Every finding on record at Willowbrooke Court SC Ctr at Matthews Glen

Based on observations and staff interviews, the facility failed to post in an area that was visible and accessible to residents, families, and visitors a list of names, addresses (email and mailing) and telephone numbers of required state agencies and advocacy groups including the State Survey Agency, Complaint Intake, State Long Term Care Ombudsman, Resident Advocacy Network, and Adult Protective Services. These observations occurred on 4 of the 4 days of the onsite recertification and complaint survey conducted on 08/10/2026 through 08/13/2026. The findings included:On 08/10/2026 at 3:08 PM, 08/11/2026 at 10:41 AM, 08/12/2026 at 11:19 AM, 08/13/2026 at 9:08 AM an observation of the front lobby area and Red Oak Way skilled unit revealed no visible postings of names or contact information for the following: the State Survey Agency, Complaint Intake, State Long Term Care Ombudsman, Resident Advocacy Network, and Adult Protective Services.A walking tour of the facility and interview on 08/13/2026 at 9:08 AM with the Administrator and the Director of Nursing revealed on initial glance of the postings affixed to the bulletin board, located across from the dining area of Red Oak Way skilled unit, no observation of required postings. The Administrator removed a posting related to mask usage and the required posting signage was behind the mask signage. The Administrator stated that the bulletin board was updated last week (week of 08/03/2026). She was uncertain when and why the mask signage was placed over the required posting signage. The Administrator stated that the required posting information was an important resource for residents, families and visitors.

Based on observations and staff interviews, the facility failed to discard expired food and milk available for use in 1 of 2 walk-in refrigerators (produce refrigerator) in the main kitchen and 1 of 2 nourishment refrigerators. This practice had the potential to affect the food served to residents. The findings included: 1. During the initial tour of the main kitchen on 7/7/25 from 10:20 AM to 10:45 AM with the Lead Chef, an observation of the walk-in produce refrigerator revealed a box of red and green bell peppers. There were four red bell peppers and three green bell peppers inside the box. Three of the four red bell peppers were covered with gray and white fuzz. There was no date on the box. The Lead Chef went through the box and discarded three of the red bell peppers that had fuzz. An interview with the Lead Chef on 7/7/25 at 10:45 AM revealed the shelf life of the bell peppers varied and depended on when they received it from their supplier. He stated that he couldn't say for sure how long they lasted because he wasn't the one who received the bell peppers, but they must have been in the produce refrigerator for at least a week. The Lead Chef stated that he saw one red bell pepper that had fuzz this morning, and he had to cut around the bell pepper to serve for the breakfast meal. He said he didn't see the other red bell peppers with fuzz, but they should have been discarded. An interview with the Dietary Manager on 7/8/25 at 1:18 PM revealed the bell peppers should have been inspected for fuzz whenever they received them from the suppliers, and daily by the chef before starting service. An interview with the Administrator on 7/8/25 at 4:15 PM revealed she was not sure how the expired bell peppers were left in the produce refrigerator, but that she would have expected them to be discarded. 2. An observation of one of the nourishment refrigerators with the Lead Chef on 7/7/25 at 11:15 AM revealed a gallon of regular milk with a best if used by date of 7/3/25. The gallon had about ¾ of milk left in the bottle. The Lead Chef removed the expired gallon of milk and brought it to the attention of Dietary Aide #1. An interview with the Lead Chef on 7/7/25 at 11:15 AM revealed both nursing and the dietary aides were responsible for checking the nourishment refrigerators for expired food and drink items. The Lead Chef stated the nurse aides more frequently used the nourishment refrigerators if residents needed snacks or drinks. During an interview with Dietary Aide #1 on 7/7/25 at 11:18 AM, she stated that she had looked in the nourishment refrigerator, but she didn't really check the expiration dates on the food and drink items inside. She further stated that she had just came in at 10:00 AM, and that the nourishment refrigerator was supposed to be checked by Dietary Aide #2 who came in at 7:00 AM. An interview with Dietary Aide #2 on 7/7/25 at 11:20 AM revealed she cleaned the nourishment station every morning before breakfast service, and she tried to check the food and drink items in the nourishment refrigerators as well. She stated that she didn't notice the expired gallon of milk inside the nourishment refrigerator, but she didn't think it got served to the residents this morning because they normally got the individual packs of milk. An interview with Nurse Aide #1 on 7/7/25 at 12:03 PM revealed the dietary aides normally gave them a heads up if any of the food and drink items in the nourishment refrigerators were expiring. She stated that she didn't look at the expiration date on the jug of milk before she poured some on a bowl of cereal and served it to one of the residents this morning. An interview with the Dietary Manager on 7/8/25 at 1:18 PM revealed both the dietary aides and nursing were supposed to check the nourishment refrigerators for expired food and drink items. An interview with the Administrator on 7/8/25 at 4:15 PM revealed she was not sure how the expired milk was left in the nourishment refrigerator, but it should have been discarded.

