Every finding on record at Williamsburg Health & Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to label and date food items in 2 (100 Unit and 300 Unit) of 3 unit refrigerators. This had the potential to affect all the residents who resided on 2 (100 Unit and 300 Unit) of 3 units in the facility.Findings included:An undated facility policy titled, Protocol for Foods Brought in From Family/Visitors, revealed, Policy: Recognizing that residents receiving foods brought in by family and friends has a positive association with their quality of life, we encourage family and friends to bring in items for their loved ones. Foods should be Checked In at Nurses' Station prior to delivering to the resident. The policy specified, The resident's nurse will label and date all home cooked food containers with the resident's name and date, if it is requested to be stored in the unit refrigerator. All items should be discarded at the end of the 3rd day by dietary personnel.During an interview on 12/09/2025 at 11:45 AM, the Dietary Manager (DM) stated that the dietary staff maintained the unit refrigerators, stocked them every day, and kept track of the items in the unit refrigerators.During interview and observation of the 300 Unit refrigerator on 12/09/2025 at 12:01 PM, two, unlabeled and undated plastic containers that contained homemade food was observed in the refrigerator. Licensed Practical Nurse (LPN) 2 stated she did not know who the plastic containers belonged to.During interview and observation of the 100 Unit refrigerator on 12/09/2025 at 12:06 PM, there were two, opened, unlabeled and undated plastic bottles of soda in the door of the refrigerator and one, unlabeled, undated, opened, almost empty bottle of ranch dressing. LPN 1 stated she did not know who the soda or ranch dressing belonged to, but she discarded the items.During a follow-up interview on 12/10/2025 at 9:28 AM, the DM stated the dietary staff checked the contents of the unit refrigerators three times a day. The DM stated her expectation was that the dietary staff were to look in the unit refrigerators and check to make sure food items were labeled with dates and resident names.During an interview on 12/10/2025 at 9:34 AM, Dietary Aide 3 stated she checked all the unit refrigerators on 12/09/2025 before 10:00 AM and did not remember if the refrigerators had any opened, unlabeled or undated food items.During an interview on 12/10/2025 at 9:48 AM, LPN 4 stated she knew the plastic containers observed in the 300 Unit refrigerator on 12/09/2025 belonged to two residents but did not know who the residents were. During an interview on 12/10/2025 at 10:37 AM, the Administrator stated the unit refrigerators were the responsibility of dietary; however, the families were instructed to give the food item to the charge nurse, and the charge nurse was to ensure the item was labeled with the resident's name and dated. The Administrator stated the charge nurse should check the unit refrigerators once a shift as well.

Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member for 1 (Resident #65) of 1 sampled resident reviewed for abuse.Findings included: A facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, revised 07/2024, indicated, Our facility does not condone or tolerate resident abuse (this includes verbal abuse, sexual abuse, physical abuse and mental abuse), neglect, misappropriation or exploitation under any circumstances by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving or visiting the resident, family members, legal guardians, sponsors, friends, or other individuals. The policy specified, Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to threats of harm, saying things to frighten a resident such as telling a resident that he/she will never be able to see his/her family again. An admission Record revealed the facility admitted Resident (R)65 on 07/16/2021. According to the admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, revealed R65 had a Brief Interview for Mental Status (BIMS) score 3, which indicated the resident had severe cognitive impairment. The facility Final Report/5 Day Follow Up dated 09/19/2025, indicated At approximately 7:20 pm on 09/13/25, State Registered Nurse Aide (SRNA) 6, and SRNA 5 were attempting to transfer resident 65 to his/her bed in their room when R65 became combative. R 65 pushed his/her walker over, almost causing SRNA 5 to fall. SRNA 6 stated that SRNA 5 said, my child doesn't' act this way, so you're not going to. SRNA 5 pushed R 65's wheelchair next to the bed in order to complete the transfer and when the bed was lowered, the rail was pushing R65's right knee. SRNA 6 told SRNA 5 to stop, that the rail was on the resident's knee. SRNA 5 moved the rail off the resident's knee and stated to R65, That's what your bratty [curse word] gets. R65 was transferred to bed and stated that their (the resident's) leg hurt and SRNA 5 stated, See R65, you lived. SRNA 6 then reported the incident to LPN (licensed practical nurse) Charge nurse. The Final Report/5 Day Follow Up revealed In conclusion, based upon interviews and witness statements to the alleged incident, the IDT (interdisciplinary team) feels that SRNA 5, responded in this interaction with resident, R65, with an inappropriate verbal response by stating, that's what your bratty [curse word] gets. During an interview on 12/08/2025 at 11:52 AM, R65 stated a staff member said something mean to them, but they could not remember what was said or who said it. During an interview on 12/10/2025 at 10:31 AM, SRNA 5 stated she did not recall saying anything inappropriate to R65 and that she was not mean to the resident. SRNA 5 denied verbally abusing R65. During an interview on 12/10/2025 at 9:27 AM, SRNA 6 stated SRNA 5 was upset because she almost fell over R65's walker. Per SRNA 6, SRNA 5 did not yell or raise her voice to R65, but she did get in R65's face after she got R65's leg out from under the bedrail. SRNA 6 stated it was then that SRNA 5 told R65 in a smart-alecky way, that's what your bratty [curse word] gets. SRNA 6 stated SRNA 5 sounded sarcastic and giggled when she told R65 that he/she would live. Per SRNA 6, what she witnessed would rise a little bit to verbal abuse. During an interview on 12/10/2025 at 12:13 PM, the Administrator stated the facility substantiated verbal abuse based on their abuse policy and SRNA 5 was terminated due to the incident.

