Every finding on record at Wilkesboro Health and Rehabilitation

Based on observations, National Weather Service online record, record review, and resident, staff, Nurse Practitioner, and Medical Director interviews, the facility failed to provide care in a safe manner when a staff member (Nurse Aide #1) assisted a resident (Resident #1) outside into a courtyard without notifying the resident's assigned Nurse Aide (NA) or nurse. Resident #1 was observed sitting in direct sunlight at approximately 12:45 PM and was noted to be hot, sweaty, with reddened skin on the back of her neck and shoulders. This deficient practice occurred for 1 of 3 residents reviewed for the prevention of accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including vascular dementia. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired, used a manual wheelchair, and required extensive assistance of one staff member to propel the wheelchair 50 feet with no turns during the assessment period.An interview conducted with Nurse Aide (NA) #1 on 07/29/26 at 11:51 AM revealed she went to get Resident #1 from an eye consultation in the facility conference room on 07/08/26. NA #1 stated she was not Resident #1's assigned NA for the day, she was just assisting residents to and from the eye clinic. Resident #1 stated she wanted to go outside as she had done in the past. NA #1 proceeded to wheel Resident #1 in her wheelchair outside to the courtyard and placed her next to the door going out of the building in a shaded area. NA #1 stated Resident #1's entire body was completely in the shade at approximately 12:00 PM. The interview revealed NA #1 did not think anything about it because she had seen Resident #1 sitting in the courtyard in the sun before. Resident #1 was in no distress at that time and was alert enough to tell staff if she needed assistance. NA #1 explained that she did not tell Resident #1's assigned NA or Nurse that day because there were student Nurse Aides on the residents hall and she let one of the NA students know. NA #1 explained looking back on the incident she should have notified the Nurse or the assigned Nurse Aide for Resident #1 and not relied on a NA student. She stated Resident #1 was able to self-propel herself in her wheelchair, but only short distances.The interview revealed she did not leave a drink with Resident #1 or encourage sunscreen. The resident was not wearing a hat. A late-entry nursing note dated 07/09/26 at 10:15 AM, written by Nurse #1, revealed she walked into the courtyard on 07/08/26 and observed Resident #1 to the right side of the door. She spoke with the resident and asked how she was doing. The resident responded, Great, I am just sunbathing. Nurse #1 asked if she was too hot or wanted anything to drink, and the resident responded, No. Nurse #1 remained outside for approximately five minutes.An interview was conducted with Nurse #1 on 07/29/26 at 11:59 AM. The interview revealed on 07/08/26 she was the Nursing Supervisor. Nurse #1 explained she had therapy dogs that day in the facility and had taken her dog outside to the courtyard around 12:15-12:30 PM to use the restroom and observed Resident #1 sitting outside in the courtyard to the right of the door sitting in a cast of shade. Resident #1's body was observed to be completely shaded right outside of the door; the resident was not in the direct sun. Nurse #1 spoke with Resident #1, and she stated she was enjoying sitting in the sun and did not need anything. Nurse #1 then returned inside of the building and left Resident #1 sitting outside. Nurse #1 explained it was not abnormal to see the resident sitting outside and she did not inform the residents assigned NA or Nurse that she was in the courtyard. While Nurse #1 was in a risk meeting around 1:00 PM Nurse #2 came in and stated Resident #1 had gotten too hot outside, the Nurse had contacted the residents family member and the Provider. Nurse #1 went into the room to check on Resident #1 who was responsive and answering questions appropriately. She stated Resident #1 was hot, but overall ok. Resident #1 was observed with a sunburn to the back of her neck where her shirt would have been. It was red that day, but by the next day it was gone. Nurse #1 explained there was no blistering to the area. A nursing note dated 07/08/26 at 1:40 PM, written by Nurse #2, revealed Resident #1 requested to go outside after a visit to the eye clinic. A staff member (Nurse Aide #1) assisted the resident outside and placed her in the shade. Nurse Aide (NA) #2 later brought the resident back inside and alerted Nurse #2 that Resident #1 was hot and sweaty after being outside. Upon assessment, Resident #1 was alert and responsive and requested to be laid down in bed. Resident #1 appeared diaphoretic (sweaty), flushed, and hot. Vital signs were as follows: blood pressure 97/64 heart rate 106, oxygen saturation 95% (normal greater than 92%) on room air, respirations 14 (normal range 12-20), and oral temperature 98.8 F (normal less than 99.0 F). Resident #1's temporal (forehead) temperature was 99.8 F. She was encouraged to drink ice water. Resident #1 was laid down in her room, and her clothing was removed. Cool washcloths were applied to her head, armpits, groin, and neck. It was reported she had been outside for approximately one hour. The Nurse Practitioner was notified and ordered intravenous fluids for dehydration: normal saline at 250 milliliters (mL) per hour for a total of 1 liter. Intravenous fluids were administered, water intake was encouraged, and cool washcloths were changed every 15 minutes for a duration of one hour. The resident's Responsible Party was notified and was on the way to the facility to see the resident. A telephone interview was conducted with Nurse #2 on 07/29/26 at 12:09 PM. Nurse #2 stated she was Resident #1's assigned nurse on 7/8/26 working the 7:00 AM to 3:00 PM shift. Nurse #2 explained no staff members told her Resident #1 was sitting outside in the courtyard. The facility had an eye clinic that day and Resident #1 was up out of the bed. Nurse #2 stated NA #2 came to her stating Resident #1 was found outside and had become overheated. Once Resident #1 was in her room Nurse #2 obtained vital signs and started providing the resident with cold fluids. Resident #1 was observed to be red, and sweaty. Nurse #2 stated she called the provider while in the resident's room and obtained orders for intravenous fluids. Nurse #2 instructed the NA's to apply cold washcloths to her armpits, groin, head and neck. Resident #1 was alert and responsive. Nurse #2 received orders to draw bloodwork and initiate intravenous fluids. The Nurse Practitioner came by during the shift prior to 3:00 PM. Nurse #2 explained Resident #1's temperature started to decrease with the interventions of cold wash clothes, intravenous fluids and oral fluids. No blistering was observed, just slight redness. The interview revealed she would have liked to have known the resident was sitting outside in the courtyard so she would have known to look for her. An interview conducted with NA #2 on 07/29/26 at 12:07 PM revealed she had observed Resident #1 during her break on 07/08/26 between 12:40-12:50 PM outside in the courtyard. NA #2 stated she had cut through the courtyard to go to the Restorative Therapy office. When she cut through, she saw Resident #1 on the other side of the gazebo in the direct sunlight. Resident #1 stated, I am burning up can you take me inside. Resident #1 looked red and was sweaty. Resident #1 was observed to be wearing a pair of capri pants, short sleeve top with the sleeves rolled up and airy open zip up shoes (thin cloth) with no socks. Resident #1's hair was braided up that day. NA #2 took her into her room and went to Nurse #2 for assistance. Nurse #2 went into the room and obtained vital signs, they started putting cold cloths on Resident #1 and she started saying she felt better. No blistering was observed. Nurse #2 was having the NA's refresh the cloths so they would be cooler. NA #2 stated the resident's temperature was 99 degrees, but within 15 minutes it started going back to normal. The interview revealed Resident #1 enjoyed sitting outside on a regular basis and would often say she was sunbathing. NA #2 stated Resident #1 could self-propel using her wheelchair and she felt like the resident had moved herself into the direct sunlight from the shaded spot. On 07/30/26 at 9:00 AM an interview was conducted with NA #3. The interview revealed she was assigned to Resident #1 on 07/08/26 during the 7 AM to 3 PM shift. NA #3 stated she was not aware that Resident #1 was outside in the courtyard. NA #3 explained she had gone on break and came back to find NA #2 had brought the resident inside of the building. Resident #1 was observed to be in a t shirt, she was hot to the touch and her skin was red. Once they started placing cool cloths on her body and removed her clothing she cooled off within 15-20 minutes. The resident then asked NA #3 if she would get her two egg salad sandwiches from the kitchen, she sat in the bed and ate the two sandwiches. Resident #1 didn't seem like she was in any pain or distress at the time. The interview revealed Resident #1 was able to self-propel in her wheelchair for short distances. A skin assessment completed on 07/08/26 at 7:46 PM revealed the skin was intact but reddened on the resident's neck and shoulders. A physician order dated 07/08/26 read; normal saline 250 milliliters via intravenous (IV) for one liter. A physician order dated 07/08/26 read; Silver sulfadiazine cream (cream used to treat burns) 1% topical twice a day to posterior neck and shoulders for a duration of 7 days. A physician order dated 07/08/26 read; complete blood count, basic metabolic panel (lab work). Resident #1's laboratory results completed on 07/08/26 revealed a sodium level of 134 (normal range 135-145), a Blood Urea Nitrogen (BUN) level of 32 (normal range 7-25), and a creatinine level of 1.65 (normal range 0.60-1.20). The BUN and creatinine are blood tests used to assess kidney function and hydration status.The National Weather Service online record for North Wilkesboro, North Carolina reported on 07/08/26 at 12:35 PM it was partly cloudy and 91 degrees Fahrenheit outside. On 07/29/26 at 11:57 an observation was conducted with NA #1. NA #1 walked the surveyor to the area of the courtyard in which she left Resident #1 on 7/8/26. The area was right outside of the courtyard door coming out from the facility door; another resident was sitting in the same area which was observed to be shaded at the time of the observation. The facility gazebo was noted to be approximately 40-50 feet from the area Resident #1 was left. A fan was observed inside the ceiling of the gazebo. An observation was conducted of Resident #1's shoulders and arms on 07/29/26 at 1:00 PM with Nurse #3. During the observation Resident #1's shoulders and neck were observed to be pale in color, with the skin intact. No redness or blistering of the skin was observed. On 07/29/26 at 1:10 PM an interview was conducted with Resident #1. During the interview she stated, I love the sun, it is my favorite thing. Resident #1 recalled being outside and getting too hot, however, could not recall further details about the situation. On 07/29/26 at 2:15 PM an interview was conducted with Resident #1's Responsible Party (RP). During the interview she stated she was contacted by the facility on 07/08/26 to let her know Resident #1 was observed sitting outside in the sun and had overheated. She stated she immediately asked the Nurse who had left her outside and how long she had been sitting outside however the Nurse was unable to give her details over the phone. The RP stated she then went to the facility to observe Resident #1 herself and that when she arrived at the facility Resident #1 was observed in her room in no distress, her shoulders looked like she had a sunburn but were not blistered. She stated she was concerned due to the potential of the situation and that the outcome could have been different and she did not want the incident to happen again. On 07/30/26 at 8:25 AM an interview was conducted with the Nurse Practitioner (NP). The NP stated she was notified of the incident while she was at another facility and she decided to drive to the facility to assess Resident #1 herself and even brought the resident a milkshake. The NP gave the nurse orders to initiate intravenous (IV) fluids due to the resident's sun exposure as a precaution after she was informed the resident's skin was hot to the touch, she was slightly tachycardic, and had a temperature of 99 F. The NP explained initiating IV fluids was a standard precaution following sun exposure. Upon arrival at the facility, she observed Resident #1's shoulders and the back of her neck to be red but not blistered. The affected areas were warm to the touch. She stated it was evident where the resident's shirt had covered her skin compared to the reddened areas exposed to the sun. The Nurse Practitioner stated she ordered Silvadene (silver sulfadiazine) cream because she did not know what the affected areas would look like the following day and wanted to take every precaution in the event blistering developed. However, the areas never blistered, there was no severe burn or broken skin, and the cream was discontinued a couple of days later. She stated the resident was in no distress during her evaluation. The resident's family was present at the bedside, and the resident stated she did not want to talk about the incident anymore and did not want a big deal made about it. The Nurse Practitioner explained she also ordered laboratory work relevant to the resident's heat exposure and those remained at her baseline. On 07/30/26 at 9:39 AM an interview was conducted with the Medical Director. During the interview he stated he remembered discussing the incident with the NP. He stated there was concern the resident was experiencing heat exhaustion from being outside. The NP ordered IV fluids and laboratory work, which he stated was appropriate because a resident's renal function should always be evaluated when heat exhaustion is suspected. The Medical Director stated he did not have the resident's laboratory results in front of him but did not recall any severe abnormalities. He stated, based on the information he received, the resident's sunburn was mild, the resident was not confused, and she became stable with a decrease in temperature shortly after interventions were initiated. The Medical Director stated the silver sulfadiazine cream was ordered by the NP as a precaution in the event the affected area developed blistering. However, based on the information he received, the area did not blister. He further stated he met with the Administrator and other members of the administrative team following the incident during a Quality Assurance (QA) meeting to discuss measures that could be implemented to prevent a similar incident from recurring.On 07/29/26 at 1:53 PM an interview was conducted with the Director of Nursing (DON). The DON stated she was not in the facility on the day of the incident. She was told Resident #1 wanted to go outside, and staff took her outside where she was positioned in an area that was partially shaded and partially sunny. The Director of Nursing stated that approximately 30 to 45 minutes later, NA #2 observed the resident outside and noted she was red and warm. She took Resident #1 inside of the facility to her room and notified Nurse #2. Nurse #2 then assessed the resident and contacted the Nurse practitioner who came to the facility to evaluate the resident. The Director of Nursing stated she returned to the facility on [DATE], at which time the resident had no blisters and her skin remained intact. The Director of Nursing further stated the resident was upset that everyone was throwing a fuss about the incident.A follow up interview conducted with the DON on 07/30/26 at 10:47 AM revealed NA #1 should have notified NA #3 or Nurse #2 (Resident #1's assigned Nurse Aide or Nurse) on 07/08/26 that she had placed the resident outside in the courtyard. The DON explained by telling a nursing student, who in return did not let anyone else know there was a communication breakdown. The facility was unable to provide any contact information for the Nurse Aide Student who was notified by NA #1 that Resident #1 was in the courtyard on 07/08/26. On 07/29/26 at 2:10 PM an interview was conducted with the Administrator. During the interview she stated the facility Ophthalmologist (Eye Physician) was in the building that day doing a clinic. She was told that when staff were wheeling Resident #1 out of her room, the Nurse Aide (NA) placed her outside because she wanted to go outside. The Administrator stated she was not made aware of the situation until the resident's family arrived at the facility upset after receiving a call from the Nurse Practitioner/nurse informing them the resident had become overheated. She stated Resident #1 often sat outside. She further stated that the very next day the resident attended activities and her face wasn't even burned, noting there was no redness the following day.

