when items are received, items are opened and put on shelf, boxes are thrown away. During an interview on [DATE] at 12:24 PM, the Dietary Aide [NAME] revealed, anything opened should be dated and anything outdated should be thrown away. If food items are close to the expiration date, its circled and after discarded. The Dietary Aide [NAME] stated when food items are pulled it should be put in the refrigerator and labeled with the date of use. During an interview on [DATE] at 12:39 PM, the CDM revealed, food items should be labeled with an open date. The CDM checks for expired food items every Monday. During an interview on [DATE] at 12:40 PM, the Dietary Technician revealed, food items should be labeled with an open date, for example, if we open on the 21st we would use by the 23rd. The Dietary Technician stated, A walk through is done to check for expired food items. The CDM checks for expired food items during inventory every Monday. During an interview on [DATE] at 12:47 PM, the Dietician revealed, items should have an open and a discard date. Food items can be used 3 days from manufacture date, if expired discard immediately.

Based on observations, interviews and review of facility policy, the facility failed to: 1) remove/dispose of expired medication from 1 of 4 medication carts. 2) Date/label open insulin pens on 1 of 4 medication carts. 3) Remove expired biological from 1 of 4 treatment carts reviewed for medication storage. Findings include: Review of the facility's policy titled, Medication Storage In The Facility dated September 21, 2022, stated, Policy: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . Procedure: . 9. Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists . 11. Multi-dose vials, ophthalmics, otics and other sterile products will be dated and initialed with the first puncture of the vial or opening. Multi-dose vials including insulin may be used after opening for 28 days unless the manufacturer has data to support longer dating . During an observation on 08/22/24 at 10:48 AM, the medication and treatment cart on the 1st floor long hall with Licensed Practical Nurse (LPN)1 revealed the following: Medication cart: 1 Basaglar Kwipen 100 units/ml (milliliters) with no open date. Manufacturer's label directed staff to discard after 28 days. 1 Insulin glargine with no open date. Manufacturer's label directed staff to discard after 28 days. 1 Lantus Solostar insulin glargine injection 100 units/ml with no open date. Manufacturer's label directed staff to discard after 28 days. 1 Lantus Solostar insulin glargine injection 100 units/ml with no open date. Manufacturer's label directed staff to discard after 28 days. 1 bottle Fluticasone Propionate nasal spray 50 mg (milligrams) with a missing cap. Treatment cart: 1 skin closure strip reinforced 1/2 x 4 open package. Manufacturer's label directed staff do not reuse. 2 boxes of 25 [NAME] Allyn thermometer probe covers boxes, covered in a sticky red substance. During an observation on 08/22/24 at 11:39 AM, of the 1st floor short hall treatment cart with LPN5 revealed the following: Treatment cart 1 box of 8 Mepilex border sacrum 22x25 cm (centimeters) 8.7 x 9.8 in (inches) pads with an expiration date of 2024-07-28. 1 Mepilex border sacrum 22x25 cm/8.7 x 9.8 in (inches) with an expiration date of 2022-05. During an observation on 08/22/24 at 12:33 PM, of the 2nd floor long hall medication and treatment carts with LPN4 revealed the following: Medication Cart: 9 Meloxicam 7.5 mg unichem (PRN) with an expiration date of 7/31/24. Treatment cart: 1 skin closure strip reinforced 1/2 x 4 opened. Manufacturer's label directed staff do not reuse. 1 4.9 oz tube ammonium lactate 12% with an expiration date of 08/20/24. During an observation on 08/22/24 at 1:28 PM, with LPN of 2nd floor short hall medication cart revealed: 1 pack skin closure strip reinforced 1/2 x 4 open package. Manufacturer's label directed staff do not reuse. 4 loose small round orange pills in the back of drawer 8. 2 loose small white pills in the back of drawer 8. During an interview on 08/22/24 at 11:23 AM, LPN1 revealed they thought the insulin pen was ok as long as it has an expiration date on them. LPN1 explains that when they open an insulin pen, they write the expiration date on it and that there is a calendar they follow from the date it was open to determine the expiration date. During an interview on 08/22/24 at 12:10 PM, LPN5 revealed that the medication and treatment carts are checked by all the nurses including the treatment nurse because we all use it. LPN5 continues to explain that the charts are checked weekly for supplies. LPN5 states that the expired medication on the treatment cart just came to the facility this week and has been here for 2 weeks. LPN5 revealed that when items come into the facility they just sign something saying they received the items but they are not left with any documentation. During an interview on 08/22/24 at 12:20 PM, the Assistant Director of Nursing (ADON) revealed we (nursing staff and pharmacy) are all responsible for making sure that the medication carts are free from expired medications. The ADON continues to explain that when insulin pens are received from the pharmacy they are put in the refrigerator and when they are opened the nurses should put an open date and end date on them. During an interview on 08/22/24 at 1:23 PM, LPN4 revealed that the Meloxicam 7.5 is a PRN (as needed) medication and there is no new order for it and had not been given to the resident. LPN4 continues to explain that the medication had been discontinued (d/c). LPN4 further explains that if medication has been d/c it should be pulled off the cart. LPN4 revealed that the carts are checked all the time, we check them and the pharmacy checks behind us and the same goes for the treatment carts. During an interview on 08/22/24 at 2:02 PM, LPN2 revealed all nurses should make sure the carts are up to par which means dates should put on items we open, we should make sure that tops are on bottles, wipe off bottles if there is spillage and pick up loose pills if we notice a pill drops.

Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)79 was screened timely for a PASARR Level II, with recommendations for further evaluation based on intellectual disabilities indicators for 1 of 3 residents reviewed for a PASARR Level II. Findings include: Review of the undated facility policy titled Preadmission Screening and Resident Review states: Level II screens are federally mandated to be performed prior to admission for all MI, ID, DD and RC applicants to Medicaid certified nursing facilities (Preadmission Screen). Subsequent assessments are required in the event of a significant change in the mental or physical condition of a resident suspected of having a mental illness, intellectual disability, development disability or related condition. All applicants to and residents of Medicaid certified nursing facilities (NFs), regardless of whether they are funded by Medicaid or utilize other sources of payment, must be screened through Level I and, if appropriate, Level II process. Residents of these facilities who exhibit significant change in mental health intellectual/development disability or related condition needs must also be re-screened through Level I as a change in status. A change in status can occur for residents with newly discovered diagnoses or symptoms of MI, ID, DD, and RC as well as residents known to have MI, ID, DD, and/or RC but whose treatment needs for those conditions change significantly. Review of R79's Face Sheet revealed the facility admitted R79 on 09/27/21, with diagnoses including, but not limited to: anxiety, depression, and intellectual disabilities. Since admission on 09/27/21, R79 has presented with diagnoses of schizophrenia, major depressive disorder, psychotic disorder with hallucinations, dementia, mood disturbance and psychotic disturbance. To date, no PASARR Level II screening has been completed for R79. Review of R79's PASARR Level I screening dated 09/27/21, prior to admission, included anxiety, depression and intellectual disabilities. Further review of the PASARR Level 1 recommended further evaluation based on the intellectual disabilities indicators. Review on 08/24/24 at 11:20 AM, of a social service note written on admission states, Resident was admitted from the hospital with diagnoses of altered mental status, anxiety and depression. Resident will be long term. Resident also has diagnoses of pressure injury of a deep tissue of buttock, Parkinson's, chronic hypotension, tremors and adult failure to thrive. Social Services will assist as needed with adjustment. During an interview on 08/24/24 at approximately 12:00 PM, the Social Service Worker for R79 stated she would have to pull the notes from her files. After a period of time the Social Service Worker provided a form completed on 08/20/24, titled Psychiatric Evaluation Level II. The form contained the diagnoses of Parkinson's Disease, dementia, major depressive disorder, anxiety disorder and intellectual disabilities. The form did not include schizophrenia, psychotic disorder with hallucinations and mood disturbance. R79 was not screened using the PASARR Level II Process, in a timely manner in which R79 may have benefited from aide of outside services not provided by the facility.

Based on observations, interview, record review, and review of facility policy, the facility failed to administer oxygen therapy at the physician's prescribed setting for 1 of 3 residents (Resident (R)78) reviewed for respiratory care and services. Findings include: Review of the facility policy titled, Oxygen Therapy with a revised date of 06/25/18, did not reveal verifying physician orders related to the flow rate of oxygen. Review of R78's admission record revealed the facility admitted R78 on 01/11/24, with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, vascular dementia, psychotic disturbance, mood disturbance, anxiety, anemia, dysarthria following cerebral infarction, and Type 2 diabetes mellitus with hyperglycemia. Review of R78's Order Summary Report for the month of August 2024, revealed an order for oxygen (O2) via nasal cannula (N/C) @ 2 liters per minute (L/Min), dated 08/01/24. Review of R78's Comprehensive Care Plan, initiated on 07/12/24, revealed the resident is at risk for respiratory distress related to (r/t) shortness of breath/end of life care. Interventions included administer oxygen as ordered by provider. Review of R78's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/24, revealed R78 had a Brief Interview for Mental Status (BIMS) of 5 out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed R78 required substantial/maximal assistance with Activities of Daily Living (ADLs). During an observation on 08/20/24 at 12:33 PM, R78 was receiving oxygen via nasal cannula and the oxygen concentrator was at a flow rate of 5L/Min. During an observation on 08/22/24 at 9:08 AM, R78 was receiving oxygen via nasal cannula and the oxygen concentrator was at a flow rate of 5L/Min. During an interview on 08/22/24 at 9:13 AM, License Practical Nurse (LPN)1 stated R78 is ordered for 2L/Min. During an interview on 08/22/24 at 9:21 AM, LPN1 stated, I don't have no idea how he was on 5L/min. I checked Oxygen when I go in the room to give med pass. During an interview on 08/22/24 at 10:02 AM, the Director of Nursing (DON) stated, We have a pharmacy tech who verifies all our orders in the system and print out a copy for the wound nurse to check every morning. During an interview on 08/22/24 at 10:25 AM, the Wound Nurse stated, I realized my oxygen print out was old. I come to work at 5 AM, so I was tasked with checking everyone's oxygen levels. [R78's] oxygen level was accurate this morning. I checked it about 6ish. I don't know how it was on 5L, that's mind boggling.

Based on review of the facility policy, observations, and interviews, the facility failed to monitor medication refrigerator temperatures in 2 of 2 medication refrigerators. These failures had the potential to decrease the efficacy of medications for all residents in need of emergency medications and 19 residents whose insulins were being stored. Findings include: Review of the facility's undated policy titled Medication storage in the facility, indicated Only licensed nurses, the consultant pharmacist, designated pharmacy staff and those lawfully authorized to administer medications (e.g., medication aides) are allowed to access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access .Medications requiring refrigeration or temperatures between 36F (degrees Fahrenheit) and 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label . Observation on 07/26/22 at 2:16 PM revealed the medication refrigerator located on the second floor did not have temperatures monitored. Further observation on 07/26/22 at 5:00 PM revealed the medication freezer on the second floor, located at the nurses' station had a temperature of 0F and was empty. The medication refrigerator temperature was 50F. The medication refrigerator contained emergency medications including five vials of insulin (diabetic medication), one bottle of [MEDICATION(S)] (anti-anxiety medication), five [MEDICATION(S)] suppositories ([MEDICATION(S)]), and six [MEDICATION(S)] suppositories (anti-nausea medication). Additionally, the medication refrigerator contained 15 [MEDICATION(S)] pens (diabetic medication), two bottles of [MEDICATION(S)] ophthalmic solution ([CONDITION(S)] treatment), five [MEDICATION(S)] suppositories (house stock- [MEDICATION(S)]), 15 [MEDICATION(S)] flextouch pens (diabetic medication), five bottles of [MEDICATION(S)] 3ml bottle (diabetic medication), one bottle of [MEDICATION(S)] 30ml bottle (diabetic medication), one bottle of Insulin [MEDICATION(S)] (diabetic medication), three [MEDICATION(S)] mix kwikpen 50/50 (diabetic medication), two [MEDICATION(S)] flexpens (diabetic medication), one vial of insulin [MEDICATION(S)], and one [MEDICATION(S)] pen (diabetic medication). Observation of the medications in the second-floor refrigerator revealed: [MEDICATION(S)] insulin pens included a sticker on the packaging from the pharmacy stating, keep refrigerated do not freeze. Insulin [MEDICATION(S)] insulin pens, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] medications included a sticker on the packaging from the pharmacy stating, refrigerate until opened. [MEDICATION(S)] ophthalmic solution included a sticker on the packaging from the pharmacy stating, refrigerate until opened. Opened bottle can be stored at room temperature up to 6 weeks. Observation on 07/26/22 at 3:58 PM revealed the medication refrigerator located on the first floor at the nurses' station did not have temperatures monitored. The medication freezer temperature was 49F and was empty. The medication refrigerator temperature was not available due to no thermometer placed in the refrigerator at that time. Licensed Practical Nurse (LPN)2 moved the thermometer from the freezer to the refrigerator to begin temperature monitoring. The medication refrigerator contained emergency medications including three vials of [MEDICATION(S)] (injectable anti-anxiety medication), twenty [MEDICATION(S)] pens (diabetic medication), one [MEDICATION(S)] injectable pen (anti-psychotic medication), 16 Insulin [MEDICATION(S)] pens diabetic medication), 11 [MEDICATION(S)] Flextouch injectable pens (diabetic medication), five [MEDICATION(S)] injectable pens (diabetic medication), one [MEDICATION(S)] [MEDICATION(S)] (diabetic medication), and one Insulin [MEDICATION(S)] injectable pen (diabetic medication). Observation on 07/26/22 at 6:24 PM revealed the medication refrigerator on the 1st floor had a temperature of 56F. Interview on 07/26/22 at 2:16 PM with LPN2 indicated the medication refrigerator for the 2nd floor nurses station was fairly new and she was not aware of any temperature monitoring logs being recorded. LPN2 confirmed there were no refrigerator logs located in/near the 2nd floor medication refrigerator and that multiple residents had insulin stored in the refrigerator along with emergency medications for all residents that receive medications for the 2nd floor. Interview on 07/26/22 at 2:36 PM with Interim Director of Nursing (IDON) indicated the maintenance department or a nurse looks at refrigerator temperatures daily and that usually the third shift (11pm-7am) checks refrigerator temperatures but do not document them anywhere. Staff are to report to maintenance if there are any temperature irregularities. IDON indicated that the medication refrigerators should maintain a temperature below 50F. Review of a receipt provided by the Maintenance Director (MD) indicated a refrigerator was purchased on 07/24/22. Interview on 07/26/22 at 3:14 PM with the MD indicated he replaced the medication refrigerator on the second floor a few days ago when the prior refrigerator was not holding temperatures properly and the thermometer was reading about 50F. Interview on 07/26/22 at 3:58 PM with LPN2 confirmed there were no temperature monitoring logs available for the first-floor medication refrigerator. LPN2 confirmed the first-floor freezer thermometer read 49 F, was empty and the refrigerator did not have a thermometer. Interview on 07/26/22 at 5:00 PM with LPN2 and IDON present, confirmed the temperatures in the 2nd floor medication refrigerator along with refrigerator temperature of 50F and freezer temperature of 0F. IDON confirmed medication refrigerator temperature reading of 50F. Both nurses could not state how long the medications had been stored in the refrigerator, how many times the door had been opened, or if the medication refrigerators had dropped below or rose above recommended temperature ranges. Interview on 07/26/22 at 5:36 PM with the Consultant Pharmacist (CP) stated that she recalled being in the facility on 07/24/22 at which time the outside of the refrigerator felt warm to her; the inside was not running warm, under 50F, and the staff had opened it several times to obtain medications. The pharmacist stated she suggested to LPN2 and the IDON that they have it replaced due to it feeling hot on the outside. The pharmacist further stated that her expectation for storage of refrigerated medications should maintain a temperature between 36F to 46F. Temperatures above this range could potentially cause the medications to be less effective depending on the length of time the medications were at suboptimal temperatures. Interview on 07/26/22 at 6:24 PM with IDON and LPN2 both confirmed that the 1st floor medication storage refrigerator had a temperature of 56F.