42440 Based on interview, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) and failed to provide documentation of ombudsman notification for three of three residents (Resident (R) 22, R27, and R68) reviewed for hospitalization out of 25 sample residents. The failure had the potential to affect the residents and/or their representatives' notification related to transfers. Findings include: Review of the facility's undated policy, What to do when a resident transfers out to the hospital, revealed If during business hours- at the time of the transfer-the office designee will talk with the resident if applicable or attempt to reach the responsible party regarding the transfer and bed hold status and mail them a copy of the notice. The facility must document multiple attempts to reach the resident representative in cases where the facility was unable to notify the representative. Always mail a copy of the notice. If the transfer happens after the office is closed- the office designee will attempt to reach the next business day and mail a copy of the notice. 1. Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/24 and located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE] and a reentry from the hospital on 01/26/24. A Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, indicating the resident's cognition was intact. Review of R22's Census tab of the EMR revealed R22 discharged to the hospital on 01/20/24 and returned 01/26/24. R22 was also at the hospital from 04/04/24 to 04/05/24. Review of R22's Health Status Note, dated 01/20/24 at 5:06 PM and located in the EMR under the Progress Note tab, revealed Resident complains of severe pain starting in right knee going to foot no swelling or redness noted pedal pulses palpable denies injury to right leg . request to go to ER [emergency room ] md [medical doctor] made aware new orders noted [RP] made aware. Review of R22's Patient Transfer Form, dated 01/20/24 and located in the EMR under the Documents tab, revealed the facility transferred R22 to the hospital for right knee pain going down to her feet. The form stated family was notified. It did not show that the resident and/or representative were provided with a written notice of transfer. Review of R22's Health Status Note, dated 04/04/24 at 4:41 PM and located in the EMR under the Progress Note tab, revealed .Writer asked resident at this time if she wanted to be sent to the hospital for evaluation and tx [treatment]. Resident stated no, she did not want to go. [Name], RP, notified. Review of R22's Health Status Note, dated 04/04/24 at 5:40 PM and located in the EMR under the Progress Note tab, revealed Resident states that she wanted to go to the hospital at this time .family notified. Review of R22's Patient Transfer Form, dated 04/04/24 and located in the EMR under the Documents tab, revealed the facility transferred R22 to the hospital for lethargy and hypoxia. It did not reveal that the resident and/or representative were provided with a written notice of transfer. Review of R22's Bed Hold Notifications, dated 01/20/24 and 04/04/24, provided by the facility, revealed no documented reason for transfer and no name/signature of who the facility notified. During an interview on 10/24/24 at 1:20 PM, R22 stated she did not remember her or her family receiving any paperwork about the reason for transfer to the hospital. 2. Review of R27's quarterly MDS with an ARD of 08/16/24 and located in the MDS tab of the EMR, revealed an admitted [DATE] and a reentry from the hospital on 01/25/24. The BIMS showed a score of 15 out of 15, indicating the resident's cognition was intact. Review of R27's Census tab of the EMR revealed R27 discharged to the hospital on 01/23/24 and returned 01/25/24. Review of R27's Health Status Note, dated 01/23/24 at 1:36 PM and located in the EMR under the Progress Note tab, revealed [RP] approached writer and said that resident agreed to go to ER. Writer spoke with resident and she stated that she would go to the ER . Review of R27's Patient Transfer Form, dated 01/23/24 and located in the EMR under the Documents tab, revealed the facility transferred R27 to the hospital for the inability to eat or drink anything for several days. It did not reveal that the resident and/or representative were provided with a written notice of transfer. Review of R27's Bed Hold Notification, dated 01/23/24, provided by the facility, revealed no documented reason for transfer and no name/signature of who the facility notified. During an interview on 10/21/24 at 1:24 PM, R27 stated she had not received any paperwork from the facility when she went out to the hospital. During an interview on 10/24/24 at 10:30 AM, Licensed Practical Nurse Unit Supervisor (LPNUN) stated she believed either social services or the business office sent out bed hold/transfer notifications. She stated nursing did not send out any papers to the residents or families. She stated nursing verbally notified families that residents were sent to the hospital. During an interview on 10/24/24 at 10:53 AM, the Business Office Manager (BOM) stated she assumed the nurses' notified families of residents when they went out to the hospital. The BOM said there was not a written form provided to residents or families regarding the reason for transfer to the hospital. During an interview on 10/24/24 at 11:44 AM, the Administrator stated she sent out encrypted emails to the ombudsman monthly, if there was a discharge. She listed the residents discharged in the email. She could not retrieve the emails. During an interview on 10/24/24 at 3:40 PM, the Director of Nursing (DON) stated a copy of the transfer form, found under the Documents tab of the EMR, went with the resident to the hospital with the reason for transfer. During an interview on 10/24/24 at 3:45 PM, the Administrator stated it was expected that both the resident and representative were notified of the reason for the transfer to the hospital verbally. She stated she had not been able to provide any evidence of her notifications of discharges to the ombudsman. 3. Review of R68's EMR undated Admission Record under the Profile: tab, revealed an admitted [DATE] with diagnoses which included closed fracture of left femur with routine healing, lack of coordination, muscle weakness, and unsteadiness on feet. Review of R68's EMR Nursing Progress Note under the Progress Notes tab and dated 06/17/24, indicated R68 was discharged to the hospital related to a fall with left hip pain. During an interview on 10/24/24 at 11:13 AM, R68, she said she could not remember receiving a notice for discharge to the hospital or a bed hold notification. During an interview on 10/24/24 at 12:06 PM the BOM stated she did not send a transfer notification to R68 or to the family but only gave them a verbal notification. During an interview on 10/24/24 at 3:36 PM, the Administrator stated she could not find evidence that she notified the ombudsman regarding the hospital transfer for R68.

Based on record review, interviews and facility policy review, the facility failed to provide written notification regarding the facility policy for bed hold, which included the duration of the bed-hold and payment, if any, during which the resident was permitted to return and resume residence in the nursing facility for three of three residents (Resident (R) 68, R22, and R27) reviewed for hospitalization of 25 sample residents The failure had the potential to affect the residents and/or their representatives notification related to bed holds. Findings include: Review of the facility's undated policy titled, What to do when a resident transfers out to the hospital, revealed If during business hours- at the time of the transfer-the office designee will talk with the resident if applicable or attempt to reach the responsible party regarding the transfer and bed hold status and mail them a copy of the notice. Always mail a copy of the notice. If the transfer happens after the office is closed- the office designee will attempt to reach the next business day and mail a copy of the notice . the 1st notice of the bed hold policy should be at admission. This information should be in your admission packets. The 2nd notice comes into play when the resident is transferred. If the resident is Medicare A . Medicare nor the Replacement policy pays for Bed Hold. The Resident and or Resident Representative are then given the choice to hold the bed privately for $210.00 per day. If they to [sic] decline to hold the bed- they will be discharged . Review of the facility's policy titled, Bed Hold, dated 05/24 and provided by the facility, revealed There are no bed hold days paid for residents whose bill is being paid by Medicare. The resident and/or resident representative may choose to hold the bed by paying privately or may choose to not hold the bed and take the first available semi-private room when discharged from the hospital . If resident is having their bill paid by any private insurance, the facility cannot bill Medicaid for bed hold. If the resident is having their bill paid by . or other third party insurances, they may choose to pay privately to hold the bed or give the bed up and the resident readmitted to the first available semi-private room after hospital discharge . 