Every finding on record at Wildwood Health and Rehab

Based on record review and staff interview, the facility failed to accurately assess one of 17 sampled residents (R) (R43). The deficient practice had the potential for R43 to be at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the electronic medical record (EMR) revealed that R43 was admitted to the facility with but not limited to diagnoses of major depressive disorder, anxiety disorder, hypertensive heart disease with heart failure, and adjustment disorder with depressed mood.The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/17/2025 revealed in Section E, Behavioral Symptoms, was coded as 0 (Behavior not exhibited).Review of the EMR revealed a behavior note from 06/11/2026: Resident very hostile and disoriented. She had incontinent episodes in bed and stating what's going on here people are hiding things from me. Later came out of room went behind nurses station grabbed cigarettes and lighter, with Certified Nurse Assistant (CNA) telling here not to, lite the cigarette and stated I don't know what you all are trying to do to me. She continued down the hall smoking. Administrator and Charge nurse stopped her and tried to get the lit cigarette when she became very hostile, refusing to give back the lit cigarette. Administrator (sic) to hold her hand while Charge nurse took the lit cigarette and take it outside. Resident went back to her room cursing and laid down.Interview with the MDS Coordinator on 02/25/2026 at 03:09 PM confirmed that R43 had behavioral note from 06/11/2025 and it should be reflected in section E of the annual MDS dated [DATE]. The MDS coordinator stated that she would submit an MDS modification.An interview with the Director of Nursing (DON) and MDS Coordinator on 02/26/2026 at 1:46 PM revealed that accurate coding of behaviors in MDS Section E would trigger the need for development of a new care plan.During a separate interview on 02/26/2026, the Administrator stated that the facility does not have a specific internal MDS policy and relie on the Resident Assessment Instrument (RAI) Manual for guidance.

Based on staff interviews, record review, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to ensure that psychotropic medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for four of eight residents (R) (R16, R25, R238, and R239) reviewed for unnecessary medications. This deficient practice had the potential to adversely affect R16, R25, R238, and R239's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of the facility's policy titled, Use of Psychotropic Medication, dated 8/28/2023, revealed the Policy Explanation and Compliance Guidelines section included .9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and for a limited duration (i.e.14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 1. Review of R16's Physician's Orders revealed an order dated 7/17/2024 for lorazepam (a psychotropic medication used to treat anxiety) 0.5 milligrams (mg) oral tablet, one tablet by mouth every six hours as needed for anxiety. The order had a stop date of indefinite. Review of R16's Electronic Medication Administration Record (EMAR) revealed lorazepam 0.5 mg was administered on 12/2/2024 at 1:42 pm, 12/5/2024 at 1:02 pm, 12/8/2024 at 11:05 pm, 12/19/2024 at 10:26 pm, 11/1/2024 at 4:13 pm, 11/5/2024 at 12:34 pm, 11/7/2024 at 8:33 am, 11/12/2024 at 1:15 pm, 10/2/2024 at 12:02 am, 10/15/2024 at 3:50 pm, 10/18/2024 at 2:37 am, 10/23/2024 at 9:56 am and 4:11 pm, 10/25/2024 at 5:31 pm, 10/26/2024 at 11:31 pm, and 10/29/2024 at 1:20 pm and 8:01 pm. In an interview on 12/21/2024 at 9:33 am, Licensed Practical Nurse (LPN) BB confirmed R16's physician's order for lorazepam oral tablet 0.5 mg one tablet PRN anxiety and confirmed there was no stop date for the order. In an interview on 12/22/2204 at 11:45 am, LPN AA and LPN BB stated if a PRN medication was not administered in a 30-day period, the order would automatically be discontinued. They stated the nurses followed the physician's orders as they were written in the electronic medical record (EMR) and did not issue a medication stop date. In an interview on 12/22/2024 at 12:55 pm, the Director of Nursing (DON) verified R16's physician's order dated 7/17/2024 for lorazepam 0.5 mg oral tablet, one tablet by mouth every six hours as needed for anxiety. She verified the order was dated 7/17/2024 and had a stop date of indefinite. 2. Review of R25s Physician's Orders revealed an order dated 9/17/2024 for lorazepam 0.5 mg oral tablet, one tablet by mouth every six hours as needed for anxiety, and an order dated 6/10/2024 for haloperidol (a psychotropic medication used to treat nervous, mental, or emotional disorders) 1 mg tablet, one tablet by mouth every four hours as needed for agitation, hallucinations, aggression. The orders had stop dates of indefinite. Review of R25's EMAR revealed haloperidol 1 mg tablet was administered on 12/2/2024 at 2:48 am, 12/18/2024 at 5:37 pm, 10/4/2024 at 11:43 pm, and 10/21/2024 at 12:02 am. Further review revealed lorazepam 0.5 mg oral tablet was administered on 12/1/2024 at 11:16 am, 12/6/2024 at 9:46 am, 12/13/2024 at 9:39 am, 12/15/2024 at 7:20 pm, 12/17/2024 at 7:40 pm, 12/19/2024 at 9:36 am and 7:19 pm, 11/1/2024 at 7:20 pm, 11/4/2024 at 7:42 pm, 11/8/2024 at 10:37 am, 11/9/2024 at 11:47 am and 6:37 pm, 11/12/2024 at 6:51 pm, 11/20/2024 at 4:55 pm, 10/4/2024 at 11:44 pm, 10/7/2024 at 1:46 pm and 7:57 pm, 10/8/2024 at 7:13 pm, 10/9/2024 at 8:58 am, 10/10/2024 at 4:52 pm, 10/11/2024 at 9:55 am, 10/14/2024 7:29 pm, 10/21/2024 at 12:01 am, 9:41 am, 4:00 pm, and 9:48 pm, 10/24/2024 9:25 am, 10/25/2024 10:46 am, 10/26/2024 at 11:12 pm, and 10/31/2024 at 9:36 pm. In an interview on 12/21/2024 at 3:30 pm, Registered Nurse (RN) DD verified R25's physician order dated 9/17/2024 for lorazepam 0.5 mg oral tablet, one tablet by mouth every six hours as needed for anxiety, and an order dated 6/10/2024 for haloperidol 1 mg tablet, one tablet by mouth every four hours as needed for agitation, hallucinations, aggression. She verified the orders did not have stop dates. In an interview on 12/22/2024 at 12:55 pm, the Director of Nursing (DON) verified R25's physician order dated 9/17/2024 for lorazepam 0.5 mg oral tablet, one tablet by mouth every six hours as needed for anxiety, and an order dated 6/10/2024 for haloperidol 1 mg tablet, one tablet by mouth every four hours as needed for agitation, hallucinations, aggression. She verified the orders had stop dates of indefinite. She stated the physician was typically asked to review PRN psychotropic medications monthly and write a new prescription if he determined the need to continue the medication. She further stated PRN psychotropic medications should have a rational and definite stop date if the date was extended beyond 14 days. 47146 3. Review of R238's Physician Orders revealed an order dated 12/12/2024 for alprazolam (a psychotropic medication used to treat anxiety and panic disorders) tablet 0.25 mg, give one tablet every eight hours PRN anxiety, with a stop date of indefinite. Review of R238's EMAR revealed alprazolam 0.25 mg was administered on 12/12/2024 at 2:37 pm and 10:40 pm, 12/13/2024 at 6:40 am and 4:27 pm, 12/14/2024 at 10:25 pm, 12/15/2024 at 11:37 pm, 12/16/2024 at 8:37 am, 12/17/2024 at 6:00 pm, 12/18/2024 at 2:02 am and 10:02 am, 12/19/2024 at 1:39 am, 9:52 am, and 6:27 pm, and 12/20/2024 at 3:08 am and 11:09 am. 4. Review of R239's Physician Orders revealed an order for alprazolam oral tablet 0.25 mg, give tablet by mouth every 12 hours as needed for anxiety related to anxiety disorder. The start date was documented as 10/25/2024 and the stop date was documented as indefinite. Review of R239's October 2024 EMAR revealed alprazolam 0.25 was documented as administered to R239 on 10/26/2024 at 3:06 pm, 10/27/2024 at 10:51 pm, 10/28/2024 at 8:56 pm, 10/29/2024 at 9:01 pm, 10/30/2024 at 10:53 am, and 10/31/2024 at 9:36 am and 9:13 pm. Review of R239's November 2024 EMAR revealed alprazolam 0.25 mg was documented as administered to R239 on 11/1/2024 at 3:02 pm, 11/2/2024 at 4:48 am, 11/3/2024 at 9:47 pm, 11/5/2024 at 3:00 am and 6:18 pm, 11/6/2024 at 1:00 pm, 11/7/2024 at 7:57 am, 11/8/2024 at 6:35 am and 9:20 pm, 11/9/2024 at 10:23 am, 11/10/2024 at 1:07 am and 1:24 pm, 11/11/2024 at 3:15 am and 7:02 pm, 11/12/2024 at 7:47 pm, 11/14/2024 at 9:31 am and 9:31 pm, 11/15/2024 at 7:03 pm, 11/16/2024 at 9:20 am, 11/19/2024 at 6:44 pm, 11/21/2024 at 8:39 am and 8:44 pm, 11/23/2024 at 9:50 am, 11/24/2024 at 10:43 am, 11/25/2024 at 7:31 pm, 11/28/2024 at 9:28 am, and 11/29/2024 at 8:07 am. Review of R239's December 2024 E-MAR revealed alprazolam 0.25 mg was documented as administered to R239 on 12/1/2024 at 12:00 pm, 12/2/2024 at 9:40 am, 12/4/2024 at 9:00 am, 12/8/2024 at 10:53 am, 12/9/2024 at 8:00 am and 8:03 pm, 12/10/2024 at 8:55 am and 7:29 pm, 12/12/2024 at 9:57 am and 10:02 pm, 12/14/2024 at 9:45 am, 12/15/2024 at 8:34 am, 12/16/2024 at 7:41 pm, 12/17/2024 at 8:00 am and 8:10 pm, 12/18/2024 at 1:23 pm, 12/19/2024 at 1:23 pm, and 12/20/2024 at 10:22 am. In an interview on 12/22/2024 at 12:37 pm, the DON revealed the normal process was for the physician to review and rewrite all prescriptions for scheduled drugs monthly. She stated once the prescriptions were written, the new orders were entered into the EMR, and there was a place to input a stop date for each order. She further stated each prescription was written for a specific number of tablets and not the number of days the prescription was good for. She confirmed the physician did not write a stop date or a rationale for the medication continuing past 14 days. She confirmed that R238 and R239's orders for alprazolam had a stop date of indefinite.