Based on observations, record reviews and interviews with the resident, staff and Medical Doctor (MD), the facility failed to ensure treatment for a non-pressure related area of skin impairment was completed daily per the standing order for 1 of 1 sampled resident (Resident #5) reviewed for skin conditions. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and Parkinsonism (brain condition that cause slowed movements, stiffness and tremors). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. He had impairment on one side of the upper and lower extremities, no skin issues and had a pressure-reducing device for the bed. Resident #5 required partial/moderate assistance with standing and bed/chair transfers and supervision or touching assistance with toilet transfers. A review of Resident #5's care plan dated 06/02/25 revealed Resident #5 had potential/actual impairment to skin integrity related to fragile skin. Interventions included to use caution when transferring or moving Resident #5 to prevent striking his arms, legs and hands against any sharp or hard surface. A staff progress note written by Nurse #1 dated 07/01/25 at 9:47 PM revealed Resident #5's family member stated that while assisting Resident #5 to the toilet, he accidentally sustained an abrasion to the right shin (front of the leg below the knee). Nurse #1 assessed Resident #5's shin and noted the area was bleeding from a small skin tear. Nurse #1 noted the area was cleaned with normal saline (sterile solution of salt and water) and dressed with a triple antibiotic ointment and gauze bandage. Review of the facility's Standing Orders for Treatment revealed in part, staff may use the following standing orders for the onset of specified symptoms or condition and the nurse will document the assessment of the symptoms and effectiveness of the measures instituted. The standing orders for treatment of skin tears noted: cleanse with normal saline and 4 x 4 gauze, pat dry with 4 x 4 gauze, approximate with thin adhesive bandages (if applicable) and cover with an adhesive border island dressing (specify size). Apply sterile gauze or self-adherent wrap that secures dressing (as needed). Change daily until healed. May use a triple antibiotic ointment, observe for redness and drainage. Review of Resident #5's Treatment Administration Record (TAR) for the period 07/01/25 through 07/08/25 revealed no treatment order for daily dressing changes to Resident #5's right shin. During an observation and interview on 07/07/25 at 11:14 AM, Resident #5 was sitting in his wheelchair in his room watching TV. On the upper right shin was a 4 x 4 bordered gauze bandage with Nurse #2's name and the date of 07/05/25 written in red ink. Resident #5 stated he was not sure exactly how the injury happened but it wasn't painful and staff had been very good to provide treatment and change the bandage. During an observation on 07/08/25 at 9:57 AM, Resident #5 was in his room sleeping soundly while seated in his wheelchair. On the upper right shin was a 4 x 4 bordered gauze bandage with Nurse #2's name and the date of 07/05/25 written in red ink. During interviews on 07/08/25 at 9:13 AM and 10:10 AM, Nurse #3 revealed she had noticed the bandage on Resident #5's shin but when she reviewed his TAR, there were no orders for treatment. She confirmed the bandage on Resident #5's shin was dated 07/05/25. Nurse #3 explained that when initiating standing orders, the nurse was supposed to enter the treatment orders on the resident's TAR to be completed daily until healed and the orders were usually entered to be completed on the evening shift (3:00 PM to 11:00 PM). During a phone interview on 07/08/25 at 10:48 AM, Nurse #1 revealed on 07/01/25 she was informed by the Nurse Aide that Resident #5's family member had reported the wheelchair had scraped Resident #5's shin when the family member had assisted Resident #5 to the bathroom. Nurse #1 stated upon assessment, the area had some bleeding but was not an open wound so she initiated the standing orders for skin tears. Nurse #1 stated once the standing orders where initiated, the nurse was responsible for entering the order on the resident's TAR so that treatments would be completed daily until the area was healed. Nurse #1 stated she thought she had entered the treatment order on Resident #5's TAR and it was an oversight. An unsuccessful telephone attempt was made for an interview with Nurse #2 on 07/08/25 at 10:43 AM. During an interview on 07/08/25 at 11:38 AM with the Director of Nursing present, the Registered Nurse (RN) Supervisor explained once standing orders were initiated for Resident #5, the nurse should have entered the treatment orders on the TAR so that nurses would know to check/change the dressing daily until healed. During an interview on 07/08/25 at 2:07 PM, the Administrator stated she would expect for nurses to follow the standing orders for treatment and enter the orders on the resident's TAR when initiated so that nurses could document that the treatment was being done. During a phone interview on 07/08/25 at 3:54 PM, the Medical Doctor (MD) stated he was not sure of the facility's protocol but would have expected for staff to follow the standing order.

Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 32 of 72 days reviewed (01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/07/25, 01/08/25, 01/10/25, 01/12/25, 01/18/25, 01/21/25, 01/26/25, 02/07/25, 02/09/25, 02/15/25, 02/20/25, 02/21/25, 02/24/25, 02/25/25, 02/27/25, 02/28/25, 03/01/25, 03/03/25, 03/05/25, 03/06/25, 03/07/25, 03/09/25, 03/14/25, 03/15/25, 03/21/25, 03/24/25, and 03/29/25). Findings included: Review of the facility's daily nurse staffing sheet revealed spaces to indicate the name of the unit, resident census each shift, and the number of staff and hours worked for Registered Nurse (RN), Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) for each 8-hour shift: day shift (7:00 AM to 3:00 PM), evening shift (3:00 PM to 11:00 PM) and night shift (11:00 PM to 7:00 AM). The facility's 24-hour day started on the night shift. a. The nursing staff time clock report revealed a LPN clocked in at 3:22 PM on 12/31/25 and clocked out on 8:03 AM on 01/01/25. The daily nurse staffing sheets dated 01/01/25 and 01/02/25 revealed there was no LPN on the night shifts. b. The nursing staff time clock report revealed a LPN clocked in at 3:05 PM on 01/02/25 and clocked out on 8:04 AM on 01/03/25. The daily nurse staffing sheets dated 01/02/25 and 01/03/25 revealed there was no LPN on the night shifts. c. The nursing staff time clock report revealed a LPN clocked in at 3:00 PM on 01/03/25 and clocked out at 7:35 AM on 01/04/25. The daily nurse staffing sheets dated 01/03/25 and 01/04/25 revealed there was no LPN on the night shifts. d. The nursing staff time clock reports revealed one RN clocked in at 3:15 PM on 01/04/25 and clocked out at 12:01 AM on 01/05/25 and one RN clocked in at 3:54 PM on 01/04/25 and clocked out at 7:44 AM on 01/05/25. The daily nurse staffing sheet dated 01/04/25 revealed there was only one RN on the evening shift. e. The nursing staff time clock reports revealed one LPN clocked in at 2:06 PM on 01/07/25 and clocked out at 8:06 AM on 01/08/25. The daily nursing staffing sheets dated 01/07/25 and 01/08/25 revealed there was no LPN on the night shifts. f. The nursing staff time clock reports revealed one CNA clocked in at 2:53 PM and clocked out at 11:15 PM on 01/10/25 and one CNA clocked in at 2:53 PM on 01/10/25 and clocked out at 7:37 AM on 01/11/25. The daily nursing staffing sheet dated 01/10/25 revealed there was only one CNA on the evening shift. g. The nursing staff time clock reports revealed one RN clocked in at 6:40 AM and clocked out at 11:45 PM on 01/12/25 and one RN clocked in at 7:06 PM on 01/12/25 and clocked out at 7:26 AM on 01/13/25. The daily nursing staffing sheet for 01/12/25 revealed there was only one RN on the evening shift. h. The nursing staff time clock reports revealed on 01/18/25 one CNA clocked in at 7:31 AM and clocked out at 3:13 PM and one CNA clocked in at 7:11 AM and clocked out at 1:12 PM. The daily nursing staffing sheet for 01/18/25 revealed there was only one CNA on the day shift. i. The nursing staff time clock reports revealed one RN clocked in at 2:40 PM on 01/18/25 and clocked out at 12:21 AM on 01/19/25 and one RN clocked in at 2:52 PM on 01/18/25 and clocked out at 8:46 AM on 01/19/25. The daily nursing staffing sheet for 01/18/25 revealed there was only one RN on the evening shift. j. The nursing staff time clock reports revealed one RN clocked in at 8:33 AM and clocked out at 11:44 PM on 01/21/25 and one RN clocked in at 2:57 PM on 01/21/25 and clocked out at 7:29 AM on 01/22/25. The daily nursing staffing sheet for 01/21/25 revealed there was only one RN on the evening shift. k. The nursing staff time clock