1. Review of R68's undated Admission Record located under the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE] with diagnoses which included closed fracture of left femur with routine healing, lack of coordination, muscle weakness, and unsteadiness on feet. Review of R68's EMR quarterly MDS, dated [DATE], indicated her BIMS score was 15 out of 15, which indicated cognition was intact. Review of R68 s EMR Nursing Progress Note under the Progress Notes tab and dated 06/17/24, indicated R68 was discharged to the hospital on 06/17/24 related to a fall with left hip pain. A nursing progress note, dated 06/22/24, indicated R68 returned to the facility on [DATE]. During an interview on 10/24/24 at 11:13 AM, R68 stated she could not remember receiving a bed hold notification. During an interview on 10/24/24 at 12:06 PM, the Business Office Manager (BOM) stated she usually mailed a bed-hold notification to the resident representative but could not provide evidence that the notification was mailed to R68 or her representative. During an interview on 10/24/24 at 3:36 PM, the Administrator stated the bed hold policy was included in the resident admission packet, and she expected an additional bed hold notification be sent to every resident and/or representative when the resident was discharged to the hospital. 2. Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/24 and located in the MDS tab of the EMR revealed an admitted [DATE] and a reentry from the hospital on 01/26/24. The Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, indicating the resident's cognition was intact. Review of R22's Census tab of the EMR revealed R22 discharged to the hospital on 01/20/24, while her stay was paid for by Medicaid, and returned 01/26/24. R22 was also out to the hospital 04/04/24, while Medicare A was the primary payer, and returned on 04/05/24. Review of R22's Health Status Note, dated 01/20/24 at 5:06 PM and located in the EMR under the Progress Note tab, revealed Resident complains of severe pain starting in right knee going to foot no swelling or redness noted pedal pulses palpable denies injury to right leg . request to go to ER [emergency room ] md [medical doctor] made aware new orders noted [RP] made aware. Review of R22's Patient Transfer Form, dated 01/20/24 and located in the EMR under the Documents tab, revealed the facility transferred R22 to the hospital for right knee pain going down to her feet. Review of R22's Health Status Note, dated 04/04/24 at 4:41 PM and located in the EMR under the Progress Note tab, revealed .writer asked resident at this time if she wanted to be sent to the hospital for evaluation and tx [treatment]. Resident stated no, she did not want to go. [Name], RP, notified. Review of R22's Health Status Note, dated 04/04/24 at 5:40 PM and located in the EMR under the Progress Note tab, revealed resident states that she wanted to go to the hospital at this time .family notified. Review of R22's Patient Transfer Form, dated 04/04/24 and located in the EMR under the Documents tab, revealed the facility transferred R22 to the hospital for lethargy and hypoxia. Review of R22's Bed Hold Notification, dated 01/20/24, and provided by the facility, revealed R22's bed would be held for 30 days since she was covered by Medicaid. It did not state the cost to hold the bed after 30 days. Review of R22's Bed Hold Notification, dated 04/04/24, and provided by the facility, revealed The resident's bed will be held for up to 30 days therefore the resident will need to return to [Facility Name] on or before 5/3/24. The resident's bed will be held for ___ days per your request. The notification did not state the cost of the bed hold. It listed the payment status of R22 as private. During an interview on 10/24/24 at 1:20 PM, R22 stated she did not remember if she or her family received the bed hold policy. She did not know how long the facility would hold her bed or the cost, but she had returned to the same room following her hospitalization . 3. Review of R27's quarterly MDS with an ARD of 08/16/24 and located in the MDS tab of the EMR, revealed an admitted [DATE] and a reentry from the hospital on 01/25/24. The BIMS showed a score of 15 out of 15, indicating the resident's cognition was intact. Review of R27's Census tab of the EMR revealed R27 discharged to the hospital 01/23/24, while her primary payer was Medicare A, and returned 01/25/24, Review of R27's Health Status Note, dated 01/23/24 at 1:36 PM and located in the EMR under the Progress Note tab, revealed [RP] approached writer and said that resident agreed to go to ER. Writer spoke with resident and she stated that she would go to the ER . Review of R27's Patient Transfer Form, dated 01/23/24 and located in the EMR under the Documents tab, revealed the facility transferred R27 to the hospital for the inability to eat or drink anything for several days. Review of R27's Bed Hold Notification, dated 01/23/24, provided by the facility, revealed The resident's bed will be held for up to 0 [zero] days . Since Medicare was the primary payer on discharge of the resident, we are not permitted by Medicare to hold the bed. You may pay privately to hold the bed. The notification did not state the cost to hold the bed. During an interview on 10/21/24 at 1:24 PM, R27 stated she had not received any papers from the facility about holding her bed when she went out to the hospital. During an interview on 10/24/24 at 10:53 AM, the BOM stated she checked the EMR dashboard daily for transfers to the hospital and sent out bed hold letters to the family, or residents if cognitively intact, and kept a copy. During an interview on 10/24/24 at 11:30 AM, the BOM provided copies of the Bed Hold Notifications and reported she did not record on the form who it was sent to. During an interview on 10/24/24 at 12:46 PM, the BOM stated the facility did not send the bed hold policy with the notifications. She stated the bed hold policy was reviewed on admission with the admission records. During an interview on 10/24/24 at 3:00 PM, the BOM reported she mailed out the Bed Hold Notification to the resident's responsible party. She stated she called the responsible party if the resident was covered by Medicare A insurance and notified them the insurance would not pay for a bed hold and marked no bed hold. She stated for the three residents reviewed, the responsible parties received the bed hold, not the residents. She stated the facility reviewed the cost per day on admission, and notices were sent out at least 30 days in advance of any room cost changes. During an interview on 10/24/24 at 3:45 PM, the Administrator stated that the Bed Hold Policy would be reviewed with the resident/representative on the day of admission or the next business day, to include the room cost. She stated the Bed Hold Notification was expected to be provided to the residents and/or representative upon discharge to the hospital. Upon review, the cost per day was not explicitly written on the Bed Hold Notification. She stated the BOM would call and notify them of the daily room charges. She stated the charges were relayed on admission and with any changes, with 30-day notice. 42440

Based on interview, record review, facility policy review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure an Admission Minimum Data Set (MDS) assessment was completed within 14 days of admission for one of 25 sampled residents (Resident (R) 200). This failure placed the resident at risk for unmet care needs due to the lack of a timely comprehensive assessment. Findings include: Review of the facility's policy titled, MDS [Minimum Data Set], revised July 2024, revealed .2. The MDS will be completed: a) By the 14th day after the date of admission . Review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, revealed .01. Admission Assessment (A0310A = 01). The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . Review of R200's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R200's MDS tab of the EMR revealed no documented evidence of a completed admission MDS which should have been completed by 10/14/24. During an interview on 10/24/24 at 4:30 PM, the MDS Coordinator (MDSC) stated an admission MDS should have been completed within 14 days of R200's admission and this did not occur. During an interview on 10/24/24 at 4:52 PM, the Director of Nursing (DON) stated it was her expectation that R200's admission MDS would have been completed according to the MDS guidelines which was within 14 days of R200's admission. The DON stated it was important the MDS would have been completed timely to ensure a comprehensive care plan was formulated. During an interview on 10/24/24 at 4:53 PM, the Administrator stated it was her expectation that R200's admission MDS would have been completed according to the RAI Manual which was 14 days from the resident's admitted .