Based on observations, record review, and resident and staff interviews, the facility failed to assess a resident's ability to keep over the counter lubricating eye drops for self-administration in the residents' room for 1 of 1 resident reviewed for self administration (Resident #28).The findings included:Resident #28 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and diabetes.Resident #28's admission Minimum Data Set (MDS) assessment dated [DATE] showed she was cognitively intact.A review of Resident #28's medical record revealed she had not been assessed for self administration of medication. On 12/08/25 at 1:52 PM, observation and interview with Resident #28 revealed a 10 milliliter bottle of over the counter lubricating eye drops containing .5% povidone (lubricant) on her overbed table, within reach as she sat in her wheelchair. She stated she had brought the eye drops from home when she moved into the facility and used them once a day or so when her eyes felt dry. On 12/09/25 at 8:38 AM, Resident #28 was observed lying in bed with the bottle of lubricating eye drops on the overbed table positioned next to her bed.During a telephone interview with Nurse #3 on 12/11/25 at 11:52 AM, she stated she had not seen the bottle of eye drops in Resident #28's room when she was assigned to her on 12/08/25 and 12/09/25 and would have removed it if she had. Nurse #3 reported she did not believe Resident #28 had been assessed for the ability to self administer medication and explained that residents should be evaluated for safety before being permitted to self administer their medications. On 12/11/25 at 12:03 PM, an interview with the Director of Nursing (DON) revealed the bottle of lubricating eye drops should not have been in Resident #28's room. The DON stated Resident #28 had not been assessed to self administer medication and explained that if she wanted to self administer the eye drops, she would need to be assessed as safe to do so, a physician order would have to be obtained, and the medication would be kept in a locked box in her room.On 12/11/25 at 1:37 PM, an interview with the Administrator revealed the bottle of eye drops should not have been left in Resident #28's room unless she had been assessed as safe to self administer medication and the medication was stored in a locked box.

Based on observations, record review, and staff and resident interviews, the facility failed to remove petroleum based jelly from a resident's room who received oxygen for 1 of 2 residents reviewed for respiratory care (Resident #96).The findings included:Resident #96 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic bronchitis.Resident #96 had a physician's order dated 11/17/25 for oxygen via nasal cannula at 1 to 5 liters per minute continuously.Resident #96's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and coded for continuous oxygen therapy.A review of Resident #96's care plan dated 11/17/25 revealed a risk for potential breathing problems with interventions including assessing for signs and symptoms of respiratory distress and administering medications as ordered.An observation on 12/08/25 at 2:38 PM revealed Resident #96 sitting in his wheelchair in his room with oxygen being administered via nasal cannula by an oxygen concentrator set at 4 liters. There was a container of petroleum based jelly on the overbed table in front of Resident #96.An observation on 12/09/25 at 8:42 AM revealed Resident #96 sitting in his wheelchair in his room with oxygen being administered via nasal cannula by an oxygen concentrator set at 4 liters. There was a container of petroleum based jelly on the overbed table in front of Resident #96.An interview with Resident #96 on 12/10/25 at 8:53 AM revealed he used the petroleum based jelly on his lips when they felt dry and indicated he applied it maybe once a day. Resident #28 stated he wasn't sure who brought him the petroleum-based jelly but thought it was probably a family member.A telephone interview with Nurse #3 on 12/11/25 at 11:52 AM revealed she did not see the container of petroleum based jelly in Resident #96's room while taking care of him on 12/08/25 or 12/09/25. She indicated she knew petroleum based jelly was a potential hazard while oxygen was in use and it should not have been in his room.On 12/11/25 at 12:03 PM, an interview with the Director of Nursing (DON) revealed the container of petroleum based jelly should not have been in Resident #96's room as he was on oxygen and it was a potential hazard. The DON indicated she was going to remove the container immediately and educate nursing staff on removal of petroleum based products from the rooms of residents receiving oxygen therapy.An interview with the Administrator on 12/11/25 at 1:37 PM revealed she and the nursing staff knew that petroleum based products should not be in the rooms of residents on oxygen therapy, but families often did not remember even after education. She indicated nurses were educated to look for and remove petroleum based products during room rounds, and family members and residents were educated on admission. The Administrator confirmed the petroleum based jelly should not have been in Resident #96's room and she would immediately confirm it had been removed.

Based on observations, record review, resident and staff interviews, the facility failed to store medicated powder in a secure locked storage area for 1 of 1 resident observed with medication at bedside (Resident #15). Findings included:Resident # 15 was admitted to the facility 09/01/21. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Review of Resident #15's medical record revealed no order for miconazole nitrate 2% powder (an anti-fungal medication). An observation of Resident #15's room on 12/09/25 at 9:57 AM revealed a 3-ounce bottle of miconazole nitrate 2% powder sitting beside her bed on top of a dresser.An interview with Resident #15 was attempted on 12/09/25 at 9:57 AM but the resident did not answer when asked about the anti-fungal powder. Additional observations of Resident #15's room on 12/09/25 at 1:23 PM, 12/10/25 at 9:38 AM, 12/10/25 at 1:05 PM, and 12/11/25 at 10:10 AM revealed a 3-ounce bottle of miconazole nitrate 2% powder sitting beside her bed on top of a dresser.An observation of Resident #15's room with Nurse #1 on 12/11/25 at 10:19 AM revealed the 3-ounce anti-fungal powder on a dresser beside her bed. Nurse #1 removed the anti-fungal powder from Resident #15's room. An interview with Nurse #1 on 12/11/25 at 10:21 AM revealed she had been in Resident #15's room once that morning and did not notice the anti-fungal powder on top of her dresser. She stated if she had seen the anti-fungal powder in Resident #15's room she would have removed it at that time. Nurse #1 stated the anti-fungal powder should be stored on the treatment cart and not in the resident's room unless there was a physician order to leave in the room. A telephone interview with Nurse #2 on 12/11/25 at 1:21 PM revealed she cared for Resident #15 on 12/09/25 during the 7:00 AM to 7:00 PM shift. She stated she did not notice anti-fungal powder in Resident #15's room, and if she had seen it, she would have removed it from the room. Nurse #2 stated unless Resident #15 had a physician order to leave the medication in her room it should be stored on the treatment cart. An interview with the Director of Nursing (DON) on 12/11/25 at 10:36 AM revealed the anti-fungal powder should not have been left in Resident #15's room. She stated the medicated powder should be stored in the treatment cart unless Resident #15 had a physician order to leave the medication in the room. An interview with the Administrator on 12/11/25 at 12:54 PM revealed the medication should not be left in Resident #15's room unless there was a physician order to do so.

Based on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 4 of 4 residents reviewed for beneficiary notices (Residents #4, #151, #45, #11). The findings included: a. Resident #4 was admitted to the facility on [DATE]. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was relayed by phone on 8/21/24 to Resident #4's representative. The notice indicated that Medicare coverage for skilled services was to end on 8/23/24. Resident #4 remained in the facility when Medicare coverage ended. Review of Resident #4's record indicated the SNF ABN dated 8/21/2024 had no estimated cost for care documented on the form. b. Resident #151 was admitted to the facility on [DATE]. The medical record revealed a CMS-10123 NOMNC was relayed to Resident #151's representative on 8/16/24. The notice indicated that Medicare coverage for skilled services was to end on what 8/20/2024. Resident #151 remained in the facility when Medicare coverage ended. Review of Resident #151's record indicated the SNF ABN dated 8/16/2024 had no estimated cost for care documented on the form. c. Resident # 45 was admitted to the facility on [DATE]. Medicare part A services began on 1/5/2024. The medical record revealed a CMS-10123 NOMNC was signed by Resident #45 on 4/16/2024. The notice indicated that Medicare coverage for skilled services was to end on 4/18/2024. Resident #45 remained in the facility when Medicare coverage ended. Review of Resident #45's record indicated the SNF ABN dated 4/16/2024 had no estimated cost for care documented on the form. d. Resident # 11 was admitted to the facility on [DATE]. Medicare part A services began on 3/27/2024. The medical record revealed a CMS-10123 NOMNC was signed by Resident #11 on 6/18/2024. The notice indicated that Medicare coverage for skilled services was to end on what 6/20/2024. Resident #11 remained in the facility when Medicare coverage ended. Review of Resident #11's record indicated the SNF ABN dated 6/18/2024 had no estimated cost for care documented on the form. During an interview on 9/10/2024 at 9:31 am with Business Office Employee #1, she said she presented SNF ABN to the resident, or resident representative after she was notified in the weekly meeting on Thursdays where the Medicare A cases were reviewed and talked to the resident or representative about the rates but had not written the rate on the SNF ABN form. Review of the SNF ABN form with Business Office Employee #1 revealed private pay was written in the block for estimated cost. Business Office Employee #1 verified 4 of 4 forms reviewed did not have the estimated cost provided on the SNF ABN form. She stated she had never been told it had to be a specific amount. During an interview on 9/10/2024 at 9:40 am with the Administrator she said a weekly meeting was held on Thursdays and all Medicare part A cases were reviewed. She said the business office gave SNF ABN notifications to residents or resident representatives. Resident #4, Resident #151, Resident #45, and Resident #11's SNF ABN form was verified with the Administrator that private pay was written in the block for estimated cost on the SNF ABN form. The Administrator stated she did not know and had not been told previously that a specific amount needed to be placed in the estimated cost section of the SNF ABN form.