reports revealed one CNA clocked in at 6:53 AM and clocked out at 11:03 PM on 01/26/25 and one CNA clocked in at 2:54 PM on 01/26/25 and clocked out at 7:27 AM on 01/27/25. The daily nursing staffing sheet for 01/26/25 revealed there was only one CNA on the evening shift. l. The nursing staff time clock report revealed on 02/07/25 a LPN clocked in at 7:09 AM and clocked out at 3:23 PM. The daily nursing staffing sheet for 02/07/25 revealed there was one RN and no LPN on the day shift. m. The nursing staff time clock reports revealed one CNA clocked in at 6:52 AM and clocked out at 3:25 PM on 02/09/25 and one CNA clocked in at 2:56 PM on 02/09/25 and clocked out at 7:22 AM on 02/10/25. The daily nursing staffing sheet for 02/09/25 revealed there were 1.5 CNAs on the day shift and 1.5 CNAs on the evening shift. n. The nursing staff time clock reports revealed one RN clocked in at 3:01 PM and clocked out at 11:01 PM on 02/15/25 and one RN clocked in at 3:07 PM on 02/15/25 and clocked out at 7:45 AM on 02/16/25. The daily nursing staffing sheet for 02/15/25 revealed there was only on RN on the evening shift. o. The nursing staff time clock reports revealed on 02/20/25 one CNA clocked in at 7:30 AM and clocked out at 3:10 PM and one CNA clocked in at 7:03 AM and clocked out at 3:03 PM. The daily nursing staffing sheet for 02/20/25 revealed there were 1.5 CNAs on the day shift. p. The nursing staff time clock reports revealed one CNA clocked in at 3:16 PM and clocked out at 11:35 PM on 02/21/25 and one CNA clocked in at 2:56 PM on 02/21/25 and clocked out at 7:06 AM on 02/22/25. The daily nursing staffing sheet for 02/21/25 revealed there was only one CNA on the evening shift. q. The nursing staff time clock reports revealed one CNA clocked in at 2:51 PM and clocked out at 11:50 PM on 02/24/25 and one CNA clocked in at 2:55 PM on 02/24/25 and clocked out at 7:10 AM on 02/25/25. The daily nursing staffing sheet for 02/24/25 revealed there was only one CNA on the evening shift. r. The nursing staff time clock reports revealed on 02/25/25 one CNA clocked in at 7:24 AM and clocked out at 3:08 PM and one CNA clocked in at 6:47 AM and clocked out at 3:12 PM. The daily nursing staffing sheet for 02/25/25 revealed there was only one CNA on the day shift. s. The nursing staff time clock reports revealed on 02/27/25 one RN clocked in at 7:00 AM and clocked out at 11:31 PM and one RN clocked in at 2:54 PM and clocked out at 11:38 PM. The daily nursing staffing sheet for 02/27/25 revealed there was only one RN on the evening shift. t. The nursing staff time clock reports revealed one CNA clocked in at 6:55 AM and clocked out at 3:21 PM on 02/28/25, one CNA clocked in at 7:16 AM and clocked out at 3:30 PM on 02/28/25, one CNA clocked in at 3:56 PM and clocked out at 8:09 PM on 02/28/25, and one CNA clocked in at 2:56 PM on 02/28/25 and clocked out at 7:22 AM on 03/01/25. The daily nursing staffing sheet for 02/28/25 revealed there were 1.5 CNAs on the day shift and 1.5 CNAs on the evening shift. u. The nursing staff time clock reports revealed on 03/01/25 one CNA clocked in at 7:07 AM and clocked out at 3:24 PM, one CNA clocked in at 7:20 AM and clocked out at 3:18 PM, and one CNA clocked in at 7:00 AM and clocked out at 8:08 PM. The nursing staff time clock reports also revealed one RN clocked in at 3:08 PM on 03/01/25 and clocked out at 12:01 AM on 03/02/25 and one RN clocked in at 3:00 PM on 03/01/25 and clocked out at 7:30 AM on 03/02/25. The daily nursing staffing sheet for 03/01/25 revealed there were only 1.5 CNAs on the day shift and one RN on the evening shift. v. The nursing staff time clock