Based on observations, interviews, review of facility policies, and review of Centers for Disease Control and Prevention (CDC) COVID-19 guidance, the facility failed to ensure two Certified Nursing Assistants (CNA)1 and CNA2 donned (put on) proper personal protective equipment (PPE) prior to providing care to one of 17 residents (Resident (R) 44) under droplet precautions for COVID-19. Additionally, the facility failed to properly isolate two of 17 residents (R24 and R71) under droplet precautions for COVID-19. Findings include: Review of a document provided by the facility titled COVID-19 PLAN, revised on 06/01/22, indicated .designated staff caring for patients in the designated separate units or areas of the facility will wear appropriate personal protective equipment (PPE) when providing care for these patients . Review of a document provided by the facility titled [NAME] Covid Surveillance Line List- Date 7/24/22 indicated R24, R44, and R71 received positive test results for COVID-19 on 07/19/22 and required 10 days of droplet isolation/quarantine until 07/29/22. Review of a document provided by the facility titled Enhanced Droplet-Contact Precautions, dated 03/2020, indicated do not enter the room, report to the nurses station with questions, and to perform hand hygiene, don mask, eye protection, gown, and gloves. Keep door closed. Review of a document provided by the facility titled General Guidelines Transmission-Based Precautions, dated 08/04/21, indicated enhanced droplet isolation for COVID-19 should include family and visitors not entering the room, private room or cohort with door closed in addition to standard precautions. 1. Review of a document provided by the facility titled Face Sheet, dated 07/26/22, indicated R44 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R44's medical record revealed a Care Plan, dated 07/19/22, which included Covid-19- Resident is at risk for complications r/t [related to] Covid 19 + .droplet precautions .keep room door closed r/t Covid 19 precautions . Review of R44's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . with a start date of 07/19/22 and a stop date of 07/28/22. During an observation on 07/24/22 at 11:44 AM, R44's doorway had signage hanging up including droplet precautions, personal protective equipment cart outside the door, and a sign stating, stop see nurse before entering, and a sign stating, keep door closed. During an observation on 07/24/22 at 12:18 PM, CNA2 was observed entering R44's room wearing a face shield and N95 mask, but no gown or gloves, while delivering the resident's lunch tray. During an interview on 07/24/22 at 12:18 PM, CNA2 confirmed R44 had COVID-19 and was on droplet precautions. CNA2 confirmed that she did not don a gown or gloves, but should have. CNA2 confirmed that she did not change out her N95 mask until prompted to do so by the surveyor. During an observation on 07/24/22 at 4:57 PM, R44 was sitting up in bed speaking with this surveyor, then CNA1 entered R44's room with her dinner meal tray. CNA1 was wearing a face shield and N95 face mask. CNA1 moved R44's used fluid filled cups with her bare hands to make room for the meal tray. During an interview on 07/24/22 at 4:57 PM with CNA1 stated she did not see the signage on the R44's bedroom door when she opened it to deliver the meal tray. CNA1 then viewed the signage on the door and confirmed that full PPE should be worn in R44's room and all other rooms with droplet precautions or isolation signs on the doors. CNA1 confirmed that she moved R44's soiled cups with her bare hands and that she did not perform hand sanitizing until surveyor prompted her to do so before leaving R44's room. During an interview on 07/24/22 at 5:00 PM with a Registered Nurse (RN), she confirmed R44 continues on droplet precautions due to COVID-19 status and that all staff entering the rooms with droplet precautions signage should don full PPE prior to entering the room. Before exiting a COVID-19 positive room, the staff member should doff (take off) their gown and gloves, discard them in the proper bin just inside the resident's room. Face shields may be wiped down with disinfectant wipe and N95's should be changed out prior to entering the next resident's room. 2. Review of R24's Face Sheet, dated 07/26/22, indicated R24 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R24's Care Plan, dated 07/19/22, included Covid-19- Resident is at risk for complications r/t [related to] Covid 19 + .droplet precautions .keep room door closed r/t Covid 19 precautions . Review of R24's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . with a start date of 07/19/22 and a stop date of 07/28/22. 3. Review of R71's Face Sheet, dated 07/26/22 indicated R71 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R71's Care Plan, dated 07/20/22, included Covid-19- Resident is at risk for complications r/t [related to] Covid 19 + .droplet precautions .keep room door closed r/t Covid 19 precautions . Review of R71's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . with a start date of 07/19/22 and no stop date. During an observation on 07/24/22 at 12:23 PM, R24's doorway had signage hanging up including droplet precautions, personal protective equipment cart outside the door, and a sign stating, stop see nurse before entering, and a sign stating, keep door closed. The door was open during observation. During an observation on 07/24/22 at 12:23 PM, R71's doorway had signage hanging up including droplet precautions, personal protective equipment cart outside the door, and a sign stating, stop see nurse before entering, and a sign stating, keep door closed. R71 had an audible cough while the door was open. The door was open during observation. During an interview on 07/24/22 at 12:23 PM with Registered Nurse (RN) confirmed that R24 and R71 were on droplet precautions due to COVID-19 and that the door should be closed to minimize exposure to other residents. Additionally, RN confirmed that R71 had an audible, productive cough. RN then explained to R24 and R71 that she was closing their bedroom door due to droplet precautions in place. During an interview on 07/24/22 at 1:47 PM, the Administrator stated R24, R44, and R71 tested positive for COVID-19 on 07/19/22 and were on droplet precautions for 10 days. It was her expectation that all staff don full PPE for residents on enhanced droplet precautions, and to don face shield and a mask for non-contact precautions throughout the facility to COVID-19 outbreak. Staff caring for COVID-19 positive residents should change out PPE prior to caring for the next resident. During an interview on 07/24/22 at 2:35 PM with the Corporate Nurse Consultant indicated if any resident that was confirmed with COVID-19 required staff to wear full PPE (gloves, gown, mask, and gloves).