Based on observations, staff and resident interviews, record review, review of the facility policy titled, Oxygen Administration, and review of the manufacturer recommendations titled, How to Change a Filter on a [brand name] Oxygen Concentrator, the facility failed to ensure an oxygen (O2) concentrator filter was in place for one of ten residents (R) (R32) who received O2 therapy. This deficient practice had the potential to place R32 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled, Oxygen Administration, copyright 2024, revealed the Policy Explanation and Compliance Guidelines section included . 5. Other infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. Review of the manufacturer recommendations titled, How to Change the Filter on a [brand name] Oxygen Concentrator, dated May 3, 2022, revealed clean filters provide a clean oxygen supply. The Tips to Properly Clean and Maintain [brand name] Oxygen Concentrators section stated the recommended cleaning interval of the air filter was seven days. The How to Clean [brand name] Oxygen Concentrator Filter section included .Remove the filter from the back of the device. Clean the filter with mild detergent and water. Rinse in water before reuse. You may notice if you do not clean your filter regularly that there may be reduced airflow and you may also not be receiving the prescribed oxygen you need. Review of the electronic medical record (EMR) revealed R32's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and asthma. Review of R32's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section J (Health Conditions) documented R32 experienced difficulty breathing when lying flat, and Section O (Special Treatments and Programs) revealed R32 received O2 therapy while a resident. Review of R32's Physician Orders revealed an order dated 8/6/2024 for O2 at 2 liters per minute (LPM) continuous every shift. Review of the facility-provided document titled, Bi-Weekly Monday's Concentrator and Filter Cleaning, dated 12/9/2024, revealed R32's O2 concentrator and filter were cleaned on 12/9/2024. Observation on 12/20/2024 at 10:03 am revealed the O2 concentrator next to R32's bed did not have a filter in the cut-out located on the back of the concentrator, and the vented area was covered with a gray fuzzy substance. Observation on 12/21/2024 at 10:01 am revealed R32 sitting up in bed receiving O2 via a nasal cannula. Observation of the O2 concentrator revealed there was no filter located in the cut-out on the back of the concentrator, and the vented area was covered with a gray fuzzy substance. During a concurrent observation and interview on 12/21/2024 at 12:28 pm, Licensed Practical Nurse (LPN) AA confirmed there was not a filter located on the back of R32's O2 concentrator and verified there should be a filter in the cut-out on the back of the concentrator. She further confirmed there was a gray fuzzy substance covering the vent where the filter should be located. During a concurrent observation and interview on 12/21/2024 at 1:38 pm, the Central Supply Clerk/Medical Records Clerk CC stated R32 was on her list of residents who received O2 therapy. She further stated she cleaned the O2 concentrators and filters every two weeks. She stated R32's O2 concentrator filter was cleaned on 12/9/2024. She confirmed R32's O2 concentrator did not have a filter on it, and the vent was covered with a gray fuzzy substance. During a concurrent observation and interview on 12/21/2024 at 12:40 pm, the Director of Nursing (DON) stated the medical records clerk had a schedule to follow for cleaning the O2 concentrators and filters for residents who receive O2 therapy. She confirmed that the filter on R32's O2 concentrator was missing, and the vent inside the cut-out on the back of the concentrator was covered with a gray fuzzy substance. She stated she was not sure why there was no filter located on the back of the concentrator. She stated her expectation was that the concentrators should be cleaned according to the schedule. She further stated not having a filter on the back of the concentrator could cause the equipment to malfunction.