Based on observations and staff interviews, the facility failed to discard expired food and food items with signs of spoilage stored for use in 1 of 1 walk-in cooler. The facility also failed to label and date food items in 1 of 1 walk in cooler and in 1 of 2 nourishment room freezers (Hall 100). Additionally, the facility failed to store a dry ingredient scoop in a manner to prevent cross-contamination of food. These practices had the potential to affect food served to residents. The findings included: a. An initial tour of the kitchen was made on [DATE] at 11:13 AM. The following food items were observed in the walk-in-cooler: soy sauce 3.79 Liters (L) opened: ,d+[DATE]with no use by or best before date salsa 8 pounds (lbs.) opened: ,d+[DATE] with no use by or best before date egg salad with the manufacturer use by date [DATE] ricotta cheese 3 lbs. unopened - Use by date: [DATE] 1 piece of egg on top of a cracked eggshell that was stuck on the egg carton noted to have fuzzy, black specks of dirt formed surrounding the cracked eggshell A follow up observation of the walk-in cooler on [DATE] at 11:07AM revealed the cracked eggshell with fuzzy, black specks was still present. During an interview on [DATE] at 2:34 PM, the Certified Dietary Manager (CDM) verbalized that for labeling and dating, they go by the manufacturer's expiration date or the day it came in from the supplier. He also mentioned that he completed daily rounds within the kitchen and the facility to check on food items and discard when expired. b. During the initial tour of the kitchen made on [DATE] at 11:43 AM an observation of the dry ingredient bins revealed, a plastic scoop (inclusive of handle) observed resting in flour bin and not stored in scoop holder. During an interview on [DATE] at 2:34 PM, the Certified Dietary Manager (CDM) stated the flour scoop (including the handle) should not have been resting in the flour. The flour scoop should have been stored in the scoop holder of the flour bin. c. During an observation on [DATE] at 3:30 PM, two sausage breakfast sandwiches were observed inside the nourishment room freezer on the 100 Hall. These items were outside of their original cardboard packaging. Ice crystals were noticed to form inside the plastic packaging. No name and use by date indicated. There was a handwritten date of [DATE] on the clear packaging. During a follow up interview with the CDM on [DATE] at 4:04 PM, he explained he put out sandwiches (variety), juices and milk cartons. The CDM explained the two frozen sausage breakfast sandwiches must be from a resident or a resident's family. He verbalized he has educated the nursing staff on all halls to place proper labels and dates on food or beverage items being placed in the nourishment refrigerators. During an interview with the Administrator on [DATE] at 11:57 AM, she verbalized that she conducted daily rounds of the facility including the nourishment rooms and refrigerators. She stated that dietary was responsible for throwing food items away that were not properly labelled, dated or expired.

Based on observations and staff interviews, the facility failed to maintain the privacy of a resident's record by leaving a medication cart laptop unattended with resident information exposed in an area accessible and visible to the public on 1 of 6 medication carts (Medication cart #3). The findings included: During an observation of 200 hall on 09/09/24 at 4:04 PM, medication cart #3 was observed unattended. The laptop screen was open and displayed resident names, medications, and diagnoses. Staff were observed in the area and the treatment nurse passed by while the residents' information was visible on the open laptop screen at 4:06 PM. On 09/09/24 at 4:07 PM, a resident passed by the open laptop screen on the medication cart #3 while residents' information remained visible. Medication Aide (MA) #2 was observed returning to the 200 hall with medication cart #2 at 4:10 PM. An interview with MA #2 was completed on 09/09/24 at 4:10 PM. She stated she was assigned to two medication carts (cart #2 and cart #3). She verbalized that she usually clicked the walkaway tab when she left the medication cart unattended, so resident information was not visible. MA #2 indicated she thought she had hit the button to minimize the screen before she left the hall. An interview with the Assistant Director of Nursing was completed on 09/09/24 at 4:21 PM. She stated staff clicked the walkaway button on the computer screen of the laptop when they left the medication cart unattended. An interview with the Director of Nursing (DON) was completed on 09/09/24 at 4:38 PM. She explained to protect the health privacy of residents, the laptops on medication carts were minimized if staff were not in attendance of the medication carts. The DON verbalized MA #2 should have made sure the laptop screen was locked, and no personal health information was visible prior to leaving the medication cart unattended.

Based on record review, resident, and staff interviews, the facility failed to ensure a prompt resolution to a grievance and failed to provide a written summary about a grievance for 1 of 1 resident reviewed for grievances (Resident #43). The findings included: Facility Grievance/Complaint filing policy stated resident or any family member of the resident could file a grievance/ complaint orally or in writing. Upon reciept of a grievance /complaint the Grievance Officer would review and investigate the allegations and submit a written report of such findings to the Administrator within 5 working days of having received the grievance/ complaint. The Grievance officer, Administrator and Staff would take immediate action to prevent further potential violations of resident rights while the alleged violation was being investigated. The Administrator would review the findings with the Grievance Officer to determine what corrective actions, if any, needed to be taken. The Resident or person filing the grievance/compliant on behalf of the resident would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct any, identified problems. Resident #43 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively intact. Record Review revealed on 07/03/2024 Resident #43 had filed a grievance with the facility Social Worker for missing 4 to 5 embroidered sheets: blue, pink yellow and peach color, 3 gowns, tote bag, and a Yeti cup. On 07/03/2024 the Social Worker documented on the grievance form under investigation/finding that the resident's room was searched, and the items were not found. The Investigation resolution on the grievance form dated 07-03-2024, had documentation by the Social Worker that she left a message for the resident's family member inquiring about when the items were delivered to the resident and inquired about the cost and quantity of the lost items. The Social Worker further documented the facility would not resolve the grievance until these items were found. An interview with Resident # 43 on 09/08/24 at 12:37PM revealed the resident had filed a grievance back in July 2024 about some personal items missing from her room. She stated she was missing embroidered sheets and gowns. She stated the facility staff had not found her items. She went on to state she had informed the staff, and the facility Social Worker. She added the housekeeping and laundry staff looked for these items and had not found them. She stated she was aggravated and gave up. She stated she was verbally informed that her missing items were not found but the facility would continue to look for it. The Guest/ Family member follow up documentation dated 09/09/2024 on the grievance form revealed, the Social Worker documented that she left a message with the resident's family member and then spoke to the resident's family member and explained to her that the grievance was not yet resolved because they were hoping the lost items would reappear. The facility settled the grievance with Resident #43 on 09/09/2024. The facility agreed to replace the resident's lost items on 09/09/2024 A follow up interview with Resident #43 on 09/10/2024 at 9:00AM revealed the facility had agreed to settle Resident # 43's grievance on 09/09/2024 evening. Resident stated the Social Worker had verbally informed her that the facility would be settling her grievance by purchasing new bed sheets and gowns for her and would embroider Resident # 43's name on it. In an interview conducted with the Social Worker who was also the Grievance Officer on 09/09/24 at 3:37PM she stated the facility's handbook documented the facility was not responsible for lost items. She stated the facility's policy for grievance resolution was to resolve within 5 days. She stated during their last care plan meeting dated 07/28/2024 Resident #43's family member who had attended the care plan meeting via telephone along with the Resident# 43 informed the care team that several embroidered sheets along with Resident #43's gowns were missing. She stated she informed the family member a grievance was already filed by Resident # 43; she stated the facility had already looked for the missing items and did not find them. She stated she informed the family member they would keep looking for the missing items. Interview with the Director of Nursing (DON) on 09/09/24 at 4:02PM indicated a grievance could be filed by anyone with the facility social worker. The grievance was then forwarded to the respective department to be processed even if it was on a weekend, as some grievance need immediate attention and cannot wait till Monday. She stated the grievance resolution time varied; it depended on the item. She stated they searched the whole facility and sometimes it took them about a month to resolve a grievance. She stated they had tried to resolve grievance faster for the short-term residents. For the long-term residents, it may take about a month to month and a half to resolve the grievance. She further stated if the lost items were not found the facility reimbursed the resident the value of the item. She stated she became aware of the grievance dated 07/03/2024 on 08/05/2024 when Resident #43's family member informed her. She stated none of the staff had seen these items mentioned in the grievance. She stated she had directed staff to look for the lost bedsheets one more time on 09/09/2024; if not found instructed staff to buy Resident # 43 new bedsheets and get them embroidered. In a follow up interview with the Social Worker on 09/10/2024 at 9:11AM, the Social Worker stated she knew it had been over 2 months since Resident #43 had filed her grievance and said it was a long time to settle a grievance, but she was hoping these items would show up. She stated it was not unusual for facility to take this long to settle grievance regarding lost clothing items because many times they were found a few weeks later. She stated she informed Resident #43 on 07/03/2024 that they were going to look for these items. The Social Worker stated that she had informed the laundry and housekeeping staff, but they were unable to find these items. She stated she kept inquiring with the resident if her items had showed up each time, she was in the resident's room but had not documented the follow ups or able to recall when the encounters with Resident#43 occurred. The Social worker did not provide a summary of investigation provided to Resident #43. The Social Worker stated they had not seen Resident #43's belongings. She stated that she had tried to contact Resident # 43's family member to determine the value of the items missing and left her a message to return her call. She stated the family member had not returned her call. Social worker did not clarify when or how attempts were made by her to contact Resident # 43's family member. She stated she decided to settle the grievance on 09-09-2024 because it was sitting on my desk and I wanted it off my desk. She stated she then contacted the family member the on 09/09/2024 and the family member said to settle the matter. The Social Worker stated they would replace the bed sheets and get them embroidered and replace all the other lost/ stolen items. On 09/09/24 at 4:18PM the Administrator was interviewed about the facility's grievance policy. She stated anyone could file a grievance which was then forwarded to the facility social worker. She stated typically they resolved the grievance within 5 days. She stated that she believed the facility handbook stated grievances were to be resolved within 5 days. She stated they very rarely had problems with missing items. When they did have a grievance, the facility would replace or reimburse the resident immediately. She stated she would contact the resident's family to determine the monetary value of the lost item and would settle the grievance. She further added sometimes the family members took time to provide the information. She stated to her knowledge Resident # 43's family member was contacted immediately by the facility social worker to determine the value of the lost items, but the family member did not follow up with the facility promptly therefore was unable to resolve this grievance sooner. The Administrator did not provide any verification of a written summary to provide to Resident #43.