Based on observations and interviews, the facility failed to maintain the kitchen adequately cleaned and sanitized, including hand-washing sink, food preparation surfaces, pots and pans, bins, and floor. In addition, the facility did not timely discard spoiled food and food with an expired use-by date. The facility also failed to properly date and label cook foods for one of one kitchen observed during the survey. Findings: During the initial walk through of the kitchen on [DATE] at 10:30 AM noticed the hand-washing sink to be unclean, brown/gold smear on the wall, sink, and underneath of it. The soap dispenser in the dishwasher area was not working properly. The dishwasher staff poured soap from a gallon into the dishware and sprayed them with water. The floor around the dishwasher area had large amounts old looking foods and large brown buildup at the foot of the wall, dishwasher's pipe, and drainage. The countertops/food preparation had water-stain on it, appeared opaque and greasy to the touch, three-compartment sink and red buckets with sanitation solution were not in use. Also noticed three white bins with clear top, cornmeal, flour, and rice bins, smeared with brown/black-looking stains. In the reach-in cooler observed 3 [NAME]-steel containers with cook foods not properly dated and labeled. In the walk-in cooler observed 1 ½ bags of broccoli and ½ a bag of shredded cabbage spoiled (not fresh looking). The registered dietitian was present during observation, [s/he] confirmed findings. In the dried/cleaned dishware area there was a minimum of 6 pans with dried food on them and greasy to the touch. Concerns shared with the Registered Dietitian. In the dried food storage area observed 6 pasta containers (clear plastic) with greasy tops and no label or use by date. Noticed one dented #10 can on the cans good shelve. Also observed 8 bags of dried mashed potatoes, 6 pancake mix boxes, 6 bottles of chocolate sauce, 14 bottles of ketchup, 3 bags of yellow cake, and 3 bags of white cake without expiration date. In addition, noticed 11 individual packed blue cheese salads dressing puffed-up not equal to other of the same. Kitchen staff #1 was present during observation. On day two of the survey process, [DATE], at 8:49 AM observed 20 web nesting and greasy pans with dried food particles on them. Also observed a kitchen staff used and dried rag to wipe a surface area. Red buckets with sanitation solutions not in use. Observed 3 white blankets on the floor by dishwasher (2 to the left and 1 to the right) completely sucked with water. The registered dietitian confirmed the findings.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment to residents for one of four halls toured during the initial observation of the survey process. Findings: During the initial tour of the facility on 4/19/2021 at approximately 11:15 AM the first room on the left of the short hall of unit 100 appeared cluttered, unclean, and potentially unsafe. The room had three beds. The first bed was by the door, the second one was by the window to the right of the room, and the third bed was to the left of the room and right corner. The second and third beds were occupied by residents. The first bed did not have a mattress on it (just the metal frame) but had two large cardboard boxes and some random items on it. A wheelchair scale was next to it and trash on the floor. Facing the first bed was a bathroom sink with drawers underneath. The middle pickguard laminate was missing, and the right and left pickguard laminates were damaged. Belongings, boxes, clothes, soft drinks, of the resident occupying the third bed, were on the floor and the area appeared unclean and cluttered. The ceiling tile to the left of the room and right corner showed water damage (largely black and brown spot) and it had a hole of approximately one foot by three inches in size. The Resident's belongings were on the floor. In an interview with Resident #34, resident occupying the third bed, on 4/21/2021 approximately 11:48 AM [s/he] stated that the room, including the hole in the ceiling title, has been like that since [s/he] got there. The resident also stated that [s/he] had brought up the issues with the facility staff several times but it hasn't been fixed. On 4/21/21 at approximately 1:30 AM a walk through with maintenance, housekeeping, and the facility administrator was conducted, and concerned areas brought up. Finding confirmed by all parties.