Based on staff interviews, record review, and review of the facility policies titled, Legionella Water Management Program and Legionella Surveillance and Detection, the facility failed to develop a water management program for the prevention of Legionella. The deficient practice had the potential to affect all residents in the facility. Findings Include: Review of the facility policy titled, Legionella Water Management Program dated July 2017 revealed: Under Policy Statement: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Review of the facility policy titled, Legionella Surveillance and Detection dated July 2017 revealed: Legionnaire's disease will be included as part of our infection surveillance activities. The facility could not confirm they had a program in place to prevent the growth and development of Legionella and other opportunistic waterborne pathogens in the buildings water system that is based on nationally accepted standards (e.g., The American Society of Heating, Refrigerating, and Air-Conditioning Engineers, (ASHRAE), Environmental Protection Agency (EPA), Centers for Disease Control (CDC). Interview on 8/16/2023 at 12:20 p.m. with the Maintenance Director (MD) revealed he did not know anything about Legionella Water Management Program nor the EPA's nationally accepted standards. He reported he did not know about flushing the lines and other opportunistic waterborne pathogens. He presented the water temperature logs for the residents' rooms that consisted of four rooms. He confirmed that he only does rooms 101, 119, 120, and 121 once per week, and not the other residents' rooms. He stated that the form comes from Corporate, and he was instructed to follow it. The front of the log has a place for shower/whirlpool temperatures, and the space for the residents' rooms. He presented temperature logs dated from multiple years back. He reported that he did not have a process in place, nor has had any formal education. A tour of the facility with the MD revealed the water heaters appeared well kept and maintained, no rust, dents, or water leakage noted from the water heaters. Interview on 8/16/2023 at 2:10 p.m. with the Director of Nursing (DON) revealed she also served as the Infection Preventionist (IP) and revealed that she had been in this dual role for three weeks. She reported that she had never worked in an IP nurse role before. She stated she was not aware of the water management program at the facility, nor was she aware that she needed to make rounds with the MD to check water temperatures in the residents' rooms. She presented the facility policies titled Legionella Water Management Program and Legionella Surveillance and Detection. Interview on 8/17/2023 at 11:35 a.m. with the Administrator revealed there was a Legionella Water Management Program policy for the entire facility, but the MD was not aware of it, nor the program. She stated that the MD has been scheduled for an online course for a Legionella and Water Management Program. She also stated that she will schedule the MD for for a CDC online education course. She reported that the county Environmental Water Management Manager will be coming out to physically train the MD and teach him to test with a kit and flush the outside building lines. She reported that the corporate Director of Maintenance Management Environmental Service Consultant conducted over the phone training with the MD on 8/16/2023. When asked about her expectations for the water management program going forward, she reported the expectation was to implement the program which has already begun. She reported that the building's water system will be flushed yearly as instructed via the facility, and they will test with a water testing kit as recommended. We will keep all documentation to present to the State at the next recertification. The goal is to have the implementations completed by the end of the month.

Based on observations, interviews, and review of facility policies titled Storage of Medications and Administering Oral Medications, the facility failed to ensure the proper disposal of expired medication, label open vials and bottles of medication, and monitor refrigerator temperatures daily for one of one medication storage rooms and two of two medication carts observed. Findings include: Observation on 12/7/21 at 9:00 a.m. of Medication Cart 2 revealed two medications were past expiration date and all dates were confirmed by Licensed Practical Nurse (LPN) AA: [MEDICATION(S)] tablets x 1 bottle expired 11/21 and Acetaminophen Extra strength x1 bottle expired 8/21. Medication Cart 2 also contained four medications that had been opened for use and were not labeled with open date or calculated expiration date: [MEDICATION(S)] 0.005% eye drops x 4 bottles; Sustain complete 0.6% eye drops x 2 bottles; Artificial tears x 1 bottle; and [MEDICATION(S)] 0.5% eye drops x 1 bottle. LPN AA verified the open dates were not on the open vials and bottles. During an interview with LPN AA 12/7/21 at 9:10 a.m., she stated that she was unaware vials of medication or eye drops had to be labeled when opened and stated that she goes by the expiration date or the dispensed date on pharmacy label. She further stated that the Pharmacy Nurse Consultant comes every other month to check cart and med room for expiring medications and confirmed that expired mediations should not be left in the cart. She further stated that every nurse on all the shifts should be checking the cart for expired medications. An observation on 12/7/21 at 10:00 a.m. of Medication Cart 1 revealed five medications were past expiration date and all dates were confirmed by LPN BB: [MEDICATION(S)] tablets x 1 bottle expired 11/21; [MEDICATION(S)] x 1 bottle 8/2021; [MEDICATION(S)] inhaler 9/20/2021; Preparation H suppository x1 8/21; and [NAME] Klenz dermal wound cleanser x1 bottle expired 2/2020. Medication Cart 1 also contained five medications that had been opened for use and not labeled with open date or calculated expiration date and were confirmed by LPN BB: [MEDICATION(S)] 0,004% eye drops x 1 bottle; [MEDICATION(S)] 1% ophthalmic solution x 1 bottle; [MEDICATION(S)] susp 40mg/ml x 1 bottle; [MEDICATION(S)] 0.1% nasal spray; and [MEDICATION(S)] nasal spray x 3 bottles. During an interview with LPN BB on 12/7/21 at 10:10 a.m., he stated that he was unaware Medication Cart 1 had expired medications and that he did not know that opened eye drops and nasal sprays should have an open date. He stated that every nurse should check and remove out of date medications from the medication carts. On 12/7/2021 at 10:45a.m. an observation of Medication Room behind the nurses station was conducted with the Minimum Data Set (MDS) Coordinator. On the counter was a small stainless steel refrigerator unit containing vaccines and medications. The refrigerator was at 40 degrees Fahrenheit, a log with recorded temperatures was attached. Review of refrigerator temperature logs for the past 12 months revealed gaps in readings and the month of June 2021 was missing. A cabinet containing over the counter floor stock was inspected with two medications found to be expired: Vitamin D 50 mcg x 1 bottle expired 10/21 and Arnicare gel x 1 tube expired 5/2021. A drawer in the cabinet contained the following expired IV supplies: [MEDICATION(S)] 3ml syringe 25gx1 expired 9/2020; Whin safe safety Huber Needle set x1exp. 8/31/2020; Replacement caps Braun male/female non vented luer lock exp. 7/2011; Normal Saline 0.9% [MEDICATION(S)] flush syringe exp. 2/4/2021 x 19 syringes; and Normal Saline 0.9% [MEDICATION(S)] flush syringe exp. 9/30/2021 x 19 syringes. During an interview with the MDS Coordinator on 12/7/2021 at 10:55a.m., she verified the medications and supplies were expired in the Medication Room. She stated that she was unaware of the expired medication and that there were not any staff members assigned to check the medication room. She stated that it is every nurses' responsibility to remove expired medications from the room and place in the med safe unit for pick up by the pharmacy. She further revealed that she was aware the refrigerator temperature was supposed to be recorded daily but that sometimes it gets missed. An interview with the Director of Nursing (DON) on 12/8/2021 at 8:58a.m. revealed she was unaware that expired medications were being left in carts and in the med room. Further interview revealed all medication nurses should be watching expiration dates and that medication expiration dates should be checked prior to administration. Continued interview revealed the facility was in the process of hiring a Certified Nursing Assistant (CNA) Manager and she would be assigning that employee to monitor the carts and the med room medications. Further interview revealed it is her expectation that there would be no expired meds available for use and that opened vials and bottles be dated. Continued interview revealed temperatures of the medication room refrigerator should be checked daily and upon reviewing the logs she had seen the had missed some. Continued interview revealed the contracted pharmacy, Consultants' Pharmacy has a book of policies that the facility uses and provided copies of pages 33-36 regarding medication storage at the facility. A telephone interview on 12/8/2021 at 10:30a.m. with the Consultants' Pharmacy Nurse Consultant revealed she comes to the facility approximately every other month. While at the facility she revealed the cart and med room are checked, and med passes are observed. Continued interview revealed she prints out her report of any F tags that she reviews with the staff. Further interview revealed the removal of medications is one of the issues she discusses with staff. Continued interview revealed if she notices a medication or supply going out of date, she removes it and sends it back to the Pharmacy. A review of the policy titled; Storage of Medications version 1.2(H5MAPL0851) indicated a Policy Statement that The Facility stores all drugs and biologicals in a safe, secure, and orderly manner. The Policy Interpretation and Implementation stated Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. A review of the policy titled: Administering Oral medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Check expiration date on the medication. Return any expired medications to the pharmacy. Consultants' Pharmacy the contracted Pharmacy for the facility includes in the policy handbook the following. Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled or 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.