Based on observation, record review, interview, and facility policy review, the facility failed to develop a person-centered care plan related to smoking for one of one resident (Resident (R) 29) reviewed for smoking out of 25 sampled residents. This failure placed the resident at an increased risk for smoking accident hazards. Findings include: Review of the facility's policy titled, Care Plan Policy & Protocol, revised September 2024, revealed .2. The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychological needs .6. The comprehensive care plan (in HER [electronic health record]) shall be periodically reviewed and revised by the interdisciplinary team after each assessment and on an as needed basis . Review of R29's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Observation on 10/24/24 at 10:36 AM revealed R29 was in the vented smoking room with a staff member who was within arm's reach supervising R29 smoking. R29 was utilizing a smoking apron. Review of R29's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/24 revealed the facility assessed the resident to not have used tobacco during the assessment lookback period. Review of the R29's quarterly MDSs revealed the question related to smoking was asked during a comprehensive assessment (Admission, Annual, and Significant Change in Status). Review of R29's nursing Progress Note, dated 02/21/24 and located in the resident's EMR under the Progress Notes tab, revealed an order administration note of Nicotine Step 1 Transdermal Patch 24 hour 21 MG [microgram]/24HR [hours] .Remove Patch and D/C [discontinue] if PT [patient] Decides to Smoke .Resident refused patch at this time. Review of R29's Smoking/Vaping/Tobacco Safety Evaluation, dated 05/29/24 and located in the resident's EMR under the Assessments tab, revealed during the assessment the resident used cigarettes, required supervision, and no safety concerns were identified. The Smoking/ Vaping/ Tobacco Safety Evaluation, documented 1b. If resident smokes cigarettes continued with evaluation .proceed to care plan. Review of R29's current Comprehensive Care Plan, initiated on 02/29/24 and located in the resident's EMR under the Care Plan tab, revealed no documented evidence a care plan related to smoking had been developed when the resident decided to smoke. During an interview on 10/24/24 at 4:35 PM, the MDS Coordinator (MDSC) stated she completed R29's smoking assessment, dated 05/29/24. The MDSC stated prior to 05/29/24, R29 had not smoked cigarettes. The MDSC also stated R29's care plan should have reflected his choice of smoking. During an interview on 10/24/24 at 4:55 PM, the Director or Nursing (DON) confirmed R29's Comprehensive Care Plan did not include a care plan related to smoking. The DON stated it was her expectation that a care plan for smoking would have been developed when R29 began smoking. The DON stated the MDS Coordinator (MDSC) would have been responsible for developing a smoking care plan for R29. The DON stated it was important that R29's care plan would have included smoking to ensure his safety and reflect his personal choice of smoking. During an interview on 10/24/24 at 4:58 PM, the Administrator stated it was her expectation R29 would have been care planned for safety and person-centered care to reflect his choice of smoking.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure Personal Protective Equipment (PPE) was discarded appropriately after care was provided to a resident who was on Transmission Based Precautions (TBP) for one of one resident (Resident (R) 59) reviewed for TBP of 25 sample residents. This failure had the potential to cause the spread of infection to other residents who resided on the hall. Findings include: Review of the facility's policy titled, Transmission Based Precautions, revised 12/20 revealed, Transmission Based Precautions will be used in addition to Standard Precautions when the routes(s) of transmission is (are) not complete interrupted using Standard Precautions .Contact Precautions. 1. Contact Precautions are intended to prevent the transmission of infectious agents which are spread by director indirect contact with the patient or the patient's environment .6. Donning PPE before entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination . Review of R59's undated Admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R59's nursing Progress Note, dated 09/23/24 and located in the resident's electronic medical record (EMR) under the Progress Notes tab, revealed Nurse Practitioner (NP) 1 reviewed R59's laboratory results, ordered a new antibiotic, and the resident was placed on contact precautions. Review of R59's Laboratory Discharge Summary Report, dated 09/23/24 and provided by the facility, revealed the urine analysis was collected on 09/18/23. The Laboratory Discharge Summary Report, documented the two organisms of Enterobacter Cloacae and Enterococcus Faecium. Observation on 10/22/24 at 10:33 AM revealed Certified Nurse Aide (CNA) 1 and CNA2 donned PPE and entered R59's room to assist her with a transfer from her wheelchair to her bed. There was a trash can with a lid outside the resident's room in the hall. Observation on 10/22/24 at 10:36 AM revealed CNA1 and CNA2 doffed their soiled PPE at the threshold of the doorway and placed the soiled PPE in the trash can outside the resident's room. Observation on 10/22/24 at 10:39 AM of R59's door revealed a PPE station hung on the door and a sign indicating the room was under contact precautions. During an interview on 10/22/24 at 2:50 PM, CNA1 confirmed R59 was on contact TBP. The CNA confirmed she doffed her PPE at the threshold of the R59's door and disposed of the PPE in the trash can outside the resident's room in the hall. The CNA stated that was how she was instructed to dispose of the PPE. During an interview on 10/22/24 at 2:52 PM, Registered Nurse (RN) 1 stated R59 was on contact precautions due to having an organism in her urine. When asked about the trash can being out in the hallway for staff to dispose of soiled PPE, RN1 stated it was her understanding that was where it should be. During an interview on 10/22/24 at 3:20 PM, the Infection Preventionist (IP) stated it was her expectation that the CNAs would have doffed their PPE and disposed of it inside the resident's room. The IP also stated the trash can should have been inside the room. During an interview on 10/24/24 at 4:43 PM, the Director of Nursing (DON) stated it was her expectation that the trash can would be inside R59's room and the CNAs would have discarded their worn PPE in the room and disposed of the PPE in the room. The DON also stated the trash can should have been in the resident's room and not the hallway to prevent outside the room from being contaminated. During an interview on 10/24/24 at 4:47 PM, the Administrator stated it was her expectation that the trash can for the soiled PPE would have been inside the isolation room.

Based on record review, interview, and facility policy review, the facility failed to maintain an antibiotic stewardship program which included a system to effectively monitor antibiotic usage for one of three residents (Resident (R) 59) reviewed for Urinary Tract Infections (UTIs) out of 25 sampled residents. This failure placed the residents at risk for potential complications related to the use of an antibiotic not effectively treating an infection. Findings include: Review of the facility's undated policy titled, Infection Prevention & Control Program, revealed The facility shall maintain an Infection Prevention & Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection .Monitoring & Investigating Causes of Infection .2. When a resident exhibits signs and symptoms of infection, the McGeer Surveillance Criteria shall be utilized for possible infection. a) Urinary Tract-Fever, dysuria, chills, frequency . Review of the facility's undated policy titled, Antibiotic Stewardship Program, revealed Refers to a set of commitments designed to 'optimize' the treatment of infections while reducing the adverse events associated with antibiotic use .4. Actions to Improve Use .Our facility will implement prescribing policies and change to improve prescribing/use of antibiotics including: .Development and implementation of specific algorithm of assessing residents (McGeer Surveillance Criteria) . Review of R59's undated Admission Record provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R59's Physician Order, dated 09/19/24 and located in the resident's electronic medical record (EMR) under the Orders tab, revealed Cefdinir Oral Capsule (an antibiotic in the cephalosporin antibiotics class) 300 MG [milligram] .take 1 capsule by mouth every morning and bedtime for UTI [Urinary Tract Infection] for 10 days. The medication was ordered by Nurse Practitioner (NP) 1. Review of R59's Laboratory Discharge Summary Report, dated 09/23/24 and provided by the facility, revealed the urine analysis was collected on 09/18/23. The Laboratory Discharge Summary Report, documented the two organisms of Enterobacter Cloacae and Enterococcus Faecium. Continued review of the report revealed the antibiotic Cefdinir was resistant to the organism in the resident's urine. The report also revealed the antibiotic Levaquin was susceptible to the organism. Review of R59's nursing Progress Note, dated 09/23/24 and located in the resident's EMR under the Progress Notes tab, revealed the resident's laboratory results were received and NP1 was notified, and a new order was placed. Review of R59's Physician Order, dated 09/23/24, located in the resident's EMR under the Orders tab, revealed Levaquin Oral Tablet (an antibiotic) 250 MG .take 1 tablet by mouth every evening for UTI for 5 days. During an interview on 10/22/24 at 3:20 PM, the Infection Preventionist (IP) stated when NP1 prescribed the antibiotic of Cefdinir, the resident did not meet the signs and symptoms criteria for an antibiotic to be prescribed before the urinalysis culture came back. During an interview on 10/24/24 at 3:02 PM, when asked when an antibiotic should be prescribed to a resident before the culture and sensitivity report came back, NP1 stated it depended on the resident. NP1 stated if she knew the resident and the urinalysis indicated an UTI, she would go ahead and start the resident on an antibiotic because of the population who resided at the facility, and she would not want them to become septic. The NP stated she was aware of the antibiotic stewardship requirement and confirmed the initial antibiotic she ordered for R59 was resistive to the organism. The NP stated a possible negative outcome from prescribing an antibiotic resistant to an organism was gastrointestinal distress from killing off good bacteria in the gut. During an interview on 10/24/24 at 4:48 PM, the Director of Nursing (DON) stated she understood the McGreer's criteria being a surveillance tool; however, it should not trump a provider's order. During an interview on 10/24/24 at 4:49 PM, the Administrator stated it was her expectation staff follow provider's orders. The Administrator also stated it was her expectation that providers were educated on the antibiotic stewardship standards and make recommendations based on their education and knowledge.