Based on observations, records review, and interviews, the facility failed to ensure Resident #39 received respiratory care consistent with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: The facility admitted R #39 on 01/13/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident during the initial survey process on 4/19/2021 at 12:45 PM two surveyors noticed the oxygen concentrator to be set at 4.5 liters per minute (L/min). Review of R #39's clinical record noted [his/her] physician ordered oxygen (O2) therapy at 2L/min via nasal cannula continuously for Shortness Of Breath (SOB). On 4/20/2021 at 12:18 PM R #39 was observed in bed with nasal cannula properly placed on [him/her] face. The oxygen concentrator was dispensing 4.5L/min. In an interview with the licensed practical nurse (LPN) #1 [s/he] confirmed that the oxygen concentrator was not set at 2L/min. The LPN #1 reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations and interview and review of the facility Infection Control Prevention the facility failed to make sure the kitchen staff wear required personal protective equipment (PPE) appropriately. The kitchen staff was observed wearing facemasks under the nose and under the chin in multiple occasions during the kitchen observation survey process for one of one kitchen observed. Findings During the initial walk through of the kitchen on 4/19/2021 at 10:30 AM observed one kitchen staff preparing salad, with [he/her] facemask below her nose, a second staff was observed walking back and ford in the kitchen with [hi/her] facemask below the nose, and a third staff entered the kitchen with [his/her] facemask down to the chin. In a follow up visits to the kitchen, same day, at 11:15 AM and 3:30 PM observed the same kitchen staff wearing facemask below the nose. Concerns were share with the Registered Dietitian. The next day, 4/20/2021 at 9:45 AM, 10:56 AM, and 3:58 PM staff were observed wearing facemask inappropriately, under the nose/chin. The registered dietitian reminded staff to wear facemask over nose and mouth. However, on 4/21/2021 at 9:30 AM a noticed a kitchen staff wearing [his/her] facemask under the nose. Dietitian present during observation. Review of the facility Infection Control Prevention Program on 4/21/2021 at 10:00 AM includes policy regarding facemask wearing.

Based on observation, interview and policy review, the facility failed to ensure essential personnel were screened for signs/symptoms of COVID-19 prior to allowing entry into the facility. This affected one (surveyor) of one essential personnel who was not screened by facility staff prior to entering the facility. This had the potential to affect all 88 residents who resided in the facility. This deficient practice occurred during the COVID-19 pandemic. Findings included: The facility's COVID-19 Plan, dated 10/12/20, documented: .All staff and/or essential individuals entering the facility will be monitored for signs or symptoms of respiratory issues, temperature will be taken, etc. On 10/13/20 at 8:50 AM, this surveyor entered the screening area just inside the front entrance of the facility. Initially, a staff member was in the screening area but left with a group of several individuals at approximately 8:58 AM to go to an orientation meeting. Beginning at 8:58 AM, the screening area was unattended by facility staff. The surveyor stood in the corner of the room near the doorway into the Administrative Assistant's office waiting for instructions for screening. On 10/13/20 at 9:00 AM, the Administrative Assistant asked the surveyor if s/he could help him/her. The surveyor stated, I am waiting for instructions. The Administrative Assistant did not ask if the surveyor had been screened and returned to the office area. The surveyor continued to stand outside the Administrative Assistant's office in the screening area. On 10/13/20 at 9:07 AM, without verifying the surveyor had been screened, the Administrator directed the surveyor into an office workspace. The surveyor had not been screened prior to being invited into the facility by the Administrator. The surveyor worked in the office workspace until 10:00 AM, when s/he asked the Administrator if there was another location available so s/he could interview her/him. S/He took him/her into her/his office. When asked to describe the screening process for employees, the Administrator stated, Before anybody can report to work, they have to come through the front door and a person is assigned to take their digital temperature. S/He stated all employees and agency staff had a screening log which was completed upon entry. S/He stated emergency medical technicians and other essential personnel were also screened. The Administrator stated screening involved the individual's temperature being taken, questions about the use of hand sanitizer, signs/symptoms of COVID-19 and travel. S/He stated the information was recorded on a screening log and was filed in binders. When asked who was responsible to ensure individuals were screened prior to entering the facility, the Administrator stated, Someone is assigned to the screening area always. The surveyor asked the Administrator if allowing an individual into the facility without screening for COVID-19 could lead to transmission of [MEDICAL CONDITION] to residents and staff. S/He stated, Yes, it could. This surveyor then informed the Administrator s/he had not been screened by facility staff prior to being allowed to enter the facility. This surveyor made a recommendation to the Administrator that s/he should be screened before continuing with the survey.

Based on interviews, record review and review of facility policy the facility failed to ensure one of seven sampled residents (Resident #1) was free from verbal abuse by a facility staff. On 07/21/20, the facility reported Certified Nursing Assistant (CNA) #1 verbally abused Resident #1. This failure had the potential to affect any resident receiving care in the facility at the time of the survey. The survey census was 87. Findings include: Review of the facility policy, Plan for the Prevention of Elder Abuse, dated 05/2017, stated, Protection of the Resident - in the case of a resident who has been the alleged victim of abuse and/or neglect, the facility will take immediate measures to protect the resident from further harm and from service interruptions, restrictions, and all other forms of retaliation. Such measures might include the following: Moving the resident to another room, changing roommates, reassignment of staff, suspension of alleged staff member pending investigation outcome, restricting visitation, supervised visitation, and Medical intervention by physician. A review of Resident #1's Face Sheet in the electronic medical record (EMR), indicated Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/20, specified a Brief Interview for Mental Status (BIMS) was completed and Resident #1 scored 99 out of 15 which meant Resident #1's cognitive response was severely impaired and the resident was not able to complete the interview. Review of the facility's incident report investigation, dated 07/28/20, revealed an Emergency Medical Technician (EMT) came to the facility to transport Resident #1 to a [MEDICAL TREATMENT] appointment on 07/21/20. The EMT reported CNA #1 was verbally abusive to Resident #1 and refused to change the resident's soiled brief prior to transfer. The report further indicated the EMT reported CNA #1 had a poor attitude and stated, that's a waste of another diaper'' before providing the requested incontinent care to Resident #1. The facility investigation further indicated CNA #1 was immediately suspended from employment on 07/21/20 and terminated from employment on 07/22/20. Review of CNA #1's employee file revealed no previous issue with resident abuse. The record further revealed evidence of background checks in place and had received training on the facility abuse policy. On 09/03/20 at 10:12 AM, an interview was conducted with the Human Resources (HR) Director. The HR Director confirmed CNA #1 was terminated from employment as a result of the facility's investigation into an allegation of verbal abuse of Resident #1. On 09/03/20 at 11:00 AM, an interview was conducted with the Administrator. The Administrator confirmed CNA #1 was terminated from employment when the facility's investigation of the reported verbal abuse on 07/21/20 was substantiated by the facility.