Based on observation, record review and staff interview, the facility failed to ensure that one item (ham) was held on the steam table at 135 degrees Fahrenheit (F) or above, and that one cold item (milk) was held at 41 degrees F. or below. In addition, the facility failed to sanitize food processor equipment between each pureed food item prepared, and failed to ensure that all items in the resident Pantry and the Pantry refrigerator were labeled and dated. There were 41 residents that received an oral diet. Findings include: 1. On 2/20/18 at 3:09 p.m., Cook II was observed preparing pureed foods for the evening meal, and stated during interview that nine residents received a pureed diet in addition to two residents that received pureed meats. She was observed to place boneless pork chops in the food processor along with beef broth and thickener, and processed them until the desired consistency was achieved, at which time she placed the pureed meat in a pan and placed it on the steam table. Cook II was then observed to pre-rinse, wash and rinse the food processor equipment in the 4-compartment sink, but failed to place the equipment in the fourth compartment to sanitize it before preparing the pureed field peas. After the field peas were pureed to the desired consistency, the food processor equipment was again rinsed, washed and rinsed and then used to prepare the pureed corn, without using the sanitizing compartment of the 4-compartment sink. During interview with Cook II on 2/20/18 at 4:12 p.m., she verified that she did not sanitize the food processor equipment after pureeing the pork chops and field peas, and that she normally did this but forgot this time. 2. On 2/21/18 at 12:11 p.m., Dietary Aide JJ was observed plating food from the steam table for lunch, and stated during interview that one cart of lunch trays had already been delivered to residents that ate in their rooms. The Dietary Manager (DM) was observed to check steam table temps with the facility's calibrated thermometer at this time, and the ham slices were noted to be 120 degrees F. Dietary Aide JJ removed the ham from the steam table and placed it back in the oven to reheat, and stated during interview that she had checked the temperature of all foods on the steam table prior to serving, and they were all fine. Observation of the temperature taken by the DM of milk poured from a gallon container placed in a bowl of ice revealed that the temperature was 50 degrees F., and Dietary Aide QQ added additional ice around the milk container. Review of the steam table temperature log revealed that no temperatures had been recorded for the lunch meal on 2/21/18, and Dietary Aide JJ stated during interview that she had forgotten to write the temperatures down when she took them, and had no documentation of what they were. On 2/21/18 at 12:33 p.m., the temperature of the milk was re-checked by the DM, and had risen to 54 degrees F. Observation of the temperature of the milk cooler, where the milk was stored prior to removing it to the tray line, was 34 degrees F. During interview with the DM on 2/21/18 at 1:17 p.m., she stated that 13 residents had already been served the sliced ham before the steam table temps were taken for the surveyor, and that staff were supposed to take steam table temps right before they plated the food, and record it on the log. She stated during further interview that when staff used the 4-compartment sink, the washed items should be left submerged in the fourth compartment for 60 seconds to sanitize them. The DM further stated that the kitchen employees recently attended inservices on rules for the kitchen. Review of Inservice Education Reports dated 1/5/18 and the facility policies and procedures for the items covered during the inservice included the following: 1. Policy: Minute Timer: Set the timer for one minute for sanitization in the 3-compartment sink. 2. Rules for Kitchen: Everyone doing pots, pans, and utensils will use the timer. Everyone using the 4-compartment sink will use them in the proper way (pre-flush, wash, rinse, and sanitize). Always date your food and put a discard date on it 7 days from the day you opened it. 3. Food Temperatures: Before serving any meal from the steam table, food temperatures will be tested and logged. All items on the steam table are required to be 135 degrees F or higher. Further review of the Inservice Education Reports revealed that both Cook II and Dietary Aide JJ attended all three of the topics covered during the inservice on 1/5/18. Review of an excerpt from the facility's Food Service manual (undated) on Food, Limiting the Growth of Pathogens revealed the following: Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding: Potentially hazardous food shall be maintained at 41 degrees F. or below, or 135 degrees F. or above. 3. During observations in the resident Pantry on 2/23/18 at 8:56 a.m., two dessert bowls covered with plastic wrap that contained what appeared to be cake portions were observed on top of the refrigerator, and one was on top of the microwave, and they were not labeled or dated. Inside the freezer one microwaveable package of sweet and sour chicken, and one microwaveable salisbury steak dinner were observed and were not labeled with a name. Observed in the butter compartment of the refrigerator were two tomato slices wrapped in a paper napkin that were unlabeled and undated. Ten mandarin oranges were observed in a plastic bag on a shelf in the refrigerator that were not labeled or dated. During interview with the Director of Nursing on 2/23/18 at 9:08 a.m., she verified the above concerns related to storage of resident food in the Pantry. Review of a sign taped to the front of the Pantry refrigerator revealed: Refrigerator for resident use only. All containers must be tightly sealed, labeled and dated. Any items found open, not labeled or dated will be thrown away.

Based on record review and staff interview, the facility failed to attempt to obtain reference checks for seven of eight employee files reviewed who were hired in the past four months. The sample size was 34 residents. Findings include: Review of the personnel files of eight employees hired between 11/1/17 and 2/6/18 revealed that reference checks could be located for only one of the eight. During interview with the Assistant Administrator on 2/22/18 at 5:30 p.m., she verified that reference checks had not been done for Certified Nursing Assistants HH, NN, and OO; Licensed Practical Nurse KK; Physical Therapy Assistant CC; and Dietary Aides LL and MM. She stated during further interview that the staff responsible for checking the references had just failed to do so, and verified that all new hires should have reference checks attempted. During interview with the Assistant Administrator on 2/23/18 at 8:55 a.m., she stated that the facility used a checklist to ensure all necessary items were done for new employees. Review of the Employee Personnel File Checklist revealed that Employment References was one of the required items. Review of the facility's Employee Personnel File subject in the Personnel Policies & Procedures Manual, with a revision date of 10/24/14, revealed that authorization by the employee to check references, and prior personal and employment references shall be placed in the employee's permanent file.

Based on observation and staff interview, the facility failed to label and store a medication in a locked area inaccessible by residents. The facility census was 41 residents, and the sample size was 34. Findings include: On 2/23/18 at 8:56 a.m., an opened, unlabeled, and approximately half-full 12-ounce bottle of an antacid/anti-gas liquid medication (comprised of aluminum [MEDICATION NAME], magnesium [MEDICATION NAME], and [MEDICATION NAME]) was observed in the resident refrigerator in the unlocked Pantry. During interview with the Director of Nursing on 2/23/18 at 9:08 a.m., she verified that the Pantry door was open and unlocked, and that any medication should be kept locked up.