reports revealed on 03/03/25 one CNA clocked in at 6:53 AM and clocked out at 3:11 PM and one CNA clocked in at 7:25 AM and clocked out at 3:11 PM. The daily nursing staffing sheet for 03/03/25 revealed there were only 1.5 CNAs on the day shift. w. The nursing staff time clock reports revealed on 03/05/25 one CNA clocked in at 6:53 AM and clocked out at 8:00 PM and one CNA clocked in at 7:00 AM and clocked out at 3:15 PM. The daily nursing staffing sheet for 03/05/25 revealed there were only 1.5 CNAs on the day shift. x. The nursing staff time clock reports revealed one CNA clocked in at 3:33 PM and clocked out at 11:40 PM on 03/06/25, one CNA clocked in at 4:17 PM and clocked out at 11:02 PM on 03/06/25, and one CNA clocked in at 3:02 PM on 03/06/25 and clocked out at 7:01 AM on 03/07/25. The daily nursing staffing sheet for 03/06/25 there was only one CNA on the evening shift. y. The nursing staff time clock reports revealed one CNA clocked in at 3:17 PM and clocked out at 11:38 PM on 03/07/25 and one CNA clocked in at 2:56 PM on 03/07/25 and clocked out at 7:10 AM on 03/08/25. The daily nursing staffing sheet for 03/07/25 revealed there was only one CNA on the evening shift. z. The nursing staff time clock reports revealed one CNA clocked in at 6:52 AM and clocked out at 10:28 PM on 03/09/25 and one CNA clocked in at 2:56 PM on 03/09/25 and clocked out at 7:15 AM on 03/10/25. The daily staffing sheet for 03/09/25 revealed there was only one CNA on the evening shift. aa. The nursing staff time clock reports revealed one LPN clocked in at 3:14 PM on 03/14/25 and clocked out at 7:58 AM on 03/15/25 and one RN clocked in at 10:51 PM on 03/14/25 and clocked out at 7:21 AM on 03/15/25. The daily nursing staffing sheets for 03/14/25 and 03/15/25 revealed there was only one RN and no LPN on the night shifts. bb. The nursing staff time clock reports revealed one CNA clocked in at 3:08 PM and clocked out at 11:13 PM on 03/21/25 and one CNA clocked in at 2:55 PM on 03/21/25 and clocked out at 7:13 AM on 03/22/25. The daily nursing staffing sheet for 03/21/25 revealed there was only one CNA on the evening shift. cc. The nursing staff time clock reports revealed one CNA clocked in at 2:58 PM and clocked out at 11:13 PM on 03/24/25 and one CNA clocked in at 2:54 PM on 03/24/25 and clocked out at 7:13 AM on 03/25/25. The daily nursing staffing sheet for 03/24/25 revealed there was only one CNA on the evening shift. dd. The nursing staff time clock reports revealed one CNA clocked in at 2:57 PM and clocked out at 11:10 PM on 03/29/25 and one CNA clocked in at 3:02 PM on 03/29/25 and clocked out at 7:11 AM on 03/30/25. The daily nursing staffing sheet for 03/29/25 revealed there was only one CNA on the evening shift. During an interview on 07/08/25 at 2:49 PM, the Health Services Coordinator revealed the daily nursing staffing sheets were filled out and posted by the evening shift nurse. The Health Services Coordinator explained around the first part of the year (2025) the former receptionist was updating the daily nursing staffing sheets as needed but currently she (Health Services Coordinator) was the person responsible for updating the nurse staffing sheets when they were collected daily. During an interview on 07/08/25 at 3:32 PM, the Administrator revealed the Administrative Assistant who works along side the Health Services Coordinator will be the person responsible for updating the daily nursing staffing sheets but she was currently learning the process. The Administrator stated the daily nursing staffing sheets should be updated as needed to reflect the actual nursing staff that worked each shift.