Based on record review and interview, the facility failed to update care plans for 2 of 3 residents with recurrent Urinary Tract Infections [MEDICAL CONDITION]. Resident #1 and #2 with histories of UTIs care plans did not reflect the episodes of infections. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the current Care Plan revealed a plan originally dated for 10/24/16- Always incontinent of urine due to urge incontinence. A goal of: Will not experience infections from incontinence. (No care plan for recurrent UTIs.) Review of the medical record revealed physician's orders [REDACTED]. 5/17/17 -Cipro 250 milligrams one bid x 7 days UTI 5/21/17-[MEDICATION NAME] milligrams one bid x 7 days UTI 6/16/17- [MEDICATION NAME] 500 mg twice a day (BID) x 7 days, pending Culture and Sensitivity (C&S) 6/19/17- Bactrim DS, one po BID x 7 days-UTI 7/31/17- Urinalysis (u/a), Culture and Sensitivity (c&s), Dysuria The resident had repeated urinary tract infections. The resident's plan of care was not updated to provide a plan for treatment or prevention of UTI's. The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a care plan for frequently incontinent of urine due to history of incontinence. Observe for acute behavioral changes that may indicate UTI, Assess for symptoms of UTI. Although the resident had been admitted with a UTI, the resident's care plan did not address the resident's history of UTI. On 10/30/17 at approximately 4:00 PM The Director of Nursing (DON) was interviewed by the surveyor. The DON reviewed the care plans of resident #1 and #2. Anyone on the Interdisciplinary Team (IDT) can update the care plan. The DON confirmed there was no care plan for the resident's history of UTI. There was no updates of the care plan regarding the residents recurrent UTI's.

Based on observation, interview and review of the facility policy titled Points to Remember in Respecting Dignity, the facility failed to promote dignity of the residents when entering resident rooms for 1 of 4 sampled residents reviewed for dignity. For Resident #137, staff failed to await permission to enter the rooms after knocking. In addition, the facility failed to promote dignity during the dining experience in 3 of 3 dining rooms. Residents were served on trays in the social dining room. The findings included: While the surveyor was conducting a resident interview on 4/12/17 at 1:40 PM, Laundry Aide #1 knocked on the resident's door and entered without awaiting permission. Resident #137 stated, Please do not enter the room. Laundry Aide #1 continued to enter the room and placed two pieces of laundry on the bed and then described the two pieces of laundry to Resident #137. After Laundry Aide #1 left the room, Resident #137 said to the surveyor, I did not want the staff member in the room during the interview. During an interview on 4/13/17 at 3:41 PM, the Director of Laundry stated that the expectation for correct room entry procedure was to Knock on the resident's door three times, state who you are and why you are in the room and then enter the room. An interview was conducted on 4/13/2017 at 3:50 PM with the Director of Nursing (DON) regarding expectations for employees entering resident rooms. The DON said the employee should knock and announce who they are. Further, the DON stated if the employee needed to provide care to another resident in the room, s/he believed that the employee did the right thing. The facility policy titled Points to Remember in Respecting Dignity #2 states, Before entering a room, knock on the resident's door, give your name, ask permission to enter, pause briefly, and then go into room. During initial tour on 4/10/17 at 11:45 AM and 12:00 PM, trays were served to residents in the social and 200 hall dining rooms. However, the plates, flatware, and glassware were not removed from the trays. The staff did not offer to remove the items. During an interview on 04/13/2017 at 4:49 PM the Director of Dietary said, s/he said the CNA should take the plates and flatware off the tray, but some residents may state preference for the dishes and flatware to remain on the tray during meal service. During a dining observation of the Social Dining Room at 11:37 a.m. on 4-10-17, all residents' plates were noted to remain on the serving trays throughout the dining experience. No efforts were made to remove them. During an interview on 4-12-17 at 12:08 p.m., the Health Information Manager explained the process for the dining experience, to include staff removing the residents' meals from the serving tray.

Based on observations, interviews, and review of the facility's policies entitled Housekeeping/Laundry and Maintenance, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior to Unit 100 and Unit 200. Resident rooms are in need of repairs and identified resident bathrooms in need of additional cleaning were identified in various areas of the units where residents reside. The findings included: Observations of the facility on 4/10-4/13/17 throughout various times revealed the following: Unit 100 Room 103: Bedroom floor corners and edges with buildup. Bathroom brown substance around and behind the toilet. Bed A footboard is missing Room 110: Bedroom (bed b) the light is not working. Bathroom tiles are heavy soiled Room 114: Bathroom vent with heavy dust build up Unit 200 Room 202 Bathroom vent with heavy dust build up. Room 203: Bedroom chipped paint on the edge of the window. Bathroom vent had dust build up. Room 204: Bedroom closet drawer for Bed C off the hinge. Light Bed D is dim. Bathroom railing is loose. Room 206: Bathroom baseboards in the bathroom are brown and exhaust fan not working. Room 210: Bed pan uncovered on the bathroom floor Room 211: Bedroom electrical plate for the phone connection coming out of the wall. Chair arms in the room are damaged. Bathroom trash on the floor and stained tiles Room 216: Bedroom chair in the room seat is torn Room 220: Bedroom rust on the vent near the window During Stage 2 of the survey on 04/13/2017 at 1:15PM, the Housekeeping Director and Maintenance Director toured with the surveyor to observe and confirm the concerns that were identified throughout the facility. An interview with the Maintenance Director revealed he/she was aware of some of the rooms that had concerns. Maintenance Director also stated the exhaust ventilation is located on the outside of the building. In addition the Housekeeping confirmed the concerns as well and stated the linen carts are the nursing staff responsibilities and will be taken care of. In addition the resident's chairs that are in disrepair will be replaced. An observation with Director of Nursing (DON) and Administrator on 4/13/17 at 1:54 PM revealed the unlabeled and uncovered basin on the floor in Room 210. Room 202 with linen cart filled with laundry DON discarded the basin and removed the linen cart. Review of the 3/22/17 resident council minutes on 04/13/2017 3:01:29 PM revealed some residents had concerns about the mop water not being changed enough in their rooms. A review of the policy provided by the facility on 4/12/17 entitled Housekeeping/Laundry revealed under Resident Rooms: resident rooms shall be clean, orderly and well ventilated. All floors shall be cleaned regularly . Under Repair and Replacement: Worn and torn articles are removed for repair or replacement. In addition the Maintenance policy revealed under Maintenance and Repair: lighting level are adequate . The facility is well-ventilated through the use of windows, mechanical ventilation, or a combination of both.