Based on observation, interview, and review of the Policy titled Use of Restraints, the facility failed to ensure that one resident (R) (#6) was free from restraints out of 41 sampled residents. Findings include: Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented R#6 with a Brief Interview for Mental Status (BIMS) score of 00, indicating that the resident was cognitively impaired, required two-person extensive assistance with all Activities of Daily Living (ADL), and no restraints used. The clinical record for R#6 revealed a [DIAGNOSES REDACTED]. Observation on 02/19/18 at 2:19 p.m. revealed R#6 in bed, alert with confusion, Two 3/4-length side rails on each side of the bed. R#6 legs were drawn up toward chest but noted to be able to move in bed. No attempt to exit the bed or climb over the rails noted during this observation. Review of the care plan last revised 11/12/17 revealed R#6 has a history of falling with interventions to include referral to Physical Therapy (PT) for evaluation as needed, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs for possible decrease in dosage/elimination of drug, use geriatric chair/wheelchair to transport, assess for possible acute condition that may have contributed to fall as needed, pressure reduction cushion for wheel chair with stabilizing straps, and complete a request for therapy screen as needed. The use of siderails was not included in the current care plan Observation on 02/21/18 at 11:00 a.m. revealed R#6 in bed with head of bed at 30 degrees and was holding on to the side rails and pulling herself toward the rail. No attempt to throw her legs over or through the side rails was observed. R#6 let go of the siderail, laid on her back, and began watching TV. Interview with Charge Nurse AA on 02/21/18 at 12:40 p.m. at R#6 bedside revealed that the resident's family requested that side rails be used for safety because R#6 moves about a lot in bed and may fall out. Interview with the Social Worker on 02/21/18 at 1:00 p.m. revealed the family requested the resident have side rails for safety. States R#6 is assessed for side rails annually and is not physically able to raise the side rails up or down. Review of Bed Rail / Assist Bar Evaluation for R#6 dated 3/28/17 revealed that the resident has levels of consciousness or a cognitive deficit, visual deficits, unable to get out of bed, has a history of falls, problems with balance or poor trunk control, uses the bed rail bar for positioning or support, rail helps the resident to rise from a supine position to a sitting position, no history of postural [MEDICAL CONDITION], possibility that the resident will climb over the bed rails, no evidence the residence has a desire or reason to climb over the bed rails or get out of the bed, does receive medications that would require safety precautions, no risk to resident if bed rails are used. Also revealed that R#6 presents with a cognitive deficit, has glasses but will seldom wear them, has poor balance, does not try to exit her bed unassisted, rails have been reduced to 1/2 rails since last assessment, will hold to the rails during ADL care and incontinent care, and is currently receiving [MEDICATION NAME] and [MEDICATION NAME]. Review of Physician order [REDACTED]. Review of Policy, Use of Restraints revealed that the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e, side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Cross reference F656

Based on record review and staff interview, the facility failed to develop care plans for diabetes and insulin use, as well as anticoagulant use, for one resident (R) (R #18). In addition, the facility failed to develop an individualized care plan for [MEDICAL CONDITION] drug use for one resident (R #7) and failure to develop a care plan for Resident (R) #6 who uses siderail and failed to assess pain for one Resident (R) #35. The sample size was 34 residents. Findings include: 1. Review of R #7's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she received an antipsychotic, antianxiety, and antidepressant all seven days of the assessment period. Review of her Annual MDS dated [DATE] revealed that [MEDICAL CONDITION] Drug Use triggered as an area of concern, with the decision to care plan for it. Review of a Psychiatric Medication Evaluation dated 11/13/17 revealed that R #7 continued to hallucinate and be delusional, and was currently taking [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (an antianxiety drug), and quetiapine (an antipsychotic). Review of R #7's physician's orders [REDACTED]. Review of R #7's care plans revealed that she had ones developed for ineffective individual coping; wandering risk; behaviors such as physical, rummaging and wandering; and for a [DIAGNOSES REDACTED]. Further review of these care plans revealed the each had an approach to give medication as ordered, but there was no care plan developed for the [MEDICAL CONDITION] medications she was receiving, and no individualized interventions to address the monitoring for behaviors and possible side effects from these drugs, nor to monitor for progress towards a therapeutic goal. During interview with the Director of Nursing (DON) on 2/23/18 at 12:49 p.m., she verified that there was no individualized care plan related to [MEDICAL CONDITION] drug use for R #7. 2. Review of R #18's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly MDS dated [DATE] revealed that she received insulin and an anticoagulant all seven days of the assessment period. Review of R #18's physician's orders [REDACTED]. Review of all of her care plans revealed that none were developed for diabetes, insulin, or [MEDICATION NAME] use. During interview with Licensed Practical Nurse BB on 2/21/18 at 2:25 p.m., she stated that R #18 received routine insulin as well as insulin per a sliding scale based on her blood sugar measurements. She stated during further interview that R #18 was not on a blood thinner. Based on observation, interview, and review of the Policy titled Use of Restraints, the facility failed to ensure that one resident (R) (#6) was free from restraints out of 41 sampled residents. 3. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented R#6 with a Brief Interview for Mental Status (BIMS) score of 00, indicating that the resident was cognitively impaired, required two-person extensive assistance with all Activities of Daily Living (ADL), and no restraints used. The clinical record for R#6 revealed a [DIAGNOSES REDACTED]. Observation on 02/19/18 at 2:19 p.m. revealed R#6 in bed, alert with confusion, Two 3/4-length side rails on each side of the bed. R#6 legs were drawn up toward chest but noted to be able to move in bed. No attempt to exit the bed or climb over the rails noted during this observation. Review of the care plan last revised 11/12/17 revealed R#6 has a history of falling with interventions to include referral to Physical Therapy (PT) for evaluation as needed, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs for possible decrease in dosage/elimination of drug, use geriatric chair/wheelchair to transport, assess for possible acute condition that may have contributed to fall as needed, pressure reduction cushion for wheel chair with stabilizing straps, and complete a request for therapy screen as needed. The use of siderails was not included in the current care plan. Observation on 02/21/18 at 11:00 a.m. revealed R#6 in bed with head of bed at 30 degrees and was holding on to the side rails and pulling herself toward the rail. No attempt to throw her legs over or through the side rails was observed. R#6 let go of the siderail, laid on her back, and began watching TV. Interview with Charge Nurse AA on 02/21/18 at 12:40 p.m. at R#6 bedside revealed that the resident's family requested that side rails be used for safety because R#6 moves about a lot in bed and may fall out. Interview with the Social Worker on 02/21/18 at 1:00 p.m. revealed the family requested the resident have side rails for safety. States R#6 is assessed for side rails annually and is not physically able to raise the side rails up or down. Review of Physician order [REDACTED]. 4. Review of R#35's care plan dated 1/11/18 revealed that the Task Care Plan included approaches for Pain / Pain Control. Upon further review of the Care Plan there was no mention of R #35 being at risk for pain. On 2/21/18 at 2:25 p.m.Observation of Charge Nurse AA in R#35's room during wound care with the assistance of Certified Nursing Assistant DD revealed when Charge Nurse AA wiped over wound to coccyx, R#35 yelled out Oh, Oh, Oh. Charge Nurse AA stated, I'm sorry I know that hurts. Charge Nurse AA repeated the process with a clean gauze and again R#35 yelled out. Charge Nurse AA did not stop treatment and assess R#35's pain. On 2/21/18 at 2:50 p.m. Interview with Charge Nurse AA, in the hall, revealed R#35 yelled out in pain when wiping over wound on the coccyx both times during care and that an apology to R#35 was offered because it was obvious it hurt. Charge Nurse #35 states that with R#35 it's body language and sometimes can say it hurts and sometimes not. Charge Nurse AA states that R#35 does not have anything ordered for pain, just a standing order for Tylenol, but states have not given R#35 any Tylenol today. Also states that when R#35 hurts and yells out repositioning relieves the pain but states it is not typical for R#35 to yell out every time during wound care. On 2/22/18 at 11:28 a.m. Interview with Family Nurse Practitioner (FNP) EE in the conference room revealed that the resident is in a wheelchair a lot and this would cause the pressure ulcer to be unavoidable. FNP EE states that any time a resident has pain during wound care treatment their office is notified and, at that time, they will give an order for [REDACTED]. Review of the Pain Assessment and Management Policy revealed that staff should observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain include but are not limited to verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc. Defining Goals and Appropriate Interventions include but is not limited to: Pain management interventions shall address the underlying cause of the resident's pain. For example, if there is acute pain associated with an infected wound the intervention shall address treating the infection in addition to pain control.