Based on record review, resident, resident representative, and staff interviews the facility failed to explain the arbitration agreement to a resident, or the resident's representative, prior to having them sign the agreement This occurred for 1 of 3 residents (Resident #296) reviewed for arbitration. The findings included: Review of the facility's Agreement for Arbitration which was not dated, revealed by signing the Agreement for Arbitration, the resident and/or resident's representative acknowledged they had read and understood the agreement. Resident # 296 was admitted to the facility on [DATE]. Review of Resident # 296's Agreement for Arbitration revealed the resident had signed the agreement on 09/05/2024 along with the rest of the admission paperwork. An attempt was made to interview Resident #296 on 09/10/2024 at 10:15 am. The resident was not able to understand or remember having been informed about an arbitration agreement. At the time of the interview, the resident was only oriented to person, and was unable to identify where she was, or the date and time. During the interview, the resident was unable to answer questions beyond her name. During a telephone interview on 09/10/2024 at 10:54 am with Resident # 296's family member, he said he did not think the resident would have been able to understand what the arbitration agreement meant. The family member said the facility should have asked one of her family members about the arbitration agreement because he did not think Resident #296 was able to sign to acknowledge she understood the agreement because she was too confused. During an interview on 09/10/24 at 01:14 pm with the admission coordinator, she said residents, or their representative were asked to sign the facility's Agreement for Arbitration on admission with their admissions paperwork. She stated she went over everything in the admission packet and the resident, or the resident representative, signed by using the electronic DocuSign. The admission coordinator said the facility had a paper titled Understanding the Arbitration Agreement, that she would offer to the resident and/or representative. The admission coordinator said she explained everything to the resident/representative before they sign and asked if they were willing to participate in the Arbitration process. The Admissions coordinator said if she was talking with a resident and the resident did not understand, or wasn't able to sign, then she would talk to their family/representative about the arbitration agreement. She said if a representative signed the arbitration agreement the representative's name would be on the arbitration agreement. During the interview with the admission coordinator, she verified Resident #296's name was listed as the person who signed the Agreement for Arbitration. The admission coordinator said she had gone over it with Resident #296, and that Resident #296 seemed fine during the admission process and was not sure why the resident could not remember. During an interview on 09/10/24 at 01:29 PM the administrator said it was up to the admissions person to make sure the resident/representative understood the agreement. The Administrator explained the resident's name was automatically populated into an electronic form once their admission information was placed into the electronic tablet and the resident did not actually sign a document. She explained the admissions coordinator would review the whole admission packet, which was also an electronic form, to include the Arbitration Agreement with the resident/representative. The Administrator verified Resident #296's name was listed as signing the Agreement for Arbitration but again explained the name was auto populated into the signature line. The Administrator discussed that a resident's representative could sign by overriding the auto populated signature.

Based on observation, record review, and staff interviews the facility failed to follow their infection control policy when the Medical Records Assistant delivered a lunch tray to a resident on Enhanced Droplet Precautions without donning a mask, gloves, gown, and/or eye protection for 1 of 1 resident who required Enhanced Droplet Precautions (Resident #19). The findings included The facility's COVID-19 Infection Control Practices policy was updated on May 8, 2023. The policy stated that staff should wear an N 95 mask, gown, gloves, and eye protection. The resident was diagnosed with COVID on September 7, 2024. On September 8, 2024, at 1:28pm, an observation was made of the lunch meal trays being delivered to residents. During the observation, the Medical Records Assistant was observed to remove Resident #19's lunch tray from the meal cart and enter the resident's room. The door to Resident #19's room was observed to have an Enhanced Droplet precaution sign that stated staff were to wear gown, an N95 mask, gloves and either face shield or goggles. Resident #19's door also had a metal holder that contained gowns, gloves, and masks. There was a small 3 drawer container next to the room with extra gowns and eye covering. The Medical Records Assistant entered the room with no gown, mask, gloves, or eye covering. The Medical Records Assistant proceeded to stand in front of Resident #19 and assist the resident in setting up her meal tray. The Medical Records Assistant was in the room in front of Resident #19 for approximately 1.5 minutes. When the Medical Records Assistant left Resident #19's room, she performed hand hygiene with hand sanitizer that was available on the wall in the hall. On September 8, 2024, at 1:32 PM, an interview took place with the Medical Records Assistant who confirmed that she had taken a lunch tray to Resident #19 that day. The Medical Records Assistant stated she was unaware of the resident being positive for COVID and that the resident was on enhanced droplet precautions. She did acknowledge there was an enhanced droplet precaution sign on the resident's door but stated I was trying to hurry and did not read what the sign said. The Medical Records Assistant stated she had received infection control training in January of 2024. The Medical Records Assistant also stated that she was aware of the need to wear the required Personal Protective Equipment (PPE) when a resident was placed on enhanced droplet precautions. On September 8, 2024, at 2:00 PM the Infection Prevention (IP) Nurse/Assistant Director of Nursing was interviewed. She stated staff had their annual infection control training in March of 2024. The IP nurse explained that staff would be aware of a resident having COVID by the Enhanced Droplet precaution sign on their door. She further stated that the Medical Records Assistant only came out of her office at mealtimes to help pass trays and probably did not look to see if the resident was on any precautions. She said that the Medical Records Assistant had received infection control training in March of 2024. The IP nurse voiced that the Medical Records Assistant should have looked prior to entering Resident #19's room. On September 8, 2024, at 3:00 PM the Director of Nursing (DON) was interviewed. The DON stated that she was unsure when the last infection control training was held. She explained that when the facility learned of Resident # 19 being positive for COVID on September 7, 2024, an education was sent out to all employees via an electronic messaging system on September 7, 2024. This education message included when and what PPE was involved, and instructions included reading the signage on the resident's door. The DON confirmed the Medical Records Assistant should have received the message on September 7, 2024, but stated that the Medical Records Assistant only came out of her office at mealtime for meal tray passing and did not read the signage on the resident's door. At 11:34 AM on September 9, 2024, an interview was completed with the Physician. The Physician stated that staff should have worn an N95 mask and all other required PPE due to Resident #19 being on enhanced barrier precautions. At 2:06 PM on September 8, 2024, the Administrator was interviewed. She stated that annual infection control training was on a computerized training system and was provided as needed when any infection control breaches occurred. The Administrator stated that staff would be made aware if a resident tested positive for COVID by the signage on the resident's door. She further stated that if staff did not understand the signage, then they were required to ask a nurse. She expressed that the Medical Records Assistant just did not read the signage on the door of Resident 19's room but should have.

Based on observations, record reviews and staff interviews, the facility failed to anchor a Resident's indwelling urinary catheter tubing (Resident #53) to prevent pulling and trauma and failed to change the drainage sponge as ordered around a Resident's suprapubic stoma (an artificial opening in the skin) where the suprapubic urinary catheter was inserted (Resident #19). This was for 2 of 3 residents (Resident #53 and #19) who were reviewed for urinary catheters. The findings include: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses that included obstructive uropathy requiring a urinary catheter. Review of Resident #53's care plan dated 04/16/23 indicated the resident required an indwelling urinary catheter related to obstructive uropathy. The goal to manage the catheter appropriately as to not exhibit signs of urinary tract infection and urethral trauma would be attained by utilizing interventions such as: avoiding obstructions in the drainage system, position catheter bag below the level of the bladder, change catheter as ordered by the physician and assess the drainage every shift. There was no care plan that addressed Resident #53 refused an anchoring device to be applied to the catheter tubing to prevent pulling or trauma. Review of Resident #53's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had an indwelling urinary catheter. Review of Resident #53's physician orders dated 11/30/21 revealed urinary catheter to bedside drainage for obstructive uropathy. On 06/12/23 at 8:48 AM an observation was made of Resident #53's urinary catheter tubing extending from the right side of the resident's brief and connecting to the drainage bag which was hung on the bedframe on the right side of the bed. There was no anchoring device in place. The resident was sleeping during the observation. On 06/13/23 at 8:57 AM during an observation and interview with Resident #53 the resident was lying in bed eating breakfast. The resident was asked if she had an anchoring device in place on her urinary catheter tubing and she lifted her bed linen from both sides of her brief and stated no, why, should I have? There was no anchoring device in place. On 06/13/23 at 10:09 AM An observation was made of Resident #53 accompanied by Nurse Aide (NA) #3 who was frequently assigned to care for the resident. The NA asked the resident if she could see if she had an anchoring device in place then observed that there was no anchoring device applied to Resident #53's catheter tubing. An interview was conducted with Nurse Aide #3 on 06/13/23 at 10:09 AM. The NA explained that she was not aware that Resident #3 did not have an anchoring device in place but that she was pretty sure there should be one in place to prevent pulling and trauma. The NA stated she would obtain one and place it on the Resident #53. During an interview with Nurse #2 on 06/13/23 at 3:54 PM the Nurse confirmed she was responsible for Resident #53 for that shift. The Nurse explained that all residents who have urinary catheters should have anchoring devices in place to prevent from pulling and trauma. She continued to explain that when she conducted a resident's full body assessment, she made sure they were wearing one if they had a urinary catheter, but she had not had to complete one on Resident #53 yet, so she did not know if she had one in place or not. The Nurse reported that no one had reported to her that the Resident did not have one in place. The Director of Nursing (DON) was interviewed on 06/13/23 at 5:18 PM who explained anchoring devices were utilized with urinary catheters but Resident #53 would often refuse the stabilizing device. During an observation and interview with Resident #53 on 06/13/23 at 5:48 PM it was noted that the resident had an anchoring device on her right thigh. The resident stated they came in and put it on her yesterday or today and that she did not mind wearing it, but she did not know what it was for. The resident also commented she could not tell that she was wearing it unless she looked at it and saw it was there. On 06/14/23 at 9:30 AM an observation was made of Resident #53 who continued to wear the anchoring device on her right thigh. The Resident commented look it is still there. During an interview with the Administrator on 06/14/23 at 1:14 PM she expressed she expected the staff to apply the stabilizing band on Resident #53. 2. Resident #19 was admitted to the facility on [DATE] with diagnoses that included chronic neurogenic bladder. Review of Resident #19's physician orders revealed: an order dated 01/03/23 for a suprapubic urinary catheter to bedside drainage and an order dated 01/04/23 to cleanse the suprapubic catheter site with saline and apply a drainage sponge every day. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19's cognition was moderately impaired and required a suprapubic catheter. Review of Resident #19's care plan dated 05/08/23 indicated the Resident required a suprapubic catheter related to chronic neurogenic bladder. The goal the suprapubic catheter care would be managed appropriately as evidence by no exhibiting obstruction, signs of infection or trauma would be attained by utilizing interventions such as: assessing drainage, provide catheter care, manipulate tubing as little as possible, keep catheter bag below level of bladder and report complications. Review of Resident #53's Treatment Administration Record (TAR) from 06/2023 indicated the treatment of cleansing and changing the drainage sponge to the Resident's suprapubic site was last completed on 06/12/23 by the Wound Nurse. On 06/13/23 at 2:08 PM an observation was made of Resident #19's suprapubic stoma accompanied by Nurse Aide (NA) #4. The NA revealed the drainage sponge on the suprapubic stoma was dated 06/11/23. The drainage sponge contained a moderate amount of greenish brown drainage and had a foul odor. An interview was conducted with the Wound Nurse on 06/13/23 at 2:15 PM who explained she worked Monday through Friday and was responsible for doing all treatments in the facility which included changing the drainage sponges on the suprapubic catheters. She stated the last time she changed the drainage sponge on Resident #19's suprapubic stoma was yesterday (06/12/23). On 06/13/23 at 2:20 PM accompanied the Wound Nurse to perform a dressing change on Resident #19's suprapubic drainage sponge. Before the Wound Nurse removed the resident's dressing the resident informedher that the area was itching and when she scratched it, she had blood on her fingers. The Nurse lowered the resident's brief to expose the old drainage sponge and noted it was dated 06/11/23 and had a moderate amount of greenish brown drainage as well as streaks of blood on the drainage sponge. The foul odor was more prominent after the old dressing was removed. The Wound Nurse cleansed the stoma area and replaced a new drainage sponge as ordered. An interview was conducted with the Wound Nurse on 06/13/23 at 2:44 PM who explained the amount of drainage and bloody streaks on the old dressing was typical of the condition of the dressings she removes during the treatments and the odor was typical as well. The Nurse stated she had no explanation of why the old dressing was dated 06/11/23 because she thought she did the treatment on Resident #19 on 06/12/23. An interview was conducted with the Director of Nursing (DON) on 06/14/23 at 11:51 AM who explained that Resident #19 was relatively new to the facility as a long-term care resident, and she contacted her previous care takers about the condition of her suprapubic stoma drainage. She continued to explain that the drainage was an issue with them as well and they had to increase the dressing changes to twice a day and that may be what the facility had to do as well. The DON indicated she expected the dressing changes to be changed as the physician ordered one time a day.