Based on observation, interview and review of the facility's policy, Dressing - Non-Sterile, the facility failed to provide treatment as ordered for Resident #121, 1 of 1 resident reviewed for pressure ulcers. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. At 11:54 AM on 04/12/2017, review of the Physician's Telephone Orders revealed orders dated 03/27/17 to cleanse the left inner ankle and the right outer ankle with normal saline, apply an Allevyn 3x3 dressing 3 times a week on Monday, Wednesday, and Friday. Another order dated 3/29/17 was noted to cleanse the sacrum with normal saline and apply a [MEDICATION NAME] dressing 3 times a week on Monday, Wednesday, and Friday. At 3:10 PM on 04/12/2017, Licensed Practical Nurse (LPN) #3 was observed providing wound care to Resident #121. During the dressing change to the sacrum, the LPN wiped the right periwound top to bottom 2 times with a skin prep and discarded, then wiped from the top periwound of the wound through the wound bed and down the bottom of the periwound with a second skin prep and finished by wiping the left periwound from the top to the bottom with a third skin prep. The wound was not cleaned as ordered. The LPN proceeded to the wound on the right ankle. Sterile water was applied to 4x4 gauze and the periwound was wiped from the top edge of the wound bed upward, from the bottom edge of the wound bed downward and the posterior periwound top to bottom using a clean gauze with each wipe. The LPN then removed her/his gloves, sanitized her/his hands, and donned clean gloves and repeated with skin prep wipes. The LPN then applied the Allevyn dressing as ordered. The wound bed and the anterior periwound was not cleaned. At 3:46 PM on 04/12/2017, LPN # 3 confirmed s/he did not clean the sacral wound bed. The nurse further confirmed s/he did not clean the wound bed of the wound on the right ankle and only the top, bottom, and posterior periwound but not the anterior periwound. At 3:54 PM on 04/12/2017, review of the policy entitled Dressing - Non-Sterile revealed 9. Open sterile dressings. Pour prescribed cleaning solutions over needed number of clean (for wound cleaning) and sterile (for wound dressing) gauze pads.11. Clean wound gently but thoroughly with prepared gauze pads. Clean from top to bottom and from center outward. Use a separate gauze pad for each stroke.

Based on record review and interview, the facility failed to maintain resident medical records that are complete and accurately documented for 1 of 2 sampled residents reviewed for notification. Resident #95 had a change in treatment orders on the bottom of the right foot, acquired a stage III pressure area on the left elbow, ran a fever overnight and was given a rapid flu test related to cough and fever. There was no documentation in the clinical record that the responsible party was notified at the time of any of these issues. The findings included: The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review of the Pressure Ulcer Report on 04/12/2017 at 3:32 PM revealed an entry on 3/8/17 that Resident #95 acquired a stage III pressure ulcer on the left elbow. A Physician's Order was noted on 3/8/17 to Cleanse area left (L) (Left) elbow with N/S (Normal Saline) -Apply Allevyn 3 x 3 3 x (times) weekly (RT) related to Pressure. There was no evidence of family notification of the new pressure area and treatment in the medical record. Record review revealed a 2/6/17 Physician's Order to Clean area on Right bottom foot with NS (Normal Saline). Pat dry. Applied (sic) Xeroform & wrap with Kerlix daily. Another Physician's Order dated 2/7/17 read to: 1) D/C (Discontinue) cleanse area right bottom foot (with) N/S. Pat dry. Apply Xeroform, wrap with Kerlix QD (every day) r/t tx (treatment) change. 2) Skin Prep Apply to area bottom of (R) (Right) foot Q (every) shift RT pressure. There was no evidence of family notification in the medical record of the new treatments. Review of Nurse's Notes at approximately 3:45 PM on 4/12/2017 revealed an entry on 1/13/17 at 6:41 am: Resident has run fever throughout the night. According to pm (7 PM to 7 AM) nurse, he (she) ran fever on that shift also. Temp-101.1 at the beginning of the shift. Resident was medicated with Tylenol 325 mg (milligrams) (2) po (by mouth). Resident's temp came down to 100.5 . A Nurses's Note dated 1/13/2017 at 2:42 PM read: Resident running temp of 101.6. Given Tylenol at 12:22 PM. Recheck temp after 1 hour 101.6 . A Nurse's Note dated 1/4/2017 at 11:30 AM: Medication Follow-up-(Rapid Flu test x 1 r/t Fever.) Negative results. There was no evidence of family notification in the medical record of the change in the resident's condition. Review of Physician's Orders and Nurses Notes revealed that on 1/14/17 Resident #95 received a Rapid Flu test x 1 related to cough and fever. A Nurse's Note dated 1/14/2017 at 11:30 AM stated: Medication Follow-up-(Rapid Flu test x1 r/t Fever.) Negative results 1/14/2017. There was no evidence of family notification in the medical record. During an interview on 04/13/2017 at 8:39 AM regarding notification Licensed Practical Nurse (LPN) #1 stated; I notify everything about the resident in the Nurses Notes; if I call family members, if I do treatments or a resident has a new drug, I notify my supervisor. I also put it on the 24 hour report at the desk. I put everything in Nurse's Notes. During an interview on 04/13/2017 at 8:59 AM LPN #4 stated, I notify the RP (Responsible Party) and then I document in the COMS system (electronic record) in Nurse's Notes. I will also tell the supervisor who places it on the 24 hour report and usually the supervisor is the one who does the order and they also place it on the shift report. During an interview on 04/13/2017 at 9:30 AM the Director of Nurses (DON) stated, Regarding the 24 hour report, RP (Responsible Party) notifications are not placed on 24 hour report. The DON reviewed the Nurse's Notes and confirmed there was no evidence of family notification for changes in resident conditions and new Physician's Orders for treatments and diagnostic tests. During an interview on 4/13/17 at approximately 3:30 PM, LPN #6 stated, in the presence of the DON, that the resident's wife was visiting frequently at that time and was aware of the fever. The nurse further stated that s/he did not document this in Nurse's Notes. The DON reported that the treatment nurse at the time of the Pressure ulcer development stated that the wife was present in the room while s/he was doing the treatment but s/he did not make a Nurse's Note about the notification. Review of the facility policy on 4/13/17 at approximately 11:00 AM titled, Acute Episode Documentation stated: Acute episode documentation is to be instituted immediately upon any change noted in the resident's physical, mental or emotional status. Detailed documentation is to be entered in nurses notes each shift until the acute episode is resolved or stabilized. Physician and resident's family/responsible party are to be notified of any acute episode and/or change in the resident's status.