Based on observations, record review, staff, Nurse Practitioner (NP), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 25 opportunities which resulted in an 12% medication error rate. This affected 1 of 3 residents observed for medication administration (Resident #57). Findings included: 1a. A Physician's order dated 5/21/24 read Ceftriaxone sodium (antibiotic) intravenous solution reconstituted 2 grams (gm), use 2 gm intravenously (IV) in the morning for sepsis until 6/27/24. A Physician's order dated 5/21/24 read Heparin (blood thinner) lock flush solution 10 units/ milliliter (ml), use 5 ml intravenously in the morning for after medication administration until 6/28/24, use SASH: saline flush, administer medication, saline flush, heparin flush. An observation and interview were made on 5/30/24 at 8:50 AM of Nurse #1 preparing Resident #57's medication. She removed a 10 milliliter (ml) normal saline (NS) flush and a heparin 5 units/ ml 5 ml flush from her medication cart. She then proceeded to take a bag of IV ceftriaxone (an IV antibiotic), IV tubing, the NS flush, and the heparin flush into Resident #57's room. Nurse #1 was observed to hang the bag of IV ceftriaxone sodium 2gm on the IV pole. She primed the IV tubing at Resident #57's bedside. Nurse #1 then cleaned the connection cap of the PICC line lumen with an alcohol swab. Nurse #1 opened the heparin flush from its packaging and connected the heparin flush to Resident #57's PICC line connection cap. Nurse #1 was stopped before she flushed Resident #57's PICC line with the heparin flush. Nurse #1 went back to her medication cart to review the flush orders for Resident #57's PICC line. After reviewing the PICC line flush orders on Resident #57's medication administration record (MAR), Nurse #1 said she was supposed to flush Resident #57's PICC line using the SASH (saline- administer medication-saline-heparin) method. She said she should have flushed the PICC line using a normal saline flush. Nurse #1 said she was nervous and got confused. 1b. Another observation was made on 5/30/24 at 9:45 AM of Nurse #1 disconnecting Resident #57's IV and flushing his PICC line. Nurse #1 was observed to take a NS 10 ml flush and a Heparin 5 unit/ml 5 ml flush from her medication cart and into Resident #57's room. She was observed to disconnect the IV tubing from Resident #57's PICC line. She cleaned the PICC line connection cap with an alcohol swab. She then held up an opened heparin flush to indicate which flush she intended to use first to flush Resident #57's PICC line, she did not connect the flush to the PICC line connection cap. Nurse #1 was stopped. She then proceeded to flush the PICC line with the 10 ml normal saline flush, followed by the 5 ml heparin flush. Nurse #1 said she was nervous and forgot which flush she was supposed to use first. An interview was conducted with the Director of nursing on 5/30/24 at 9:55 AM. She said Nurse #1 should have flushed Resident #57's PICC line using the SASH method. She said Nurse #1 had received training on IV administration, which included flushing of IV devices. She said she was not sure why Nurse #1 failed to flush Resident #57 PICC line correctly, except that she was nervous. An interview was conducted with the NP on 5/30/24 at 11:00 AM. She said there would probably be no adverse effect from using heparin to flush the PICC line before administering medication through the PICC line. She said Nurse #1 should have followed protocol and flushed the PICC line as ordered using the SASH method. An interview was conducted with the pharmacist on 5/30/24 at 11:19 AM. The Pharmacist said there was no adverse reaction between heparin and ceftriaxone. She said there would not be an adverse effect to the resident. The Pharmacist said that the heparin flush dose was not enough to be absorbed systemically and adversely affect the resident, even if the resident received other anticoagulant medications. An interview was conducted with the Administrator on 5/30/24 at 11:56 AM. The Administrator said she expected Nurse #1 to follow the protocol for flushing of PICC lines and that Nurse #1 should have followed the physician's orders. 2. A Physician's order dated 5/22/24 read Voltaren External Gel (topical analgesic) 1% (Diclofenac Sodium (Topical)) Apply to right shoulder topically three times a day for osteoarthritis, apply 2 grams (gm) to right shoulder three times daily. An observation was made on 5/30/24 at 8:58 AM of Nurse #1 preparing and administering Resident #57's medications. She was observed to squeeze a quarter sized amount of Voltaren 1% gel onto her gloved hand four separate times and applied the gel to Resident #57's left lower back, right lower back, left side, and right shoulder. An interview was conducted with Nurse #1 on 5/30/24 at 9:32 AM. She stated had never measured Voltaren gel for administration. Nurse #1 said she was not aware that Voltaren gel was supposed to be measured or that there was