Based on record review and resident and staff interviews the facility failed to honor a resident's request to be assisted out of bed for 1 of 1 resident reviewed for choices (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility, transfers, dressing and personal hygiene. The MDS indicated it was very important for Resident #1 to do her favorite activities. Review of a form dated 05/09/23 titled 200 Hall Rounds indicated 300/Float hall to assist with getting Resident #1 out of the bed. There was no specific time recorded. The care plan dated 05/10/23 revealed Resident #1 preferred activities that identified with her prior lifestyle. The goal was that Resident #1 would express satisfaction with her daily routine and leisure activities. The interventions included informing the resident of upcoming activities by providing an activity calendar and involving the resident in the activities with shared interests. An observation and interview were conducted with Resident #1 on 06/12/23 at 11:46 AM. The resident was sitting up in her wheelchair. Resident #1 expressed she was not able to get up as early as she wanted to get up on 06/11/23 and 06/12/23 because there was not a float person on third shift to assist Nurse Aide (NA) #5 in getting her out of the bed. She explained that she was always an early riser and liked to get up early so that she could have some alone time to drink her coffee and sketch and draw in the cafe, but when there was not a third nurse aide on third shift she had to stay in the bed until first shift came in to get her out of bed. Resident #1 added, she would like to get up between 5:30 AM and 6:00 AM but since there was not a third shift nurse aide to assist NA #5 over the weekend, she did not get up until after 7:00 AM. An interview conducted with Nurse Aide (NA) #5 on 06/13/23 at 11:18 AM confirmed that on 06/10/23 and 06/11/23 third shift she was assigned to the hall where Resident #1 resided and that there was not a third nurse aide assigned as a float during the shifts. The NA explained that Resident #1 was alert and oriented and could voice her wants and needs and the resident requested to get up early both mornings of 06/11/23 and 06/12/23 but because she was the only nurse aide on the resident's hall, she could not get the resident up because she required two persons assist to attend to her. The NA stated Resident #1 had to wait until first shift came on duty so that she could get help in getting the resident up out of bed. NA #5 continued to explain that the resident liked to get up early and go to the cafe to draw and sketch but she was not always able to do that when there were only two nurse aides for 200 and 300 halls and no float which was what the staffing was this past weekend. During an interview with Unit Manager (UM) #1 on 06/14/23 at 11:13 AM she explained that Resident #1 had not given her a specific time that she wanted to get up early in the mornings but informed her that the third shift float aide was supposed to assist in getting her out of the bed. The UM continued to explain that she had educated the staff that when they work short, they needed to focus on providing the basic needs of all the residents. She stated she was not aware that there were only two nurse aides for the long-term care side for third shift over the weekend and if she had known she would have come into work herself to work the hall. An interview conducted with the Director of Nursing on 06/14/23 at 11:39 AM revealed she had a lot of staff to get the residents up in the morning, but Nurse Aide #6 was usually assigned to float, and the NA was on vacation the weekend of 06/10/23 and 06/11/23. During an interview with the Administrator on 06/14/23 at 1:28 PM she expressed that it was not an unreasonable request for Resident #1 to be gotten out of bed when she requested.

Based on observations, record review, resident, and staff interviews the facility failed to provide routine incontinence care to a resident before his breakfast meal was served to him for 1 of 2 residents reviewed for activities of daily living (Resident #143). The findings included: Resident #143 was admitted to the facility on [DATE] with diagnoses that included paraplegia, neurogenic bladder, and others. Review of a comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #143 was cognitively intact, required extensive assistance with bed mobility was frequently incontinent of bowel and had an indwelling catheter during the assessment reference period. An observation and interview were conducted with Resident #143 on 06/12/23 at 8:30 AM. Resident #143 was resting on an air mattress, covered with a sheet and was alert and verbal. Resident #143 proceeded to grab the right-side grab bar on his bed and turn over, pulled the sheet back. His brief was not in place and was stuck between Resident #143's knees, there was a ball of feces laying under his bottom along with other fecal matter in the area. No offensive odors were noted durnig the observation. The bottom sheet and top sheet were soiled with a brown dried substance. Resident #143 added that he was waiting for his breakfast to come so he could eat. An observation and interview were conducted with Resident #143 on 06/12/23 at 10:12 AM. Resident #143 remained in bed and indicated that the staff had not been in to check on him and had not provided care to him. He stated that he had eaten breakfast and it was good. An observation and interview were conducted with Resident #143 on 06/12/23 at 11:06 AM. Resident #143 remained in bed and was alert and verbal. He stated that the staff had not been in to check or change him. Resident #143 stated, do I need to be changed? he explained, I am a paraplegic and don't have any feeling there. Resident #143 was told that yes, he was soiled and needed to be cleaned up and he was observed to turn his call light on. Resident #143 again grabbed the right-side grab bar and turned over his brief remained between his knees and the ball of fecal matter remained under him. Nurse Aide (NA) #1 was interviewed on 06/12/23 at 11:07 AM. NA #1 confirmed that she was taking care of Resident #143. She stated that she had been in his room earlier on the shift to check on him but had not provided any care to him since coming on her shift at 7:00 AM. NA #1 was notified that Resident #143 had turned his call light on because he was soiled and needed to be cleaned up. NA #1 stated that she would find some help and get him cleaned up. An observation of NA #1 and NA #2 providing incontinent care to Resident #143 was observed on 06/12/23 at 11:09 AM. NA #1 and NA #2 were observed to turn Resident #143 onto his right side and remove his top sheet exposing the brief that was still between his knees and the ball of fecal matter remained under him. NA #1 and NA #2 used soap and water to clean Resident #143's peri area and also removed the soiled linen and replaced it with clean linen. When they were finished providing incontinent care, they covered Resident #143 with a top sheet and exited the room. A follow up interview was conducted with NA #1 on 06/12/23 at 12:47 PM and again confirmed she was caring for Resident #143. She stated that when she arrived for her shift at 7:00 AM, she had not gotten any report. NA #1 stated that normally any one of the staff members that were working the unit would get report from the previous shift. NA #1 stated she did not get a chance to check Resident #143 that morning because it was Monday morning and there was a lot going on. She added normally he would tell us if he needed incontinent care. She again confirmed that the first time she provide incontinent care to Resident #143 on 06/12/23 was at 11:09 AM. Nurse #1 was interviewed on 06/13/23 at 9:07 AM and confirmed that she was working Resident #143's unit on 06/12/23. She added that Resident #143 was not able to tell the staff all the time if he was soiled but the NAs should be checking him for incontinent issues during their regular rounds. The Director of Nursing (DON) was interviewed on 06/13/23 at 5:03 PM who stated that Resident #143 should have been checked for incontinent issues and provided incontinent care before being served his breakfast meal.