Based on record review, observation and interviews, the facility failed to provide adequate supervision for 1 of 3 residents reviewed for falls. Resident #1 exited the front porch through the gate to the handicap ramp via his/her wheelchair sustaining a fall, which resulted in injuries. The findings included: The facility admitted Resident #1 with a [DIAGNOSES REDACTED]. A review of the medical record on 11/18/14 at 10:10 AM revealed that on 5/26/14 the resident sustained [REDACTED]. Further review of the medical record revealed the Annual Minimum (MDS) data set [DATE] and the Quarterly MDS dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BIMS) of "4" indicating s/he had memory problems and impaired cognitive skills for daily decision-making. A review of the nurse's notes on 11/18/14 at 12:05 PM, revealed that Registered Nurse (RN) #1 documented on 5/26/14 at 10:36 PM that upon returning to the facility from a pharmacy at approximately 6:40 PM, a person was noted laying face down on the ramp/sidewalk area. RN #1 called for help and applied pressure to the head laceration. The facility staff called 911 and emergency medical service arrived at approximately 6:50 PM. The resident was transported to the hospital emergency room at 7:05 PM. The physician and responsible party were notified of the incident and the location of the resident. A review of the Occurrence Report dated 5/26/14 at 6:45 PM, revealed that the location of the occurrence was the front porch ramp/sidewalk and that Resident #1 had discomfort/pain located in his/her head, right hand, left hip and right arm. The head laceration was documented as being "approximately 6 inches in wide by 3 inches long" and the right hand laceration was "approximately 2 cm (centimeters)". Resident #1 was documented as bleeding from the nose and bruised. A review of the Accident /Incident Report completed and submitted to the State Licensing Division, documented that Resident #1 was observed on the surveillance video opening the porch gate and propelling his/her self down the wheelchair ramp holding onto the hand rail. "...Resident (#1) lost control of the wheelchair when the wheelchair rolled into the hand rail, stopping the chair, causing the resident to fall out of the wheelchair onto the wheelchair ramp/sidewalk. resident sustained [REDACTED]. Transferred to ...emergency room for further evaluation of injuries..." The physician and responsible party were notified. The documented preventative action taken by the facility regarding the incident was to re-evaluate and replace the latch as necessary. A review of the physicians orders on 11/18/14 at approximately 11:00 AM, for the month of May 2014, documented that the resident was receiving Aricept 10 milligrams by mouth daily; Namenda 5 milligrams by mouth twice daily for dementia and Celexa 20 milligrams by mouth daily for Depression. Also, Resident #1 was to have two siderails up to enable resident to turn and reposition related to Syncope, Osteoarthritis and Alzheimer's Dementia. A review of the care plan on 11/18/14 at approximately 11:30 AM included the following problems/need identified by the facility: 1. Resident #1 was identified as having a [DIAGNOSES REDACTED]. The problem onset date was documented as 2/8/10. 2. S/he was also identified as a fall risk related to the [DIAGNOSES REDACTED]. Under the approach for the fall risk was for nursing to provide safety checks on rounds and as needed. The problem onset date was documented as 10/21/11. 3. S/he was identified as needing encouragement to pursue activity of her choice to maintain quality of life. Under the approach dated 7/20/11-encourage Resident #1 to pursue activities in example porch (on nice days), reading and game books. The problem onset date was 2/8/10. An interview conducted with Registered Nurse (RN) #1 on 11/18/14 at 12:05 PM, revealed that prior to leaving the facility there was no one on the front porch, but when s/he returned there was a person (Resident #1) lying on the ramp at the bottom with the wheelchair 1/2 further up the ramp. RN #1 stated it was Resident #1's routine to go out onto the porch unattended. RN #1 stated there were a lot of family members visiting with other residents that day. S/he stated that Resident #1 did not wear a wander guard and that despite the [DIAGNOSES REDACTED]. That was part of his/her quality of life. S/he stated that eh staff would look out periodically to check on the porch activities. S/he stated that prior to the fall Resident #1 never attempted to get off the porch. RN #1 stated that s/he never comes or goes through that entrance and has never seen the gates opened or unlocked. On the day of the fall, Resident #1 had gone by the nurse's station and said, "Hi" to the staff and then went to his/her room for dinner. RN #1 stated that Resident #1 was at his/her normal base line. There had never been any complaints expressed to RN #1 related to the latches on the gates not working or gates being left open. An interview conducted with certified nurses aide (CNA) #1 on 11/18/14 at 1:40 PM, revealed that s/he worked that night and that Resident #1 was up and down the halls. The CNA stated that Resident #1 enjoyed sitting outside in the sunshine, would sit outside by him/herself, but did not wear a wander guard. S/he stated that Resident #1 was not behaving any differently that day. CNA #1 stated that Resident #1 would propel him/herself with his/her feet in the wheelchair. S/he stated that Resident #1 could push the door open by him/herself or family members would help him/her. CNA #1 stated that s/he does go out the porch gates, but has not noticed them being left open. CNA #1 stated that s/he had not received any complaints related to the latches on the gates not catching. The CNA #1 stated that the staff would peep in on the resident every now and then. On the day of the fall, "I was going out the door looking for the resident as the supervisor was coming in and Resident #1 was on the ground". An interview conducted with Licensed Practical Nurse (LPN) #1 on 11/18/14 at 1:45 PM, revealed that Resident #1 rolled around in his/her wheelchair and went go back and forth on the porch that day. S/he remembers telling him/her that supper was ready and the resident ate in his/her room and then went back to the porch. LPN #1 stated that Resident #1 could go in and out of the door by him/herself, which s/he had done for years. The next thing s/he knew they were stating that Resident #1 had rolled off the porch. LPN #1 stated that Resident #1 had never tried to leave the porch before. The resident did not wear a wander guard and that s/he never attempted to go off the porch for the past 2-3 years. "We make rounds to look for her and s/he likes to sit by the door by the window. We check every two hours on all residents and as needed". LPN #1 stated that Resident #1 was his/her normal self that day. An interview conducted with the Director of Nursing (DON) on 11/18/14 at 3:15 PM, revealed that the staff rounded every two hours and as needed on the residents. S/he stated that Resident #1 did not wear a wander guard and was not an elopement risk or wanderer. That s/he never made attempts to leave before and that s/he is able to move in and out of the porch at will. The DON confirmed that Resident #1 was able to open and close the door by him/herself and there had been no other falls for this resident that the DON was aware of. The DON stated that the latches on the porch gates had been replaced after Resident #1's fall. The latches on the gates prior to Resident #1's fall were heavy cast iron with a U shape latch, which had to be lifted over the gate. The DON stated that Resident #1's exit from the porch may have happened during a three minute lapse of time when residents and family were on the porch and then went back inside, it was thought that during this time Resident #1 exited from the porch. The DON stated that s/he had no concern regarding the [DIAGNOSES REDACTED]. The DON stated, "This is what s/he did". S/he stated that Resident #1 never tried to leave in the five years s/he was here. The DON stated that the video shows a deliberate attempt to leave. An interview conducted with the Director of Maintenance on 11/18/14 at 3:25 PM, revealed that the latches on the gates had been changed after Resident #1 fell per the Administrators instruction. The Maintenance Director stated that there have been no other residents seen leaving the porch unattended. An observation on 11/18/14 at 3:47 PM of the video surveillance footage of Resident #1 falling on 5/26/14 showed that the video monitor was positioned over the ramp and overlooking the front parking area in front of the building. During the observation, seen at the bottom of the video was a hand and then the resident was visualized in his/her wheelchair rolling down the ramp then falling out of the wheelchair onto the ramp/sidewalk. The wheelchair remained on the ramp with the resident positioned at the bottom of the ramp/sidewalk. The resident was face down with arms at his/her side. The resident was seen moving his/her right arm after the fall. An interview conducted with the Administrator on 11/18/14 at 3:40 PM, revealed that s/he had no concerns with Resident #1 being outside on the porch alone.