Based on interview, record review, review of the facility investigation and facility policy, it was determined the facility failed to ensure one (1) of one (1) sampled residents remained free from abuse (Resident #1). Interviews and record reviews revealed on 11/07/2021, State Registered Nurse Aide (SRNA) #1, smacked Resident #1 on the shoulder after the resident grabbed the SRNA in her private area. Interview with the SRNA on 01/27/2021 confirmed she slapped the resident without thinking after the resident grabbed her; however, the nurse aide stated she immediately realized hitting a resident could be considered abuse, so she reported herself to the charge nurse and was immediately removed from the facility. The findings include: Review of the facility policy titled Abuse, Neglect, Misappropriation and Exploitation Policy last revised in January 2018, revealed the facility would not condone or tolerate resident abuse which included verbal abuse, sexual abuse, physical or mental abuse by anyone including staff members or other residents. According to the policy, abuse was the willful infliction of injury, with resulting physical harm, pain or mental anguish. Review of the policy revealed willful, as used in this definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy stated physical abuse included hitting, slapping, pinching, and kicking. Review of Resident #1's medical record the facility admitted the resident on 12/29/2015 with diagnosis which included Schizophrenia and Alzheimer's Disease. Review of Resident #1's Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating he/she was interviewable. The MDS also revealed Resident #1 required extensive assistance of one (1) staff member for transfers and getting dressed in the facility. Review of the facility investigation for Resident #1 dated 11/07/2021 revealed at approximately 8:25 AM, SRNA #1 reported to Licensed Practical Nurse (LPN) #1, as she attempted to put a shirt on Resident #1, the resident grabbed her in the crotch (private area). SRNA #1 also informed the nurse she immediately reacted and smacked him/her on the shoulder and informed the resident do not touch me there ever again. Review of the investigation also indicated SRNA #1 was visibly upset and crying and was immediately escorted out of the facility after the report was made. An interview was unable to be conducted with Resident #1 during the investigation due to an active COVID-19 outbreak in the facility. However, per interview with LPN #1 on 01/07/2022 at 2:45 PM, the resident was interviewed and assessed by staff immediately following the incident on 11/07/2021. Interview with LPN #1, on 01/27/2022 at 2:45 PM, revealed she was working on 11/07/2021 when SRNA #1 reported to her when she attempted dress Resident #1 for the day, the resident grabbed her in the crotch area. The nurse stated SRNA #1 was very upset and crying and informed the nurse, she had smacked the resident's shoulder in response to the resident grabbing her in the private area. The LPN stated she immediately removed the aide from the facility and assessed Resident #1. According to the LPN, Resident #1 had no visible signs of injury immediately following the incident; however, Resident #1 reported to the nurse SRNA #1 had hit him/her on the shoulder because she was trying to get him/her out of bed. Interview with SRNA #1, on 01/27/2021 at 4:15 PM, revealed she was assisting Resident #1 to put on a clean shirt, on 11/07/2021 and the resident unexpectedly grabbed me in the private area. The SRNA stated I slapped him/her on the left shoulder without thinking to get the resident to let go of me. SRNA #1 stated she immediately realized what she had done could be considered abuse. Per the SRNA, she immediately reported the incident to LPN #1 and was removed from the facility. SRNA #1 stated she had been trained on abuse in the facility, and acknowledged she should have paused and thought before immediately reacting after Resident #1 grabbed her inappropriately. The SRNA stated she should not have slapped the resident, but should have summoned help from another staff member to assist in getting the resident to let go of her private area. SRNA #1 stated her employment was terminated from the facility, after the incident occurred on 11/07/2021. The SRNA stated she does not feel like she abused Resident #1, and also stated she had not been named in any other allegations of abuse or mistreatment regarding a resident. Interview with the Administrator, on 01/28/2022 at 2:15 PM, revealed she was the Abuse Coordinator at the facility and was informed of the incident that involved Resident #1 on 11/07/2021. The Administrator stated she was responsible to ensure allegations of abuse were thoroughly investigated and the facility policy and procedures were followed when allegations of abuse occurred in the facility. She stated the facility unsubstantiated abuse regarding the incident with SRNA #1 and Resident #1. According to the Administrator, abuse was unsubstantiated because she felt the nurse aide had no willful intent to harm the resident, and had smacked Resident #1 out of a reaction only to being grabbed in the private area. However, the Administrator stated SRNA #1's employment was terminated due to a code of conduct violation. She also stated residents had the right to be free from abuse and staff were expected to follow the facility policy.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure that pain management was provided for one (1) of two (2) sampled residents. Resident #1 was noted to be in pain on [DATE], the resident had as needed (PRN) [MEDICATION NAME] (pain medication) ordered; however, the resident did not receive the pain medication. The findings include: Review of the facility policy titled, Pain Management Policy and Procedure, not dated, revealed Assess for pain by noting verbal and non-verbal cues. Further review of the policy revealed, Medicate resident as ordered by physician. Record review for Resident #1 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility did not interview the resident for mental status (BIMS). The resident was assessed as being rarely/never understood. Further review of the MDS revealed the resident had both short-term and long-term memory problems and cognitive skills for daily decision-making were severely impaired. Continued review of the MDS revealed the resident was assessed to be totally dependent on staff for all activities of daily living. Furthermore, the MDS revealed the facility had assessed Resident #1 to have no indicators of pain in the five days prior to the MDS on [DATE]. Review of Resident #1's Care plan, dated [DATE], revealed the resident had a problem of Potential for alteration in comfort (pain) with a goal of will have pain controlled. The care plan included an intervention to Administer meds as ordered. Review of Resident #1's Physician orders dated [DATE] revealed the resident had an order for [REDACTED]. Review of Resident #1's nursing note dated [DATE] at 9:10 PM revealed, Called into room by SRNA (State Registered Nurse Aide) at this time. Resident noted to have swelling in left leg and pain when moving leg. Attempted to contact physician no answer this time, left voicemail, awaiting return call. Further review of the nursing notes revealed at 10:20 PM, Attempted to call Medical Doctor again, no answer left voicemail. Awaiting return call. Another note dated [DATE] at 11:30 PM revealed, Attempted to call medical doctor again, medical doctor answered and gave new orders to send to emergency room . There was a nursing note timed 12:00 Midnight revealing EMS (Emergency Medical Services) here to transport resident. Review of a facility Resident Incident Report revealed, Called to room by SRNA. Resident showing signs/symptoms (nonverbal) of pain during movement especially with left lower extremity. Observed swelling and somewhat outward rotation of left leg. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Hospital Medical Record dated [DATE] revealed the resident had an Acute Displaced Oblique Distal Left Femur Fracture. An interview and observation of the resident was not completed as the resident expired on [DATE]. Interview on [DATE] at 3:00 PM with Licensed Practice Nurse (LPN) #1 revealed two (2) SRNAs came to her at about 9:00 PM on [DATE] and told her Resident #1's leg looked different and the resident seemed different. LPN #1 stated she assessed Resident #1 at the time, compared the right leg to the left leg, and noticed there was a difference. The LPN said Resident #1 did moan and groan but that was normal for the resident. LPN #1 said, It has been a long time since the incident; the resident yells out a lot but there must have been a difference because I called the doctor. The LPN stated she could not remember if she gave the resident any pain medication. Attempts to interview the SRNAs who provided care for Resident #1 on [DATE] were unsuccessful as the SRNAs were no longer employed by the facility. Review of a facility investigation revealed, At approximately 9 PM, two (2) SRNAs transferred the resident back to bed and noted swelling of (his/her) left lower extremity, and felt that the resident was more tearful than (his/her) normal behavior. Interview on [DATE] at 4:30 PM with the Administrator revealed Resident #1 was total care, the resident would yell out at times, and there was no indication of change.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure that the care plan for pain management was implemented for one (1) of two (2) sampled residents. Resident #1 was noted to be in pain on [DATE]. The resident had a care plan for pain with an intervention for as needed (PRN) [MEDICATION NAME] (Tylenol) that could be administered; however, the resident did not receive pain medication on [DATE]. The findings include: Review of the facility policy titled, Care Plan Policy & Protocol, not dated, revealed, The care plan shall be periodically reviewed and revised by the interdisciplinary team after each assessment and on an as needed basis. The policy did not address following or implementing the resident's plan of care. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility did not interview the resident for mental status (BIMS) due to the resident being rarely/never understood. The resident was assessed to have both short-term and long-term memory problems and the resident's cognitive skills for daily decision-making were severely impaired. Further review of the MDS revealed the resident was assessed to be totally dependent on staff for all activities of daily living. In addition, the MDS revealed the facility had assessed Resident #1 to have no indicators of pain in the five days prior to the MDS on [DATE]. Review of Resident #1's Care plan, dated [DATE], revealed the resident had a problem of Potential for alteration in comfort (pain) with a goal of will have pain controlled. The care plan included an intervention to Administer meds as ordered. Review of Resident #1's Physician orders dated [DATE] revealed the resident had an order for [REDACTED]. Review of Resident #1's nursing note dated [DATE] at 9:10 PM revealed, Called into room by SRNA (State Registered Nurse Aide) at this time. Resident noted to have swelling in left leg and pain when moving leg. Attempted to contact physician no answer this time, left voicemail, awaiting return call. Further review of the nursing notes revealed at 10:20 PM, Attempted to call Medical Doctor again, no answer left voicemail. Awaiting return call. Another note dated [DATE] at 11:30 PM revealed, Attempted to call medical doctor again, medical doctor answered and gave new orders to send to emergency room . Review of a nursing note at 12:00 AM revealed EMS (Emergency Medical Services) here to transport resident. Review of a facility Resident Incident Report revealed, Called to room by SRNA. Resident showing signs/symptoms (nonverbal) of pain during movement especially with left lower extremity. Observed swelling and somewhat outward rotation of left leg. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Hospital Medical Record dated [DATE] revealed the resident had an Acute Displaced Oblique Distal Left Femur Fracture. An observation or interview with the resident was not completed. The resident expired on [DATE]. Interview on [DATE] at 3:00 PM with Licensed Practice Nurse (LPN) #1 revealed two (2) SRNAs came to her at about 9:00 PM on [DATE] and told her Resident #1's leg looked different and the resident seemed different. LPN #1 stated she assessed Resident #1 at the time, compared the right leg to the left leg, and noticed there was a difference. The LPN said Resident #1 did moan and groan but that was normal for the resident. LPN #1 said, It has been a long time since the incident; the resident yells out a lot but there must have been a difference because I called the doctor. The LPN stated she could not remember if she gave the resident any pain medication. Attempts to interview the SRNAs who provided care for Resident #1 on [DATE] were unsuccessful as the SRNAs were no longer employed by the facility. However, review of a facility investigation revealed, At approximately 9 PM, two (2) State Registered Nursing Assistants (SRNAs) transferred the resident back to bed and noted swelling of (his/her) left lower extremity, and felt that the resident was more tearful than (his/her) normal behavior. Interview on [DATE] at 4:30 PM with the Administrator revealed Resident #1 was total care, the resident would yell out at times, and there was no indication of change.

Based on observation, interview, and record review it was determined the facility failed to accurately assess one (1) of twenty-four (24) residents. Review of Resident #21's Minimum Data Set quarterly assessment revealed the facility had assessed the resident to have a ventilator/respirator. However, observation, interview, and record review revealed the resident has never had a ventilator/respirator. The findings include: Interview with the Director of Nursing (DON) on 04/19/18 at 1:12 PM, revealed the facility utilized the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14, dated (MONTH) (YEAR), as a resource to code MDS assessments. The DON stated the facility did not have a policy related to accuracy of MDS assessments. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14, Section O Special Treatments, Procedures and Programs 100F, revealed this section would be coded if the resident had any type of electrically or pneumatically powered closed system mechanical ventilator support device that ensured adequate ventilation in the resident. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of Resident #21's Comprehensive Care Plan dated 05/26/17 revealed Resident #21 had never had a plan of care addressing the resident receiving treatment with a ventilator/respirator. Observation of Resident #21 on 04/19/18 at 9:29 AM revealed the resident was not receiving treatment with a ventilator or respirator. Interview with Licensed Practical Nurse (LPN) #2 on 04/19/18 at 12:34 PM, revealed Resident #21 had never received treatment with a ventilator or respirator since being admitted to the facility. LPN #2 further revealed the MDS assessment had been coded incorrectly. Interview with the Director of Nursing (DON) on 04/19/18 at 1:12 PM, revealed she does random MDS assessment reviews quarterly while performing chart audits. The DON further revealed she randomly picks the MDS assessments to review. The DON revealed the resident has never been treated with a ventilator/respirator while at the facility.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care in accordance with the Comprehensive Plan of Care for one (1) of twenty-four (24) sampled residents (Resident #18). Resident #18's Comprehensive Care Plan contained an intervention that the resident's self-care needs will be met on a daily basis. However, on 01/08/15 at 9:40 AM and 10:40 AM Resident #18 was observed with long, jagged fingernails. The findings include: Review of the facility's policy titled "MDS/Careplan Guidelines," (not dated) revealed the resident would be assessed and an initial care plan formulated and updated on an as needed basis. Review of the medical record revealed the facility admitted Resident #18 on 10/07/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #18 to be cognitively impaired and not interviewable. The resident was also assessed to require limited assistance with personal hygiene. Review of the Comprehensive Care Plan revealed Resident #18's self-care needs would be met on a daily basis. Review of the Treatment Administration Record (TAR) revealed nail care would be provided weekly and as needed. Resident #18 was observed on 01/08/15 at 9:40 AM and 10:40 AM to have long, jagged fingernails. Interview with Nurse Aide (NA) #1 on 01/08/15 at 10:35 AM revealed she had been assigned to Resident #18 on 01/07/15 and 01/08/15. She further revealed Resident #18 was care planned to need limited assistance with personal hygiene and the resident often refused nail care. According to NA #1, if a resident refuses treatment that is on the care plan it should be reported to a nurse. Continued interview with the NA revealed the resident's refusal of nail care had not been reported to the nurse. Interview with the Clinical Coordinator on 01/08/15 at 12:50 PM revealed the NAs were responsible to provide the treatment that is on the care plan. She further stated if a resident refused treatment that is on the care plan, the NA was responsible for notifying a staff nurse, and the staff nurse was responsible to ensure the care plan interventions were being followed. Interview with the Director of Nursing (DON) on 01/08/15 at 1:45 PM revealed the nurse aides were to follow the Comprehensive Care Plan to ensure residents' needs were being met and should report to a nurse if a resident was refusing care. The DON further stated that a problem with following the care plan had not been identified.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure nail care was provided for one (1) of twenty-four (24) sampled residents. Resident #18 was observed to have long, jagged fingernails on 01/08/15 at 9:40 AM and 10:40 AM. The findings include: Review of the "Protocol for Nail Care" (not dated) revealed nail care would be provided weekly and as needed per nurse aide staff and documented on the nurse aide flow sheet. Review of the medical record revealed the facility admitted Resident #18 on 10/07/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #18 to be cognitively impaired and not interviewable. The resident was also assessed to require limited assistance with personal hygiene. Review of the Resident Kardex revealed the resident was to receive personal hygiene with one assist. Review of the Treatment Administration Record (TAR) revealed nail care would be provided weekly and as needed. Resident #18 was observed on 01/08/15 at 9:40 AM and 10:40 AM to have long, jagged fingernails. Interview with Nurse Aide (NA) #1 on 01/08/15 at 10:35 AM revealed she had been assigned to Resident #18 on 01/07/15 and 01/08/15. The NA stated she was responsible to provide nail care for Resident #18 and that the resident was to receive nail care weekly and as needed. She further revealed Resident #18 often refuses nail care; however, she stated she failed to report Resident #18's refusal for nail care to the staff nurse. Interview with the Clinical Coordinator on 01/08/15 at 12:50 PM revealed the NAs were responsible to provide nail care to the residents. She further stated if a resident refuses nail care the NA was responsible for notifying a staff nurse. The Clinical Coordinator stated she made rounds on the floor daily and had not identified any problems with nail care. Interview with the Director of Nursing (DON) on 01/08/15 at 1:45 PM revealed the nurse aides were to ensure resident fingernails were clean and cut on a weekly basis, and should be reported to a nurse if a resident was refusing care. The DON further stated a problem with nail care had not been identified.