Based on observations, record review, resident, staff, and Wound Provider interviews the facility failed to keep a Stage 4 pressure ulcer covered and free from contamination of fecal matter for 1 of 4 residents reviewed for pressure ulcers (Resident #143). The findings included: Resident #143 was admitted to the facility on [DATE] with diagnoses that included paraplegia, open wound of left buttock and others. Review of an Admission skin assessment dated [DATE] written by the Wound Nurse read in part, pressure ulcer noted to left ischium (8.5x5.2 with undermining of 4.4cm @12 o'clock and 2.3 cm @ 6 o'clock). Orders in place to clean left ischium (hip area) with soap and water, apply barrier cream to peri wound, pack wound bed with Dakin's (bleach substance used to clean wounds) moistened gauze and cover with padded dressing twice a day. Review of a comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #143 was cognitively intact, required extensive assistance with bed mobility and had one stage 4 pressure ulcer that was present on admission. The MDS also revealed that Resident #143 received pressure ulcer care, was frequently incontinent of bowel and had an indwelling catheter during the assessment reference period. Review of a physician order dated 06/08/23 read, clean wound to left ischium with soap and water, apply barrier cream to wound boarder, then dampen kerlix (rolled gauze) with Dakin's solution and pack into wound bed. Cover with foam dressing change daily and as needed. Review of the Medication Administration Record (MAR) dated June 2023 revealed that Resident #143 wound care had been provided daily as ordered. An observation and interview were conducted with Resident #143 on 06/12/23 at 8:30 AM. Resident #143 was resting on an air mattress, covered with a sheet and was alert and verbal. Resident #143 stated that while at home he developed a wound to his left hip area and because I would not stay off it of the wound got bigger and got infected and required a hospitalization . Resident #143 proceeded to grab the right-side grab bar on his bed and turn over, pulled the sheet back exposing a large gaping hole on his left ischium. His brief was not in place and was stuck between Resident #143's knees, there was a ball of feces laying under his bottom along with other fecal matter in the area. The bottom sheet and top sheet were soiled with brown and pink substances. No stool was visible in the gaping hole wound which was pink with some patchy areas of grey dead tissue. Resident #143 stated that he had told the staff that his dressing needed to be replaced but stated he had not learned the staff's names yet so was not sure who he had told. Resident #143 added that he was waiting for his breakfast to come so he could eat. An observation and interview were conducted with Resident #143 on 06/12/23 at 10:12 AM. Resident #143 remained in bed and indicated that the staff had not been in to redress his wounds or check on him. An observation and interview were conducted with Resident #143 on 06/12/23 at 11:06 AM. Resident #143 remained in bed and was alert and verbal. He stated that his wound had not been redressed yet and the staff had not been into check or change him. Resident #143 stated, do I need to be changed? he explained, I am a paraplegic and don't have any feeling there. Resident #143 was told that yes, he was soiled and needed to be cleaned up and he was observed to turn his call light on. Resident #143 again grabbed the right-side grab bar and turned over and exposing a very large gaping hole to his left ischium, his brief remained between his knees and the ball of fecal matter remained under him. Nurse Aide (NA) #1 was interviewed on 06/12/23 at 11:07 AM. NA #1 confirmed that she was taking care of Resident #143. She stated that she had been in his room earlier on the shift to check on him but had not provided any care to him since coming on her shift at 7:00 AM. NA #1 was notified that Resident #143 had turned his call light on because he was soiled and needed to be cleaned up. NA #1 stated that she would find some help and get him cleaned up. An observation of NA #1 and NA #2 providing incontinent care to Resident #143 was observed on 06/12/23 at 11:09 AM. NA #1 and NA #2 were observed to turn Resident #143 onto his right side and remove his top sheet exposing his wound and brief that was still between his knees. As they cleaned Resident #143 the dressing that had been over Resident #143's left ischium was found stuck to his right buttock area and was discarded by NA #1 and NA #2. NA #1 stated that she would go and let the Wound Nurse know that his dressing needed to be changed as soon as they finished the care. NA #1 and NA #2 used soap and water to clean Resident #143's peri area and also removed the soiled linen and replaced it with clean linen. When they were finished providing incontinent care, they covered Resident #143 with a top sheet and NA #1 stated she was going to find the Wound Nurse and let her know that his dressing needed to be replaced. A follow up interview was conducted with NA #1 on 06/12/23 at 12:47 PM and again confirmed she was caring for Resident #143. She stated that when she arrived for her shift at 7:00 AM, she had not gotten any report. NA #1 stated that normally any one of the staff members that were working the unit would get report from the previous shift. NA #1 stated she did not get a chance to check Resident #143 that morning because it was Monday morning and there was a lot going on. She added normally he would tell us if he needed incontinent care. She again confirmed that the first time she provide incontinent care to Resident #143 on 06/12/23 was at 11:09 AM. An observation and interview were conducted with Resident #143 on 06/12/23 at 1:47 PM. Resident #143 was dressed and in his wheelchair at bedside. He stated that someone had come and replaced his wound dressing around 12:30 PM and then he had gone down to the therapy room for his therapy session. Nurse #1 was interviewed on 06/13/23 at 9:07 AM and confirmed that she was working Resident #143's unit on 06/12/23. She stated that she had completed his admission to the facility, and he had since completed his intravenous antibiotics for a wound infection that he was prescribed from the hospital. She stated that on most days the Wound Nurse completed Resident #143's wound care but if the Wound Nurse was off or unavailable, she could certainly do the care. Nurse #1 added that if the dressing was soiled in between routine wound care, she would be responsible for changing it at that time. Nurse #1 stated that no one had informed her yesterday (06/12/23) that Resident #143's dressing was off, or she would have gone and replaced the dressing or called the Wound Nurse to replace the dressing. She added that Resident #143 was not able to tell the staff all the time if he was soiled but the NAs checked him for incontinent issues during their regular rounds. The Wound Nurse was interviewed on 06/13/23 at 9:30 AM who confirmed that Resident #143 had a wound to his left ischium that was treated on a daily basis. She stated that yesterday (06/12/23) she had completed Resident #143's wound care around lunch time after NA #1 notified her that Resident #143's dressing needed to be replaced. The Wound Nurse stated she was not aware prior to that, that Resident #143's dressing was off. She stated that from 8:30 AM to 12:30 PM was a long time for the wound to be exposed to stool and if someone would have notified her sooner, she certainly would have immediately gone and completed the wound care. The Wound Nurse stated if the any wound dressing became dislodged or soiled, she would expect it to be replaced as soon as possible. The Director of Nursing (DON) was interviewed on 06/13/23 at 5:03 PM who stated that Resident #143 should have been checked for incontinent issues before breakfast, provided incontinent care and immediately let the nurse or Wound Nurse know that the dressing was off and needed to be replaced. The Wound Provider was interviewed via phone on 06/15/23 at 12:26 PM who confirmed that he had evaluated Resident #143 today 06/15/23 and measured his wound. He stated that comparing today measurements with last week measurements there was no change to the wound in size. He stated that it definitely was no worse but appeared stable and had no overt signs of infection. He stated that wound had good pink tissue with some yellow slough which he had debrided (removed). The Wound Provider stated that there was always a concern for wounds in that area to be covered and kept clean of fecal matter and urine. He stated that the dressings they used were pretty good about keeping feces and urine out of the wound and they should be in place at all times except when removed to clean and place a new dressing.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following a focused infection control survey on 11/12/20 a focused infection control and complaint survey on 1/29/21, and the recertification and complaint survey conducted on 12/02/21. This failure was for two deficiencies originally cited in the area of Infection Control (F880) and Quality of Care (F686) that were subsequently recited on the current recertification survey of 06/15/23. The repeat deficiencies during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F880: Based on observation, record review and interviews the facility failed to perform hand hygiene and change gloves after removing a soiled dressing and before cleansing a resident's suprapubic stoma (an artificial opening through the abdomen to the bladder) site for 1 of 1 resident (Resident #19) reviewed for dressing change. During the focus infection control survey of 11/12/20 the facility failed to implement their infection control policies and the CDC guidelines when staff did not don full Personal Protective Equipment (PPE) including gloves and in a resident rooms, failed to sanitize a multi-use stethoscope between residents and failed to perform hand hygiene after cleaning environmental surfaces in a resident room for 3 of 3 residents on enhanced droplet precautions on the Covid-19 quarantine hall. These failures in infection control practices occurred during a Covid-19 pandemic. During the focused infection control and complaint survey of 1/29/21 the facility failed to implement their infection control policies when facility staff members failed to don and doff Personal Protective Equipment (PPE), perform hand hygiene before entering or after contact with objects in resident's rooms who were under enhanced droplet isolation precautions and disinfect reusable equipment between residents on the general population halls (Resident #1, #2) for 2 of 5 staff observed for infection control practices. The failures in infection control practices occurred during a global COVID-19 pandemic. A total of 28 residents and 2 staff members were confirmed positive for COVID-19 as of 01/27/21. F686: Based on observations, record review, resident, staff, and Wound Provider interviews the facility failed to keep a Stage 4 pressure ulcer covered and free from contamination of fecal matter for 1 of 4 residents reviewed for pressure ulcers (Resident #143). During the recertification and complaint survey of 12/02/21 the facility failed to identify and assess a change in a resident skin condition for 1 of 3 residents reviewed for pressure ulcers resulting in the development of an unstageable deep tissue injury to the resident's sacral area. The Administrator was interviewed on 06/13/23 at 5:33 PM and stated that she had been at the facility since March 2023 and had met at least twice with the QA committee. She stated they met monthly and all department heads, some direct care staff, and the Medical Director all attended their meetings. She stated that each department head brought their own reports specific to their department and they would discuss any items that needed to be discussed. On a monthly basis the QA committee discussed wounds and infection control along with a list of other topics. The Administrator felt like the facility was moving in the right direction and were very productive in the QA meetings. The Administrator stated that they would look at the newly identified infection control issues and pressure ulcer issues and identify new ways and strategies to achieve and maintain compliance.

Based on observation, record review and interviews the facility failed to perform hand hygiene and change gloves after removing a soiled dressing and before cleansing a resident's suprapubic stoma (an artificial opening through the abdomen to the bladder) site for 1 of 1 resident (Resident #19) reviewed for dressing change. The finding included: Review of an undated policy titled Wound Care revealed Policy: Provide wound care for the purpose of healing and decreasing the potential for nosocomial infections. Procedure: 9. Put on exam glove and loosen tape and remove dressing. 10. Pull glove over dressing and discard. 11. Perform hand hygiene. 12. Wear gloves for new or deep wounds, wounds which bleed, when physically touching the wound 13. Cleanse wounds with saline unless otherwise indicated. On 06/13/23 at 2:20 PM a treatment observation was made of a dressing change on Resident #19's suprapubic catheter stoma by the Wound Nurse. The Nurse assembled the supplies for the ordered dressing change and explained the procedure to Resident #19 who responded that she was glad because it had been itching and when she scratched it, she had blood on her fingers. The Nurse sanitized her hands and applied clean gloves then removed the old drainage sponge dressing which had a moderate amount of greenish brown drainage that contained bloody streaks had a foul odor. The Wound Nurse threw the soiled drainage sponge in a cup that she utilized for a trash receptacle. The Nurse then picked up the saline gauze and proceeded to cleanse the drainage and blood from the area around the stoma and threw the gauze in the trash cup. She then removed her dirty gloves and sanitized her hands before she applied a new drainage sponge dressing around the stoma. An interview conducted with the Wound Nurse on 06/13/23 at 2:44 PM revealed the Nurse explained that she knew she did not remove her gloves, sanitize her hands and apply a new pair of gloves after she removed the dirty dressing and before she cleansed the drainage from the stoma. She stated she was nervous. An interview was conducted on 06/13/23 at 4:07 PM with the Assistant Director of Nursing (ADON) who also served as the Infection Control Nurse. The Nurse explained that the Wound Nurse rounded with the Wound Care Provider on a weekly basis, and she had not received any feedback regarding a lack of proper wound care technique performed by the Wound Nurse. The ADON continued to explain that the Director of Nursing had observed the Wound Nurse during wound treatments, but she did not know how often. Regardless, the ADON stated the Wound Nurse should have removed her gloves, sanitized her hands and donned a new pair of gloves after she removed the old drainage sponge and before she cleansed the stoma area. On 06/13/23 at 5:22 PM during an interview with the Director of Nursing (DON) she explained that she had observed the Wound Nurse during wound treatments, and she did get nervous but even so the Wound Nurse should have removed her dirty gloves and donned a fresh pair of gloves before she cleansed the stoma site.