a dose card to measure the grams to be administered. She said she should have only applied the Voltaren gel to Resident #57 right shoulder as it was ordered. She said she applied the Voltaren gel to other areas because Resident #57 had requested it. An interview was conducted with the Director of Nursing (DON) on 5/30/24 at 9:55 AM. The DON said she had spoken to the pharmacy, and they confirmed Voltaren gel should be measured using a dosing card before being applied. She said she did not know why there was not a dose measuring card for Resident #57's Voltaren gel. She said the dose measuring card could have fallen out of the package or accidentally been thrown away. The DON stated that not measuring the Voltaren gel was a medication error. She said Nurse #1 should have only applied the Voltaren gel to Resident #57's right shoulder as specified in the order. She could not say why Nurse #1 applied the Voltaren gel to other areas. An interview was conducted with the NP on 5/30/24 at 11:00 AM. She said Nurse #1 should have measured the Voltaren gel before administering the medication. She said Nurse #1 should follow the physician's orders and should have only administered the Voltaren gel to Resident #57's right shoulder as specified in the order. An interview was conducted on 5/30/24 at 11:19 AM with the Pharmacist. She stated Voltaren gel should be measured using a dosage card before being applied. The Pharmacist stated that there was a maximum daily dose for Voltaren gel of 32 gm for the entire body. She stated if the maximum daily dosage was exceeded there could be adverse reactions. The Pharmacist explained Voltaren gel was a non-steroid anti-inflammatory (NSAID) medication. The Pharmacist said anytime an NSAID was used with an anticoagulant medication, there was always a labeled risk of an increased risk of bruising and bleeding. The Pharmacist stated with Voltaren gel being a topical medication the risk of it being absorbed systemically and causing an adverse effect was low. An interview conducted on 5/30/24 at 11:56 AM with the Administrator. She said the nurse should follow physician orders when administering medications. She said Nurse #1 should have measured the Voltaren gel before administration.

Based on observations, record review, and staff and resident interviews the facility failed to store a medication and left it unattended at the bedside for 1 of 1 resident (Resident #5) reviewed for medication storage. The findings included: Resident #5 was admitted to facility on 5/9/24 with diagnosis that included constipation. A review of the Resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. A review of Resident #5's physician order dated 5/25/2024 revealed he was ordered Senna S Oral Tablet 8.6-50 milligrams (MG). The order continued to give 2 tablets by mouth one time a day for constipation and hold for loose stool. There was no self-administration assessment for any medication in Resident #5's medical record. Review of Resident #5's medical record revealed no care plan for self-administration of medications. On 5/29/24 at 9:29 AM an observation and interview was conducted with Resident #5 in his room. During the interview with Resident #5 was observed to knock over a napkin that contained an orange round pill off his bedside table. The pill was observed to fall to the floor. Resident #5 indicated the orange round pill was from the morning, and it was for his constipation. Resident #5 further indicated he liked to finish his breakfast prior to taking his medication for constipation. He stated that he took the rest of his morning medication but took his constipation pill later. An interview on 5/29/24 at 9:32 AM with Nurse #1 revealed Resident #5 wanted his stool softener after eating breakfast. Nurse #1 indicated she had left the Senna S Oral tablet on Resident #5's bedside table on purpose so he could take it after breakfast. Nurse #1 also indicated this was a consistent morning routine for Resident #5. An observation with Nurse #1 of Resident #5's Medication Administration Record (MAR) revealed it had been signed on 5/29/24 prior to Resident #5 taking the pill. On 5/29/24 at 2:34 PM the Nurse Supervisor indicated that a nurse should stand and observe a resident taking their medication before leaving the room. The Nursing Supervisor further indicated Nurse #1 should not have left Resident #5's medication at bedside. The MAR should not have been signed due to Resident #5 not consuming the Senna S Oral tablet. An interview was conducted with the Director of Nursing (DON) on 5/29/24 at 3:02 PM. The DON stated Resident #5 should have been observed taking his medication before Nurse #1 left the room. Medication should not be left for residents to take at their discretion. The DON further stated when a resident wanted to take a medication later than the time ordered, the nurse should not sign off on the MAR. The nurse should hold the pill and come back when the resident requests.