Based on observation, staff interview, and record review the facility failed to assess pain for one Resident (R) #35 during wound care out of 41 sampled residents. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#6 Brief Interview for Mental Status (BIMS) as the Resident is rarely/never understood and an interview could not be conducted, is an extensive two person assist for all Activities of Daily Living (ADL), is incontinent of bowel and bladder, and does not take any opioids, anti-depressant, anti-anxiety, antipsychotic, or diuretic medication. Review of R#35's care plan dated 1/11/18 revealed that the Task Care Plan included approaches for Pain / Pain Control. Upon further review of the Care Plan there was no mention of R #35 being at risk for pain. Findings include: On 2/21/18 at 2:25 p.m.Observation of Charge Nurse AA in R#35's room during wound care with the assistance of Certified Nursing Assistant DD revealed when Charge Nurse AA wiped over wound to coccyx, R#35 yelled out Oh, Oh, Oh. Charge Nurse AA stated, I'm sorry I know that hurts. Charge Nurse AA repeated the process with a clean gauze and again R#35 yelled out. Charge Nurse AA did not stop treatment and assess R#35's pain. On 2/21/18 at 2:50 p.m. Interview with Charge Nurse AA, in the hall, revealed R#35 yelled out in pain when wiping over wound on the coccyx both times during care and that an apology to R#35 was offered because it was obvious it hurt. Charge Nurse #35 states that with R#35 it's body language and sometimes can say it hurts and sometimes not. Charge Nurse AA states that R#35 does not have anything ordered for pain, just a standing order for Tylenol, but states have not given R#35 any Tylenol today. Also states that when R#35 hurts and yells out repositioning relieves the pain but states it is not typical for R#35 to yell out every time during wound care. On 2/22/18 at 11:28 a.m. Interview with Family Nurse Practitioner (FNP) EE in the conference room revealed that the resident is in a wheelchair a lot and this would cause the pressure ulcer to be unavoidable. FNP EE states that any time a resident has pain during wound care treatment their office is notified and, at that time, they will give an order for [REDACTED].#35 screams out a lot and doesn't want to be touched sometimes. FNP #35 Stated that it depends on the person and situation as to if a nurse would stop wound care for a resident and call for pain medication because some residents yell out all the time. Also stated she has not, at any time, received notification of R#35 having pain during wound care. On 2/22/18 at 02:55 p.m. Interview with CNA FF in the hall revealed that each time assisting with wound care R#35's body language made it seem like it hurt a little. On 2/22/18 at 3:00 p.m. Interview with CNA GG in the hall revealed that during wound care for R#35 he scrunches his bottom together like it hurts but stated has never heard R#35 yell out loud but is more noticeable by his body language. Review of record for R#35 Incident Notes revealed from 10/1/17 through 2/22/18 there were no signs or symptoms of discomfort documented for this resident. Review of the Pain Assessment and Management Policy revealed that staff should observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain include but are not limited to verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc. Defining Goals and Appropriate Interventions include but is not limited to: Pain management interventions shall address the underlying cause of the resident's pain. For example, if there is acute pain associated with an infected wound the intervention shall address treating the infection in addition to pain control. Cross reference F656

Based on record review, Nurse Practitioner (NP) and staff interview, the facility failed to respond to a consultant pharmacist recommendation to provide a rationale for the continued use of PRN (as needed) anti-anxiety drugs ([MEDICATION NAME] and [MEDICATION NAME]) past 14 days for two residents (R) (R #9 and R # 18). In addition, the facility failed to respond to a recommendation to consider a dose reduction for [MEDICATION NAME] (an anticonvulsant also used for [MEDICAL CONDITION] disorder) for one resident (R #9). The sample size was 34 residents. Findings include: 1. Review of R #9's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she received an antianxiety drug all seven days of the assessment period. Review of her physician's orders [REDACTED]. Review of a Consultant Pharmacist Consultation Report dated 12/20/17 revealed that R #9 had received [MEDICATION NAME] (an antidepressant medication) 150 mg at bedtime and [MEDICATION NAME] 250 mg bid since 6/17, and a recommendation for a consideration for a dosage reduction in either of these meds at this time. Further review of this report revealed that the physician's response dated 1/3/18 was to reduce the [MEDICATION NAME], but it did not address a possible reduction of the [MEDICATION NAME]. Continued review revealed that a handwritten sticky note was attached to this Consultation Report which noted Still working with (the facility's contracted psychiatric services provider) on the [MEDICATION NAME], OK to reduce [MEDICATION NAME]. Review of a Consultant Pharmacist Consultation Report dated 11/24/17 revealed that R #9 had an order for [REDACTED]. Review of a physician Nursing Home Visit dated 12/14/17 noted that R #9 was followed by (psychiatric services provider) for physical and verbal behaviors, and a Nursing Home Visit report dated 1/3/18 noted to reduce [MEDICATION NAME] to 100 mg at bedtime. Further review of these two Progress Notes revealed that no documentation was seen of the clinical rationale for continuing the PRN [MEDICATION NAME] past 14 days. Review of R #9's February Medication Record (MAR) revealed that she received a PRN dose of [MEDICATION NAME] on 2/18/18. During interview with R #9's attending physician's NP EE on 2/22/18 at 11:23 a.m., she stated that the [MEDICATION NAME] was for treating R #9's [MEDICAL CONDITION] disorder, and verified that the continued use of the [MEDICATION NAME] on the 12/20/17 pharmacist recommendation was not addressed, and referred to the sticky note attached to the recommendation that staff were still working with the facility's psychiatric services provider on the [MEDICATION NAME]. NP EE further stated that the nursing staff should follow-up with the psychiatric provider about the [MEDICATION NAME], and verified that there was no clinical rationale provided for the continued PRN use of the [MEDICATION NAME] past 14 days per the pharmacist request on 11/24/17. During interview with the Director of Nursing on 2/23/18 at 1:05 p.m., she stated that the physician usually reviewed and addressed any consultant pharmacist recommendations in the facility when she made her monthly rounds, and that either the RCC (Resident Care Coordinator) or her (the DON) would transcribe any orders written on the pharmacy recommendations onto the physician's orders [REDACTED].#9's [MEDICATION NAME] was her note. 2. Review of R #18's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly MDS dated [DATE] revealed that she had not received an antianxiety drug during the seven days of the assessment period. Review of R #18's physician's orders [REDACTED]. Review of a Consultant Pharmacist Consultation Report dated 11/24/17 revealed that R #18 had a PRN order for an anxiolytic, which had been in place for greater than 14 days without a stop date. Further review of this report revealed a recommendation to discontinue the PRN [MEDICATION NAME], and that if it could not be discontinued at this time, current regulations required that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Continued review of this recommendation revealed that the physician signed it on 12/13/17, with a notation for a 90-day stop date of 3/12/17 (sic), but no rationale for the extended time period was provided. Review of a physician Nursing Home Visit report dated 12/14/17 revealed the [MEDICATION NAME] (an antipsychotic) dose was decreased as suggested by the pharmacy consultant, and to continue other meds per plan. Review of a physician Nursing Home Visit report dated 1/3/18 revealed that R #18's [MEDICATION NAME] ([MEDICATION NAME]) was reduced, and assessment included depression with psychotic symptoms, but no mention of the need for the extended use of the PRN [MEDICATION NAME]. Review of R #18's January and February MARs revealed that she received the PRN [MEDICATION NAME] on 1/10/18 and 2/20/18. During interview with NP EE on 2/22/18 at 11:23 a.m., she verified that there was no rationale provided for the extended use of the PRN [MEDICATION NAME] through 3/12/18, other than the resident had a documented [DIAGNOSES REDACTED].