Based on record review, staff, Nurse Practitioner, and Medical Doctor interview the facility failed to identify and assess a change in a resident skin condition for 1 of 3 residents reviewed for pressure ulcers (Resident #143) resulting in the development of an unstageable deep tissue injury to the residents sacral area. The findings included: Resident #143 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #143 was severely cognitively impaired for daily decision making and required extensive assistance with bed mobility and transfers. The MDS further indicated Resident #143 was at risk for developing pressure ulcers but had none on admission. The MDS did indicate Resident #143 had a surgical wound on admission to the facility. Review of a Wound assessment dated [DATE] indicated Resident #143 had a surgical incision to his right hip. The wound Assessment was completed by Nurse #2. Review of Skin assessment dated [DATE] indicated Resident #143 had no skin impairment. The assessment was completed by Nurse #2. Review of a Wound assessment dated [DATE] indicated that Resident #143's surgical incision was healed. The Wound Assessment was completed by Nurse #2. A Nurse Practitioner (NP) note dated 09/24/21 read in part, discussed that patient will most likely need long term skilled nursing care due to comorbidities and baseline prior surgery. Palliative or Hospice care would also be appropriate at this time given poor overall prognosis. Family voice understanding. The note was electronically signed by the NP. Review of a nurses note dated 09/26/21 at 1:57 PM read in part, Resident was observed to have moderate amount of rectal bleeding. Vital signs taken and heart rate shown to be between 180-190 and blood pressure 108/54. Resident was very lethargic. The on-call provider notified and requested resident to be sent to the emergency room (ER) for evaluation. Report called to the local hospital. The note was signed by Nurse #2. Review of an Emergency Department (ED) to hospital admitted d 09/26/21 read in part, deep tissue pressure (injury to the deep layers of skin) injury to buttock, deep purple tissue injury around the coccyx and pink blanchable (when pressed on the skin the blood leaves the capillaries leaving the skin pale) stage 1 around the outside of the deep tissue injury that was present on admission to the ER. The admission was electronically signed by Medical Doctor (MD) #1. Review of a Wound Care Consult note from the local hospital dated 09/28/21 read in part, noted to have a deep tissue injury to coccyx area and rectum noted to be necrotic. Area cleaned with soap and water and dressing applied. The note was electronically singed by the Wound Care Nurse from the local hospital. Review of a hospitalist discharge summary dated 09/29/21 read in part, principal discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 was interviewed via phone on 11/29/21 at 4:34 PM. Nurse #2 explained that she was the former wound nurse at the skilled facility and was only in that position for approximately 3 months. Nurse #2 stated that she recalled Resident #143 but could not recall any other wounds he had except for his surgical incision. She added that she would check on Resident #143 daily because of his surgical incision and because he was on a blood thinner, but her daily check only included assessing his surgical incision. Nurse #2 explained that on 09/26/21 she was the nurse on call and had received a call stating that Resident #143 had some rectal bleeding, so she came to the facility to assess the situation. Nurse #2 stated that Medication Aide (MA) #2 had reported the rectal bleeding to Nurse #1 in addition to Nurse #2. Nurse #2 stated when she arrived at the facility, she assessed Resident #143 and he was noted to have bright red blood coming from his rectum, she further explained she did not see any signs of deep tissue injury or skin breakdown that she could recall. Resident #143's pulse was 150 and he did not look well so the on-call provider was called, and Resident #143 was sent to the ER. MA #2 was interviewed on 11/30/21 at 10:28 AM. MA #2 stated that on 09/26/21 she was caring for Resident #143 and around 8:00 AM to 8:30 AM she and Nurse Aide (NA) #1 went into provide incontinent care to Resident #143 and when we rolled him over, he was noted to have dark red blood in his brief and his anus was black. She stated that they continued to provide care to Resident #143 and once they were finished, she had gone to Nurse #1 to report the bleeding and the condition of his anus. MA #2 stated that Nurse #1 came to Resident #143's room and looked at the brief and when offered to stand Resident #143 up so she could assess the wound Nurse #1 decline and exited room without looking at Resident #143's bottom. She added that the black part was not a bruise and initially she thought it was feces until she tried wiping it off and it would not come off, she explained the black area was right around the anus. MA #2 also stated that at the top of his coccyx he had a healing bed sore, that was healing it was red but not open. When Nurse #2 came to the facility on [DATE], MA #2 stated she did look at Resident #143's bottom and eventually Nurse #2 sent Resident #143 to the ER. Nurse #1 was interviewed on 11/30/21 at 10:20 AM. Nurse #1 stated she did not recall Resident #143 and after reviewing his medical record recalled that he had some bleeding from the rectum. Nurse #1 did not recall if MA #2 had reported anything about Resident #143 coccyx area but stated she did recall looking at Resident #143's brief on 09/26/21 and it had right much blood in it. Multiple attempts were made to speak to NA #1 on 11/30/21 and 12/01/21 without success. The local hospital Wound Care Nurse was interviewed via phone on 12/01/21 at 10:46 AM. The Wound Care Nurse stated she evaluated Resident #143 on 09/28/21 in the hospital and he had an unstageable pressure ulcer to both his sacrum and rectal area. She explained the one on Resident#143's coccyx was deep purple and non-blanchable and explained it would have taken quite some time for the wounds to get that advanced. She added that Resident #143's rectum was necrotic as well. The wounds were documented by the admitting ER nurse on 09/26/21 at 6:42 PM approximately 4 hours after he arrived in the ER and a consult was placed for her to see and assess the wounds which she did on 09/28/21. MD #1 was interviewed via phone on 12/01/21 at 1:41 PM. MD #1 stated that he examined Resident #143 when he was being admitted from the ER to acute care on 09/26/21. Resident #143 was noted to have an unstageable deep tissue wound to his coccyx and sacral area. MD #1 stated he could not recall what they looked like but stated Resident #143 was very weak and deconditioned. He added that although Resident #143's wound may have been unavoidable they would have taken several days to weeks to develop to the point they were when he came to theER on [DATE]. The Director of Nursing (DON) was interviewed on 12/02/21 at 12:49 PM. The DON stated that Resident #143 was very demented and had a left hip fracture that had been repaired. Sometime on the 09/26/21 Resident #143 had some rectal bleeding and the nurse on call came to assess him and ended up sending him to the ER. The DON stated she would have expected Nurse #1 to assess the wound and make a judgement call on how to proceed. The NP was interviewed on 12/02/21 at 1:42 PM. The NP stated that while Resident #143 was initially in the hospital he had a somewhat complicated course that ultimately required a blood transfusion. Despite working with therapy when he came to the nursing facility, Resident #143 was really just not making great improvements. The NP added that while Resident #143 was in the facility he had closely monitored his hemoglobin level and it had gone up. He further explained that he did not recall Resident #143 having any wound but added he would not be surprised if he had signs of skin breakdown because he was not eating and was very skinny.

Based on observations and staff interviews the facility failed to remove loose unsecure medications from the medication cart drawers for 3 of 3 medication carts reviewed for medication storage (300 Hall Cart, 200 Hall Cart #3 and #2). The findings include: An observation was made on 12/02/21 at 12:18 PM of the 300 Hall medication cart. The observation revealed 8 unidentified medications of various shapes, sizes and colors and a half of a white tablet lying loose and unsecure in the drawers of the medication cart. An interview was conducted with Medication Aide (MA) #2 on 12/02/21 at 12:18 PM. The MA who had been employed for 2 years observed the loose medications and stated she could not identify the various medications and that the medications should not be loose in the drawers. The MA explained that the medication carts should be cleaned daily. An observation was made of the 200 Hall medication cart #3 and medication cart #2 on 12/02/21 at 12:38 PM. The observations revealed 5 unidentified medications of various shapes, sizes and colors and 2 white medication pieces lying loose and unsecure in the drawers of the #3 medication cart. An observation of the #2 medication cart yielded one white capsule lying loose and unsecure in the drawer of the medication cart. An interview was conducted with Medication Aide #3 on 12/02/21 at 12:38 PM. The MA who had been employed for 9 days stated she could not identify the loose medications and that the medications should not be loose in the medication cart. The MA explained she thought the medication carts should be cleaned daily. Interviews were conducted with the Unit Manager (UM) #1 and the Administrator on 12/02/21 at 1:04 PM. The UM explained that all the medication carts were thoroughly checked and cleaned on Monday (11/29/21) and indicated the amount of loose medications should not have been found in the medication carts. The UM stated the nurses should be keeping the medication carts clean every day. The Administrator added, the loose medications should not have been found in the medication carts.

Based on observation and staff interviews, the facility failed to discard expired food in 1 of 1 walk in refrigerator and failed to remove open and expired milk in 1 of 4 facility dining room refrigerators. Findings include: An initial tour of the kitchen on [DATE] at 10:10 AM with the Dietary Supervisor revealed a 1 gallon container of extra heavy mayonnaise opened with no date when opened and a bag of shredded lettuce with a use by date of [DATE]. Observations of the facility's dining room refrigerators on [DATE] at 9:10 AM revealed an open carton of white milk dated [DATE] and 2 unopened cartons of white milk dated [DATE]. An interview with the Dietary Supervisor on [DATE] at 10:10 AM revealed the Kitchen Manager checked the dates twice a week in the dry storage area, and the walk in refrigerator and freezer. The Dietary Supervisor further revealed the kitchen had a runner that checked the facility hallway refrigerators in the mornings and in the afternoons by 3:00 PM. The Dietary Supervisor stated the lettuce and mayonnaise should have been thrown out and further stated she would have liked for them to date food when it was opened. The Dietary Supervisor indicated they would all need to get together to discuss the food items that were found. During an interview on [DATE] at 12:30 PM the Administrator revealed she was aware of the issues in the kitchen and facility hallway refrigerator. She further revealed she expected food to be dated when opened and discarded after the expiration date.

Based on record review and staff interviews, the facility failed to revise a resident's care plan for weight loss for 1 of 7 residents (Resident #14) reviewed for nutrition. The finding included: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment and required supervision of one person for eating. The MDS also indicated Resident #14 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14 did not have a feeding tube at the time of the 10/03/21 MDS. A review of Resident #14's medical record revealed a feeding tube placed on 10/27/21. A review of Resident #14's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. (Brand name) tube feeding formula three times a day via feeding tube at 5:00 AM, 2:00 PM and 8:00 PM for weight loss. This order was started on 10/28/21. 2. Regular puree diet by mouth of fortified food at all meals. This order was started on 11/3/21. On 12/02/21 a review of Resident #14's current care plan for weight loss revealed there was no feeding tube documented as an intervention to Resident #14's weight loss care plan. During an interview on 12/02/21 at 11:28 AM the Minimum Data Set (MDS) Nurse acknowledged there was no care plan for Resident #14's feeding tube. The MDS Nurse explained she updated the care plans quarterly and as needed when there was a new intervention put into place such as an intervention after a fall. The MDS Nurse continued to explain that Resident #14's feeding tube was a new intervention for her weight loss and that she should have updated the care plan to include the feeding tube. The MDS Nurse stated she should have remembered to update the care plan because she had been aware of Resident #14's feeding tube placement for several months. During an interview with the Administrator on 12/02/21 at 11:44 AM she stated she reviewed Resident #14's weight loss care plan for the addition of the feeding tube intervention. The Administrator acknowledged the feeding tube was not present on the care plan and explained the care plans were updated quarterly and as needed and the feeding tube intervention should have been added to the weight loss care plan by now.