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective infection control program to prevent the spread of infection for one (1) of twenty-four (24) sampled residents. On 01/06/15, A Nurse Aide (NA) was observed to provide direct care for Resident #10, and proceeded to set up the resident's meal tray without first washing her hands. In addition, the NA handled the resident's food with bare hands without first applying gloves. The findings include: Review of facility policy, "Feeding a Person," (not dated) revealed staff would practice hand hygiene during services provided for a resident. Review of facility policy, "Standard Precautions," (not dated) revealed staff would wash hands after touching contaminated items, whether or not gloves are worn. Review of the medical record revealed the facility admitted Resident #10 on 04/26/10 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/14, revealed the resident required total assistance for feeding. Review of the Nurse Aide (NA) care plan for Resident #10 revealed Resident #10 was a "feeder" who required total assistance with meals. Observation on 01/06/15 at 4:50 PM revealed NA #2 while wearing gloves assisted Resident #10 with positioning in the bed. The NA removed her gloves and set up Resident #10's supper tray without first washing her hands. Further observation revealed NA #2 handled Resident #10's food (sandwich) with her bare hands. Interview with NA #2 on 01/07/15 at 1:45 PM revealed staff should wear gloves if handling residents' food per facility policy. She further stated she was very nervous during the evening meal the day before because she was being observed by a surveyor. Interview with the Charge Nurse on 01/07/15 at 2:50 PM revealed staff should wear gloves when handling residents' food. She further stated she did rounds, at times, during mealtime to ensure staff was washing hands/using gloves and had not identified any problems. Interview with the Director of Nursing (DON) on 01/07/15 at 3:10 PM revealed the staff was trained to wear gloves when handling residents' food and no problems had been identified with NAs feeding residents. She further stated she did rounds to check that staff was wearing gloves when they needed to and she believed NA #2 was nervous and just forgot to wash her hands and apply gloves.

Based on observation, interview, and record review, it was determined the facility failed to ensure substitutes were offered to residents that refused foods served and/or that had identified food dislikes for two of twenty-four sampled residents (Resident #7 and Resident #10), and two of two unsampled residents (Residents A and B). Observation of meal tray cards during the noon meal service on 12/03/13, revealed Resident #7 disliked stewed tomatoes, however, facility staff served Resident #7 stewed tomatoes during the noon meal service; Resident #10 disliked apple juice, but facility staff served the resident apple juice during the meal service; Resident A disliked green beans, but staff served Resident A green beans; and Resident B disliked chicken and was served chicken and dumplings on his/her meal tray. The findings include: Interview conducted with the Administrator on 12/04/13, at 9:05 AM, revealed the facility did not have a policy related to resident food preferences. 1. Observation of Resident #10's noon meal tray on 12/03/13, at 11:35 AM, revealed staff served the resident apple juice on his/her meal tray. Review of the tray card for Resident #10 revealed the resident disliked apple juice. An interview was attempted with Resident #10 on 12/03/13, at 11:35 AM, and the resident did not respond. Interview with State Registered Nurse Aide (SRNA) #3 on 12/03/13, at 11:50 AM, revealed she was required to check the meal tray cards prior to serving the resident's meal tray. The SRNA stated she was required to check food dislikes and return any food listed as a food the resident disliked to the kitchen for replacement and she had "missed" that Resident #10 had a dislike for apple juice. 2. Observation of the noon meal service on 12/03/13, at 11:40 AM, revealed staff served Resident #7 stewed tomatoes on his/her meal tray. Review of the tray card for Resident #7 revealed the resident disliked stewed tomatoes. An interview was attempted with Resident #7 on 12/03/13, at 11:40 AM, and the resident did not respond. Interview conducted with SRNA #2 on 12/04/13, at 1:20 PM, revealed she was required to check the resident's tray card prior to serving the meal, and if a food dislike was identified on the tray card she was required to take the food item back to the kitchen for replacement. The SRNA revealed she had not identified the stewed tomatoes on Resident #7's meal tray as a food the resident disliked. The SRNA stated she had been trained by the facility to check food dislikes and return any food listed as a food the resident disliked to the kitchen for replacement and she had "missed" that Resident #2 had a dislike for stewed tomatoes. 3. Observation of the noon meal in the 200 Unit Dining Room on 12/03/13, at 12:15 PM, revealed staff served Resident A green beans on his/her meal tray. Review of the tray card for Resident A revealed he/she disliked green beans. An interview with Resident A on 12/03/13, at 12:15 PM, revealed, "I do not like green beans and I have not been asked if I wanted a substitute for the green beans." Interview conducted with SRNA #4 on 12/05/13, at 1:30 PM, revealed she had delivered food trays in the 200 Unit dining room on 12/03/13, for the noon meal. SRNA #4 stated she did not recall if she had delivered the meal tray to Resident A. However, the SRNA stated if a dislike was on a resident's meal tray, she was required to return the food item to the kitchen for a replacement. 4. Observation of the noon meal service on the 200 Unit revealed SRNA #6 fed Resident A chicken and dumplings on 12/03/13, at 12:45 PM. Review of the tray card for Resident A revealed the resident disliked chicken. An interview was attempted with Resident A on 12/03/13, at 12:55 PM, and the resident did not respond. Interview conducted with SRNA #6 on 12/03/13, at 12:45 PM, revealed she was required to check all residents' tray cards prior to feeding the resident. The SRNA stated she did not know why she had not identified the resident's dislike for chicken and stated she should have returned the food to the kitchen for a replacement. Interview conducted with Cook #1 on 12/03/13, at 12:50 PM, revealed she had prepared the food trays for the noon meal on 12/03/13. The Cook stated she had been "nervous" and had overlooked the resident's food dislikes, and that the facility had food substitutes available. Interview conducted with the Registered Dietitian (RD) on 12/04/13, at 4:45 PM, revealed she monitored meal service two times per week at the facility. The RD stated she also talked to three residents every week regarding their meal service. The RD stated meal trays were monitored as part of the facility's Quality Assurance process and she had occasionally observed a meal tray that had been prepared to be served that contained an identified food dislike; however, the RD stated she had not identified this to be a pattern at the facility. The RD stated staff was required to obtain a replacement food item for the resident if the resident received an item on the food tray he/she disliked and that the facility had food substitutes available.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure foods were served at the proper temperature for residents on the Sunny Brook Hall for the evening meal on 12/03/13. A test tray conducted of a regular diet tray, on 12/03/13, revealed the pudding and milk temperatures were not in accordance with the facility's policy. The findings include: A review of the facility policy titled Meal Pass, not dated, revealed residents meals would be delivered and served timely. Further review of the policy revealed residents were to receive food at the appropriate temperatures; cold food was to be 41 degrees or below. Observations of the evening meal on 12/03/13 revealed an enclosed meal cart arrived on the Sunny Brook Hall at 5:35 PM. The last tray was intercepted at 6:25 PM (50 minutes later), and milk and pudding temperatures were obtained with facility staff. The temperature of the milk was 70 degrees. The pudding, which contained milk, was 55 degrees. Interview conducted with State Registered Nurse Aide (SRNA) #1 on 12/04/13 at 4:00 PM confirmed she had passed trays on the Sunny Brook Hall during the evening meal on 12/03/13. The CNA stated trays should be delivered to facility residents within 15 minutes of arrival to the floor. The CNA acknowledged the trays were on the floor "too long" yet was unsure exactly how long the trays remained in the enclosed cart prior to being passed to facility residents. Interview conducted with the Registered Dietitian (RD) on 12/04/13 at 4:15 PM revealed milk and foods containing milk should be delivered to facility residents at a temperature of 40 degrees or below. Interview with the Director of Nursing (DON) on 12/05/13 at 4:00 PM revealed trays should be delivered to facility residents within 15 or 20 minutes after meal carts arrived to the floor. The DON further stated milk and foods which contained milk should be safely served at 40 to 50 degrees.