Based on observation, staff interview and facility policy review, the facility failed to ensure that proper hand hygiene was followed by staff during two of two dining observations. This deficient practice had the potential to affect 41 residents receiving an oral diet. Findings include: Observation on 1/30/17 of breakfast served in the dining room revealed the following: At 8:05 a.m. Certified Nursing Assistant (CNA) EE failed to hand sanitize between pulling a resident up in a chair and continuing to serve trays to other residents. At 8:12 a.m. CNA EE failed to hand sanitize between touching a residents ' clothing and continuing to serve trays to other residents. At 8:15 a.m. CNA EE failed to hand sanitize between touching the wheelchair of a resident and removing the biscuit from its' packaging with her hands for another resident. The resident consumed 75% of the biscuit. At 8:27 a.m. CNA EE failed to hand sanitize between picking up a chair and placing it next to a resident and feeding that same resident. At 8:10 a.m. Certified Occupational Therapist Assistant (COTA) failed to hand sanitize between pulling a resident up in a wheelchair and continuing to serve trays to other residents. At 8:28 a.m. CNA FF failed to hand sanitize between pulling a resident up in her wheelchair, placing a pillow behind her head, pushing the wheelchair closer to the table and feeding the resident. Observation from 8:00 a.m. until 8:30 a.m. revealed a bottle of alcohol gel sanitizer was observed on a cart next to the window where resident trays were being picked up. Observation on 1/30/17 of lunch served in the dining room revealed the following: At 12:13 p.m. CNA EE failed to hand sanitize before removing with her bare hand a residents ' roll from the packaging. The resident consumed 50% of the roll. At 12:18 p.m. CNA EE failed to hand sanitize between touching one residents ' wheelchair and feeding another resident. At 12:21 p.m. CNA FF failed to hand sanitize before removing with her bare hand a residents ' roll from the packaging. The resident consumed 75% of the roll. At 12:23 p.m. CNA FF failed to hand sanitize before removing with her bare hand another residents ' roll. The resident consumed 25% of the roll. At 12:24 p.m. CAN FF failed to hand sanitize between touching a residents ' wheelchair, the residents ' shoes and clothing and feeding this same resident. Observation from 12:00 p.m. until 12:30 p.m. revealed a bottle of alcohol gel sanitizer was observed on a cart next to the window where resident trays were being picked up. During an interview with the Director of Nursing (DON) who is also the Infection Control Nurse on 2/2/17 at 9:26 a.m. she stated she expects staff to sanitize their hands between passing trays to residents by using the alcohol gel during meals. She also stated the staff is to not touch the residents' food while passing trays. She also expects the staff to sanitize after touching the chair or wheelchair before feeding the resident. She also stated touching the resident while feeding the resident is okay. During an interview with CNA EE on 2/2/17 at 11:00 a.m. she confirmed she had touched the residents' biscuits and rolls before sanitizing her hands. She also stated she should sanitize before starting to pass meal trays and between passing trays, between residents when feeding residents, after touching residents, and after touching resident wheelchairs and chairs. Review of the policy titled Handwashing/Hand Hygiene Policy revised April 2010 revealed Highlights:When to Wash Hands: Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); Before and after eating or handling food (hand washing with soap and water); Before and after assisting a resident with meals. When to Use Alcohol-Based Hand Rub: In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: Before and after direct contact with residents; After contact with resident's intact skin; After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident.

Based on observation and interviews, the facility failed to ensure that two of two dumpsters were maintained free from rust and holes and that the dumpster area was free from debris. Findings included: On 2/1/2017 at 12:40 p.m. the dumpster area was observed. There were two dumpsters observed on asphalt. Each of the dumpsters were observed to have a rusted hole near the bottom of the containers. The Kitchen Manager confirmed that the holes could be a problem if small animals got into the containers. Also, behind the dumpsters, there was bags of trash, buckets and other garbage. The Kitchen Manager stated that she believes that it is the responsibility of the Maintenance Department to clean the trash from the dumpster area because the kitchen staff does not perform that task. On 2/1/2017 at 1:12 p.m. the Nursing Home Administrator and the Assistant Nursing Home Administered confirmed that there was facility no policy related to the maintenance of the dumpsters because they use and outside company. They confirmed that it is the responsibility of the maintenance department to keep that area clean and that they have no policy related to the maintenance of the dumpsters or the dumpster area. On 2/1/2017 at 1:29 p.m. during an interview with the Maintenance Director, he confirmed that he is responsible for maintaining the grounds including cleaning the trash from the dumpster area. DONE