Based on observations, record reviews and staff interviews the facility failed to ensure the lift gate was in the elevated position before unloading a resident from the back of the facility van for 1 of 3 residents sampled for accidents (Resident #91). Resident #91 was pushed from the van out the back door and fell to the ground resulting in minimally displaced left sided rib fractures 4th through 9th, left base atelectasis (lung collapse) thought to be related to splintering secondary to rib fractures (where the bone splintered and punctured the lung), [MEDICATION NAME] femur, and scalp hematoma related to trauma with moderate laceration. The findings included: Resident #91 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility document titled Driver Safety and Training Competency Checklist for Transportation Aide (TA) #1 dated 04/04/17 was made. The checklist indicated that TA #1 had received training in the following areas: using the facility vehicle, safe driving practices, prohibiting use of cell phone while driving, refueling protocol, properly securing wheelchairs in the vehicle, securing residents using seatbelts, and emergency situations. The form was signed by TA #1 and the Project Manager (PM). TA #1's individual competency check off list on using the facility's transportation van was included in the packet of training material. The competency check off list included all aspects of the van including use of the lift and loading/unloading residents. The competency check off list revealed that TA #1 had met all competencies on 04/04/17 and had been signed off by the PM. Review of an incident report dated 04/21/17 at 9:30 AM read in part, received a call from TA #1 from the local [MEDICAL TREATMENT] clinic stating that Resident #91 had fallen from the facility's transportation van. TA #1 stated, the resident is stating that she is ok and that just the back of her head hurts a little bit, no open areas noted, no bleeding, but the back of her head is noted to be having some swelling, she denies pain to her hips, legs, arms, back, buttocks, feet, and hands. I have called Emergency Medical Service (EMS) to transport her to the emergency room (ER). Family was notified of the fall and that Resident #91 was being taken to the ER for evaluation. The report was signed by the Director of Nursing (DON). Review of a statement signed by TA #1 dated 04/21/17 read in part, while pushing another resident into the [MEDICAL TREATMENT] clinic her lunch cooler got caught on the wheel of the wheelchair and it pinched my left middle finger. TA #1 returned to the van and entered from the right side of the van, unhooked Resident #91's wheelchair and pushed her to the back of the van not realizing the lift gate was not up in place. The lift gate remained on the ground. Resident #91 fell backwards out of the van. TA #1 immediately spoke to Resident #91 and asked if she was alright and she stated she was alright. EMS was then notified as was the facility. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #91 was cognitively intact and required total assistance of 2 staff members. The MDS further revealed that Resident #91 required [MEDICAL TREATMENT] during the assessment period. An interview was conducted with Resident #91 and her family member on 02/15/18 at 12:25 PM. The family member stated that Resident #91 had fallen from the facility van in April of 2017 when the driver forgot to put the lift gate back up after unloading one resident and before attempting to unload Resident #91. Resident #91 stated that the driver pushed me right off the back of the van and I hit the ground did not even see it coming. The family member stated that Resident #91 suffered broken ribs, hematoma to her head and other injuries and went to the hospital for a few days before returning to the facility. Resident #91 stated that she had recovered from her injures and had no further incidents with the van since the incident on 04/21/17. An interview was conducted with TA #1 on 02/15/18 at 4:32 PM. TA #1 stated that she was also a Nursing Assistant (NA) who had worked at the facility for 3 years and had been driving the facility van for approximately 6 weeks but currently was no longer employed by the facility. TA #1 stated that she had received most of her training from TA #2 which was minimal. TA #1 stated that she was shown how to use the lift, seat belts, and where the fire extinguisher was and she drove around and observed TA #2 for a couple of days and then she was released to transport residents independently. Prior to being released to transport residents independently TA #1 stated that the PM went over the procedures for using the lift and seat belt and did go on a test drive with her. TA #1 could not recall if she had completed a skills check off list at that time. TA #1 stated that she felt comfortable with her ability to transport residents when she was released to transport independently. TA #1 explained that the day of the incident 04/21/17 she had transported 2 residents to the local [MEDICAL TREATMENT] clinic and she had taken the first resident off the van and was carrying a cooler and the cooler got caught on the wheel of the wheelchair and it jerked her fingers and she was in pain and crying and she thought she had broken her finger. TA #1 further stated that she was in a hurry and moving swiftly because she was late and she immediately returned to the van and went in the right side door and unbuckled Resident #91 and pushed her off the back of the van not realizing the lift gate was on the ground. TA #1 stated that she was in a hurry and did not hear or see the alarms in the van that would indicate that the lift was down. She added that Resident #91 had fallen out of the back of the van and landed on her back and hit her head, she then rolled to her left side and a bystander who she did not know pulled the wheelchair out from under her. She added that the [MEDICAL TREATMENT] clinic was surrounded by a lot of doctor's offices and there were nurses that came out and tried to assist. Resident #91 was complaining of her head and hip hurting but could not recall which hip. She stated that she felt the back of Resident #91's head and there was a knot but no bleeding that she could see. TA #1 stated that she called EMS and notified the facility of the incident and she stayed with Resident #91 until the medics arrived and transported her to the hospital. TA #1 stated that following the incident the facility offered retraining to drive the van but she declined the offer. An interview was conducted with the DON on 02/15/18 at 03:25 PM. The DON stated that on 04/21/17 she received a call from TA #1, who was transporting Resident #91 that day to her [MEDICAL TREATMENT] appointment. TA #1 stated she had pushed Resident #91 off the back of the van with the lift gate in the down position (the lift gate was on the ground). The DON stated she immediately drove over to the [MEDICAL TREATMENT] clinic and Resident #91 was already on the EMS stretcher. Resident #91 was alert and awake and was taken to the hospital for evaluation. The DON stated that at the time you could tell the resident hit the back of her head, she had a hematoma that was bleeding. The hospital discovered that Resident #91 suffered rib fractures and [MEDICAL CONDITION] as a result of the fall but no surgery was required. TA #1 told the DON that just before the incident, she unloaded another resident from the van and pushed that resident into [MEDICAL TREATMENT] holding the resident's lunch box. TA #1 stated that while pushing the other resident the lunch box got caught in the wheel of the wheel chair and it jerked TA #1's finger. TA #1 thought her finger was broken and she was in pain and crying. TA #1 stated she went in the right side door of the van and did not realize that she had left the lift gate in the down position. The DON explained that the van had a pressure sensitive alarm on the van's floor and if the gate was down and pressure was applied there was an audible and visual alarm that sounded. TA #1 stated that she was so frazzled she did not hear the alarm. The DON stated that Resident #91 remained in the wheelchair and no one moved her until EMS arrived. An observation of the facility's transportation van was made on 02/15/18 at 3:50 PM. The van was a conversion (van converted to transport residents) van with a lift. The floor of the van was approximately 26 inches from the ground. There was hand control that was used to raise and lower the lift. There was a pressure sensitive sensor on the floor of the van that set off an audible alarm and a red flashing light inside the back of the van if the lift was in the down position. When the back doors of the van were open there was a visual sign located on the rear door that read STOP!! Check lift position before moving resident toward exit door. An interview was conducted with the PM on 02/15/18 at 3:55 PM. The PM described the procedure for unloading and loading 2 residents. The PM stated that after unloading the first resident in a safe location the lift gate was returned to the upright position and the driver entered the vehicle from the right side door and placed the 2nd resident on the lift gate and then lowered the lift gate and removed the 2nd resident. He added that he was responsible for training of new drivers and that most of his training scenarios were based on only one resident being transport. An interview with the Executive Director (ED) was conducted on 02/15/18 at 4:00 PM. The ED stated that they had not thought about an accident happening with 2 residents being transported on the van until the accident happened. An interview was conducted with TA #2 on 02/16/18 at 9:11 AM. TA #2 stated that he had worked at the facility for 5 years and had been driving the transportation van for 2 years. He added that he had received his training from the PM which included how to properly load/unload residents in the van. He added that the PM drove around and demonstrated how the process was completed, went over the security measures inside the van, the pressure sensitive plate on the floor of the van and the audible and visual alarm that went off if the lift gate was down and pressure was applied. TA #2 stated that the PM had verified his skills a few times in the parking lot by using a wheelchair with no resident and they would go through the motions of proper loading/unloading the wheelchair. TA #2 stated that he did assist in training new drivers once the PM had done the initial training he would again go over the steps for loading/unloading and the safety features that were used. He added that he always trained the new drivers that once the first resident was off of the van and in a safe location you were to raise the lift back up and there was never a time that the lift should be left in the down position. TA #2 confirmed that he had done the same training steps with TA #1 and she had rode with him for about a week, first just observing then assisting and by the end of the week TA #1 was doing the steps and transports independently while he observed. TA #2 stated that once TA #1 had completed the training with him the PM would do a final check off and TA #1 was then released to transport residents independently. He added that TA #1 was doing very well with the transports and he had no concerns when she was released to drive and transport residents independently. TA #2 stated that on 04/21/17 the day of the incident with Resident #91 he was on an out of town appointment. When he returned to the facility, the Administrator and the PM went over the process for loading and unloading residents again and the new policy that stated we would only transport one resident at a time. After going over the training with the Administrator and the PM, TA #2 returned to the [MEDICAL TREATMENT] clinic to pick up the resident while Resident #91 was at the hospital. TA #2 stated that he had been trained that if there was an incident or an emergency he was to pull over and call for assistance and this included if the driver became injured. An observation of TA #2 unloading Resident #91 at the local [MEDICAL TREATMENT] clinic was made on 02/16/18 at 10:10 AM. TA #2 was observed to back the facility's van to the door of the [MEDICAL TREATMENT] clinic and open the back doors of the van. When the back doors of the van were opened there was a visual sign located on the rear door that read STOP!! Check lift position before moving resident toward exit door. Using the hand held control TA #2 lowered the lift gate from the back of the van to the ground and then raised to the loading position. TA #2 was observed to enter the van through the right side door and release the safety belts from Resident #91 and her wheelchair and push her backwards to the lift gate. Once on the lift gate TA #2 locked Resident #91's wheelchair wheels and exited the van and again using the hand held control lowered Resident #91 safely to the ground where she was removed from the lift gate and moved away from the vehicle. Before assisting Resident #91 into the [MEDICAL TREATMENT] clinic TA #2 lifted the gate using the hand held control and shut the rear doors of the transportation van and assisted Resident #91 into the [MEDICAL TREATMENT] clinic. A follow up interview with the PM was conducted on 02/16/18 at 11:36 AM. The PM confirmed that he was responsible for training drivers of the facility's transportation van and had done so for 7-8 years. The PM stated that once an employee was assigned to drive the van he would sit down with the employee and complete a packet of paperwork and go through the training material on safety of the van, road safety, signage, proper speed limit, cell phone policy and emergency situations. The PM stated that he discussed emergency situations that included weather related issues, accident issues, and injury (both to driver and resident). He added that he always instructed the drivers that if they become injured for whatever reason they were to make sure the residents were safe and call both the facility and EMS if they were in need of medical assistance. The PM stated that if TA #1 had become injured on 04/21/17 then she should have stopped what she as doing and called the facility and requested assistance and if needed called EMS for medical assistance and he could not speak to why TA #1 did not call the facility and ask for assistance. An interview was conducted with the Administrator on 02/16/18 at 12:00 PM. The Administrator stated that he believed TA #1 became so wrapped up in getting Resident #91 to her [MEDICAL TREATMENT] appointment that she did not follow what she had been trained to do and did not hear the alarm or see the flashing light. He added that he would have expected that if TA #1 was injured that she would have called the facility and requested assistance before attempting to unload Resident #91. The Administrator added that following the van incident on 04/21/17 the DON had driven the van back to the facility and the van was inspected by the PM and the Administrator and all safety features were in working order. An interview was conducted with the Medical Director (MD) on 02/17/18 at 12:12 PM. The MD stated that she was new to the facility and had only been in the facility for about 30 days. The MD stated that she was notified of the incident with Resident #91 that occurred on 04/21/17 in the last 2 weeks. She stated that she had reviewed the plan of correction and the procedural/process changes and agreed with them. She stated that the audits were also reviewed and revealed that the plan of correction that was immediately put into place was effective. She added that the facility took swift and appropriate actions and there have been no other incidents like this with the van since the 04/21/17 incident with Resident #91. The facility provided a plan of correction with a correction date of 04/26/17. The plan of correction included: F689: - On 04/21/17 TA #1 transported 2 residents to the local [MEDICAL TREATMENT] clinic and proceed to unload the first resident and accompany the resident into the clinic. While assisting the resident into the clinic the cooler that TA #1 was carrying became entangled in the wheelchair pinching her finger. TA #1 returned to the van and entered through the right side door and pushed Resident #91 out of the back of the van not realizing she had left the lift gait lowered to the ground. Resident #91 fell backward out of the van to the ground, TA #1 immediately exited the van and checked on Resident #91 and called EMS and the facility. Resident #91 was transported to the local ER for evaluation and treatment. - All transportations were immediately suspended and the van was returned to the facility. - Upon return to the facility the van was immediately inspected by both the Administrator and the PM and all aspects of the van including safety alarms were in correct working order. - The policy and procedure for loading and unloading was changed to include the provision that the lift gate was never to be left in the down position. - The facility would only transport 1 resident at a time. - Visual reminders were added to both of the facility's transportation vans. - All TAs were reeducated on the policy/procedure changes with observed return demonstration before being allowed to transport residents. - The plan of correction was submitted to the medical director for review and the Administrative personnel would observe loading/unloading of residents at the facility 4 times a week for 4 weeks then at random intervals. - Findings of the audits reported to the Quality Assurance Performance Improvement (QAPI) monthly. - The plan of correction was completed on 04/26/17 when the DON observed the safe loading/unloading of Resident #91 at the [MEDICAL TREATMENT] clinic after her return to the facility from the hospital. The plan of correction was validated on 02/16/18 and 02/17/18. The validation included: -observation of TA #2 loading/unloading Resident #91 at the facility and at the [MEDICAL TREATMENT] clinic. -Interviews with the TA #2, TA #3, and TA #4 verifying the policy/procedural changes that went into effect 04/21/17. -Review of the policy/procedural changes that occurred effective 04/21/17. -Review of the monitoring that occurred weekly x 4 as stated in the plan of correction. Additional monitoring was also evident through 08/2017.