Based on observation, interview, review of Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policies/procedures, it was determined the facility failed to ensure medication for resident use had not expired. Review of the CDC guidelines revealed if a multi-dose vial of medication had been opened or accessed, the vial should be dated and discarded within 28 days from the date the vial had been opened (unless the manufacturer specifies a different date). However, a multi-dose vial of pneumococcal vaccine dated as opened [DATE], was in the medication refrigerator available for use on [DATE]. The findings include: Review of the facility policy/procedure, "Medication Storage in the Facility," dated as effective [DATE], revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures were immediately removed from stock and disposed of according to procedures for medication disposal. Further review of the policy/procedure revealed medication storage conditions were to be monitored on a monthly basis. Review of the CDC guidelines for storage and handling of multi-dose vials of medications revealed if a multi-dose vial had been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Observation of the medication refrigerator on the Derby Lane Hall on [DATE], at 2:50 PM, revealed a multi-dose vial of Pneumovax pneumococcal vaccine with an opened date of [DATE], available for resident use. Interview on [DATE], at 2:50 PM, with Licensed Practical Nurse (LPN) #1 revealed all multi-dose vials should be dated when opened and discarded after 30 days. According to LPN #1, facility staff members "try" to monitor the medication refrigerators on a monthly basis to ensure outdated medications were discarded.

Based on observation, record review, interview, and a review of facility policies, the facility failed to ensure the drug regimen for one of twenty-four sampled residents included adequate monitoring and was free from unnecessary drugs. Resident #1 received an anti-[MEDICAL CONDITION] medication without adequate indication for the use of the medication. The findings include: A review of the Protocol for Review & Reduction of Psychoactive Medications and the Pharmacy Drug Regimen Review Policies, no dates given, revealed the Consultant Pharmacist would review the medication regimen for each resident on a monthly and as needed basis and the Interdisciplinary Team, including the resident's physician, would make every effort to ensure residents were receiving appropriate medications according to their individualized needs. A review of the "Nursing Drug Handbook 2011" reference manual revealed [MEDICATION NAME] Acid was used for [MEDICAL CONDITION] and mania, and the prevention of migraine headaches. The manual further indicated that levels of the drug should be monitored and that therapeutic levels were between 50 and 100 micrograms (mcg) per milliliter (ml). A review of the medical record for Resident #1 revealed the facility admitted the resident on 05/09/04, with [DIAGNOSES REDACTED]. A review of the medication regimen for Resident #1 revealed the resident received 125 milligrams of [MEDICATION NAME] Acid (anti-convulsant) daily at 5:00 PM, for Anxiety/[MEDICAL CONDITION]'s Disease. A review of the lab results revealed the resident's [MEDICATION NAME] Acid level on 05/22/12, was 16 mcg/ml (subtherapeutic) and on 11/07/12, the [MEDICATION NAME] Acid level was 11 mcg/ml (subtherapeutic). Observations of Resident #1 on 11/26/12, at 6:45 PM and 7:00 PM, revealed the resident was in bed with eyes open, but did not respond to staff or the surveyor. Observations on 11/27/12, at 9:15 AM, 10:30 AM, 12:30 PM, 2:50 PM, and 4:00 PM, revealed staff turned and repositioned the resident at two-hour intervals. Observations revealed the resident would sometimes have his/her eyes open but was not responsive to staff in the room. Incontinence care was observed at 11:00 AM, and treatment to the resident's left heel was observed at 1:30 PM on 11/28/12. Although staff talked to the resident, the resident was not responsive to staff's conversation or treatment. An interview with State Registered Nurse Aide (SRNA) #2 at 2:00 PM on 11/28/12, revealed the SRNA had been employed at the facility for over two years and had not ever observed the resident having any [MEDICAL CONDITION] activity. The SRNA stated the resident at one time had non-purposeful movements of hands. An interview with Licensed Practical Nurse (LPN) #4 on 11/28/12, at 2:00 PM, revealed she had been employed at the facility for several years and was not aware of Resident #1 ever having any [MEDICAL CONDITION] activity. An interview with the Clinical Coordinator at 2:10 PM on 11/28/12, revealed she had not ever seen Resident #1 have [MEDICAL CONDITION]. The Clinic Coordinator further stated she was aware the drug levels for the [MEDICATION NAME] Acid were subtherapeutic, and that the physician was aware as well. An interview with Resident #1's physician on 11/28/12 at 3:45 PM, revealed the physician had accepted Resident #1 as a patient five years ago and that the patient had a history of [REDACTED]. The physician further stated he was aware the drug levels for Resident #1 were subtherapeutic, but since the resident had not had any [MEDICAL CONDITION] he did not want to change the dosage. The physician also stated that he had not lowered the dosage or discontinued the [MEDICATION NAME] Acid for fear the resident might have a [MEDICAL CONDITION].

Based on observation, interview, and record review, it was determined the facility failed to accommodate residents' preferences related to food. Residents #8 and #17, and the group interview revealed the residents were not provided with mayonnaise for the chicken sandwiches at the noon meal on 11/27/12. The findings include: Review of the menu spreadsheet for the noon meal on 11/27/12, revealed mayonnaise was not listed to be given to any of the residents unless the residents were on a calorie-restricted diet. The mayonnaise was listed on the menu spreadsheet for additional calories for residents on a calorie-restricted diet. Observation of the lunch meal in the dining room at 11:40 AM on 11/27/12, revealed staff went to the kitchen and asked for mayonnaise for Resident #8's chicken sandwich. Interview with Resident #8 at 11:45 AM on 11/27/12, revealed the resident had not received mayonnaise on the resident's lunch tray. The resident stated staff went to the kitchen and requested mayonnaise for the chicken sandwich after the resident asked staff for mayonnaise. Observation of Resident #17's lunch tray at 11:30 AM on 11/27/12, revealed the resident had a chicken sandwich with lettuce, tomato, and onion. However, there was no mayonnaise on the tray for the sandwich. Interview with Resident #17 at 11:30 AM on 11/27/12, revealed the resident had mayonnaise packets "stashed" in the resident's clothes chest. The resident stated he/she keeps all the extra condiments from meal trays in order to have condiments available when they were not sent on the tray. The resident further stated he/she could not have eaten the chicken sandwich without the mayonnaise because the sandwich was dry. However, Resident #7 stated he/she would have asked for the mayonnaise if he/she had not had some mayonnaise in the chest. A group interview with nine residents on 11/27/12, at 3:30 PM, revealed residents often received meal trays without condiments. The residents stated the chicken sandwich served on 11/27/12, at the noon meal was dry and needed mayonnaise; however, there was no mayonnaise on the residents' trays. The residents stated they could have asked for mayonnaise, and staff would have gone to the kitchen and requested mayonnaise for them. An interview was conducted with the Registered Dietitian (RD) at 10:15 AM on 11/29/12. The RD stated mayonnaise should have been on the tray for all the residents. However, the RD stated it was an oversight that the mayonnaise was not listed on the menu spreadsheet.