Based on observation, interviews and record review the facility failed to ensure that one of one low temperature commercial dish washer and one of one reach in refrigerator were maintained in a safe operational manner. The census was 41 and affected all residents. Findings included: An initial tour of the kitchen was conducted on 1/30/2017 at 9:20 a.m. revealed the low temperature commercial dish washer was observed being operated by Kitchen Aide CC. When questioned about the expectation of the wash and rinse cycle temperatures on the dishwasher, she was unsure of what the expectation of the temperature. The dial thermostat was observed and the following was noted on the thermostat: Minimum Temperature 120 degrees Fahrenheit. Kitchen Aide CC ran two cycles. The fist cycle measured 90 degrees Fahrenheit for the wash and 100 degrees Fahrenheit for the rinse. The second cycle measured 100 degrees Fahrenheit for the wash and 100 degrees Fahrenheit for the rinse. A review of the Dishwasher temperature log dated January 2017 noted ok for the temperature. When Kitchen Aide CC was asked what ok meant, she stated that she did not know. She asked Kitchen Aide DD who stated, We check the strips for the dishwasher and strips for the buckets of sanitizer. The strips checks the right temperature. If the sanitizer water is not at the right temperature it will not turn the color it needs to be. She stated, We do it every morning. She confirmed that she writes ok when the sanitizer strip is checked. She confirmed that she does not look at the dial thermostat on the dishwasher at all and only uses the sanitizer strips to check the temperature. Kitchen Aide CC stated, As far as a temperature log, I haven't seen one of those. Both Kitchen Aides CC and DD confirmed that the process is to wash the dishes completely before putting the dishes into the commercial dish washer. On 1/30/2017 at t 10:15 a.m. the Assistant Nursing Home Administrator stated that due to the chemicals being used, the temperature is not a problem and has not been a problem. At 10:20 a.m. the Maintenance Director and the Assistant Nursing Home Administrator accompanied this surveyor into the kitchen. The dish washer temperature at that time measured 98 degrees Fahrenheit for the wash cycle and 104 degrees Fahrenheit for the rinse cycle. The chemical test strips were checked and was 100-200 parts per million (ppm). It was pointed out at time that that the thermostat dial noted a minimum temperature for the dish washer wash and rinse cycle was 120 degrees Fahrenheit, both the Maintenance Director and the Assistant Nursing Home Administered confirmed that that was noted on the thermostat. On 1/30/2017 10:30 a.m. the Maintenance Director and the Kitchen Manager were observed in the kitchen. To ensure that the dish washer thermostat was functioning and accurately measuring the water temperature, the temperature of the dish washer cycles was checked with a hand held dial thermometer which was calibrated with ice water to the temperature of 32 degrees Fahrenheit. The water in the dish washer tested at 100 degrees Fahrenheit which matched the dial thermostat on the dish washer. At this time the Kitchen Manager stated that they only check the sanitizer and that they have had this process for many years. She stated no one has ever told her that she has had to check the temperature. She stated that she just took it for granted that it was okay. On 1/31/2017 at 4:13 p.m. during an interview with the Nursing Home Administrator and the Assistant Nursing Home Administrator and the Kitchen Manager, they all confirmed that there was no process in writing or any policy related to the maintenance of the dish washer and the monitoring of the temperature of the dish washer. Further interview with the Kitchen Manager at this time revealed that, We never had to do that before. We only checked the sanitizer. On 2/1/2017 at 12:50 p.m. a comprehensive tour of kitchen was conducted. The reach in refrigerator was observed with rusted shelving and the white coating covering the non-rusted areas was cracked and pealing. The Kitchen Manager confirmed the rusted areas in the refrigerator and that the white coating was pealing from the shelves. She stated that she does place the shelves in the dishwasher to clean them but the rust is still there. She stated that the refrigerator is very old and she was not sure if they could even replace the shelves.

Based on observations, staff interview and review of product labels and Material Safety Data Sheets (MSDS), the facility failed to ensure that bath and hygiene products was kept secured for one (1) of (1) shower room on one (1) of one (1)unit. The facility census was thirty-nine (39) residents. Findings include: Observation conducted 05/17/2015 at 9:45 AM, during initial tour, revealed an unlocked cabinet in the shower room with no staff in the room. This cabinet contained various hygiene products including bottles of prescription shampoo, alcohol based hand gel, liquid soaps and hair sprays. There were two (2) open gallon size containers of shower soap on the floor of the shower room. Further observation on 05/20/2015 at 11:00 AM revealed two unlocked cabinets in the shower room with no attendant, which contained the following items: Five (5) 16 ounce bottles of tearless shampoo with regular non-safety cap lids One (1) 32 ounce spray bottle of degreaser cleaner Six (6) 18 ounce pump bottles of Germex skin hand sanitizer with 70% Ethanol Seven (7) gallon bottles of liquid skin soap One (1) partial gallon of perineal cleanser One (1) partial four (4) ounce bottle of skin prep Two (2) bottles Crest Pro Health mouth wash Three (3) bottles of Electric Pre Shave Liquid Eight (8) partial prescription squeeze bottles of Ketoconazole 2% Shampoo Five (5) 4 ounce aerosol cans of deodorant Five (5) 4 ounce bottles of pump liquid deodorant Also, on the shower room floor were: One (1) partial gallon bottle of liquid skin soap with no lid One (1) open partial bottle of tearless shampoo with no lid Review of product label for Ketoconazole Shampoo revealed severe hypersensitivity reactions including anaphylaxis have been reported following exposure. Review of the product label for Crest Pro Health mouth wash revealed if swallowed Poison Control should be consulted. Review of Germex alcohol based hand gel MSDS revealed ingestion can cause Narcosis, Kidney and Liver injury. Interview conducted 05/20/2015 1:38:47 PM with the Director of Nurses (DON) revealed the cabinets in the shower room should be locked. Residents should not have access to these products because of the possibility of ingestion. The DON further indicated twenty-eight (28) of thirty-nine (39) residents in the facility are of independent for mobility.

Based on observations and staff interview the facility failed to ensure handrails were secured in the main lobby and for one (1) of one (1) hall. Findings include: Observation during initial tour on 05/17/2015 at 9:45 AM revealed one (1) loose handrail in the main lobby, with one (1) support ready to fall out of the cement block wall. Residents in wheelchairs were observed pulling on the handrail to move around the lobby. Hand rails were loose to be loose in the following areas: Between rooms 116 and 114 Between rooms 116 and 118 Between rooms 119 and 121 Between the Director of Nurses (DON) office and shower room Between the Oxygen Storage area and soiled utility room Between the nurses station and room 112 Between maintenance closet and room 121 Between room 105 and 103 During interview conducted on 05/20/2015 at 2:43 PM with the facility's maintenance worker, he acknowledged the above hand rails were loose. The maintenance worker revealed the rails were fastened to the walls by plastic anchors that need to be replaced with metal cement anchors.

Based on record review, and staff interview the facility failed to ensure laboratory services were obtained in a timely manner for one (1) residents (#40) from a sample of twenty-one (21) residents. Findings include: Record review for resident #40 revealed physician orders [REDACTED]. Further record review revealed no results these laboratory tests had been done and no results could be provided. Interview with the Director of Nurses (DON) on 05/20/2015 at 2:28 PM revealed the above laboratory tests were not performed because the order had been overlooked.

Based on observation and staff interview, the facility failed to dispose of one (1) outdated medication, and label one (1) medication with an open/puncture date. Findings include: Observation of the medication storage refrigerator on [DATE] at 8:50am revealed one (1) vial of Tuberculin Purified Protein (PPD) with an expiration date of [DATE]. The vial appeared less than half full. There was one (1) vial of PPD, which was open but not labeled with an open/puncture date. This vial was approximately half empty. Each vial contained ten (10) doses of the medication. Interview with the Licensed Practical Nurse (LPN) "BB" on [DATE] at 9:00am revealed that all medications should have an open or punctured date, and that all expired medication should be removed from the refrigerator. "BB" had no idea when the PPD was used, or how many residents might have received the out dated medication. .

Based on observations, and staff interview the facility failed to dispose of garbage and refuse in a sanitary manner. Findings include: Observation of the dumpster's on 8/24/14 at 10:00am revealed both dumpster's were open, with tops thrown back. The refuse/garbage bags were approximately two (2) feet higher than the height of the dumpster, not allowing the top to close. During a general tour of the kitchen conducted 8/24/14 at 10:30am with the cook on duty, there were approximately thirty (30) to thirty five (35) various sized trash bags piled in and over three (3) trash cans on the outside screened mop area of the kitchen. Interview with the Dietary Manager on 8/26/14 at 11:00am revealed it took three (3) trips to transport the trash off of the screened area, after the dumpster's were emptied on Monday 8/24/14. The dumpster's are emptied one (1) time per week on Mondays. Kitchen thrash was kept on the back porch when the dumpster's were full, to minimize vermin at the dumpster site. The two (2) dumpster's were for all trash from the facility.