Based on observations, record review, staff, and Nurse Practitioner (NP) interview the facility failed to wear personal protective equipment (PPE) while administering medications through a peripherally inserted central catheter (PICC line) for a resident requiring Enhanced Barrier Precautions (EBP). This deficit practice occurred for 1 of 2 residents reviewed for EBP (Resident #57). Findings included: Review of the facility's policy and procedure revised on 3/2023, entitled Policy and procedures guidelines for isolation precautions read in part: Enhanced Barrier Precautions (EBP) are used as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). This precaution expands on the use of PPE and refers to the use of gown and gloves during high-contact resident care activities. That provides opportunities for transfer of MDROs to staff hands and clothing. EBP will be applied to resident with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Implementation- High-contact care activities that require gown and glove use for Enhanced Barrier Precautions include Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ ventilator. Resident #57 was admitted to the facility on [DATE]. Review of Resident #57 active physician orders for May 2024 revealed he had an order for EBP dated 5/21/24. He had an order dated 5/21/24 that read: Double Lumen PICC to left brachial vein inserted 5/20/24. An observation was completed on 5/28/24 at 12:41 PM and revealed Resident #57 had a double lumen PICC line in place to his left upper arm. There was an EBP sign on the outside of his door. There was a cart with PPE supplies including: gowns, mask, and gloves outside the door of his room. An observation was completed on 5/30/24 at 8:50 AM of Nurse #1 accessing Resident #57's PICC line prior to administering his intravenous (IV) medication. The nurse performed hand hygiene using hand sanitizer and donned clean gloves. She did not don a gown. Nurse #1 hung the IV medication on the IV pole and primed the IV tubing. She cleaned the PICC line lumen connection cap with an alcohol swab and connected a flush to the PICC line lumen. An interview was conducted with Nurse #1 on 5/30/24 at 8:58 AM. Nurse #1 stated she was aware that Resident #57 had EBP in place. She explained EPB should be used when providing direct care and changing wound dressings. Nurse #1 stated that if she was providing care for the PICC line or using the PICC line she should use EBP and wear a gown. She stated she had been nervous and forgot to put on the gown. An interview was performed with the Director of Nursing (DON) on 5/30/24 at 9:55 AM. The DON said Nurse #1 should follow EBP guidelines, which included wearing a gown when she accessed the PICC line to administer medications. An interview was performed with the Infection Preventionist (IP) on 5/30/24 at 10:50 AM. The IP stated that residents with indwelling medical devices such as PICC lines should have EBP in place. She said if a nurse was using the PICC line or changing the dressing then they should follow EBP, which included wearing a gown and gloves. An interview was performed with NP on 5/30/24 at 11:00 AM. The NP stated she was aware of EBP being used by the facility. She said Resident #57 had EBP in place for his PICC line and wounds. She stated Nurse #1 should have followed EBP when accessing Resident #57's PICC line. An interview was performed with the Administrator on 5/30/24 at 11:56 AM. She stated if residents have EBP in place, staff should follow the EBP guidelines when performing procedures. The Administrator said Nurse #1 should have followed EBP guidelines and worn a gown when accessing Resident #57's PICC line. She said Nurse #1 did not follow protocol.

Based on observations and staff interviews, staff failed to change gloves and sanitize hands between handling soiled and clean dishware for 1 of 1 dietary aide (Dietary Aide #1). This practice had the potential to cross-contaminate food served to residents on the Red Oak dining hall. The findings included: During a continuous observation on 3/1/22 from 9:15 AM to 9:32 AM, a tour of the satellite kitchen on the Red Oak dining hall, Dietary Aide (DA) #1 was observed wearing gloves when handling a dish cart with soiled dishware (3 coffee cups, 4 dessert or fruit bowls, 14 pieces of silverware including knives, forks, and spoons). DA #1 was observed pushing the soiled dish cart towards the dish machine area in the satellite kitchen. DA #1 removed a clean dish rack of 10 scoops and placed them on the counter with the same gloved hands. She then placed soiled dishware on the dish cart and placed the dish cart in the dishwasher with the same soiled gloved hands. DA #1 failed to perform hand hygiene before handling clean dishware. An interview dated 3/1/22 at 9:35 AM with DA #1 revealed she had training and in-services on cross-contamination and that she should change her gloves when moving from soiled dishes and utensils to clean dishes and utensils. DA #1 further revealed that she usually changes her gloves three to four times each day. DA #1 did not recall why she did not remove her soiled gloves and sanitize her hands after handling soiled dishware and before handling clean dishware. Review of the Professional Development Tracking In-services form revealed DA #1 received an in-service on 12/21/21 related to debris on non-food contact and gloves. A review of Relias Course Completion History dated 3/2/22 revealed DA #1 completed in-service for safe food handling and safety in the kitchen on 1/5/22. During an interview on 3/1/22 at 9:45 AM the Dietary Manager verbalized staff received in-service training on cross-contamination and proper hand hygiene when they were first hired and on-going as needed. The Dietary Manager indicated gloves should be changed and proper hand hygiene performed when transitioning from soiled dishes to clean dishes. She further indicated DA #1 failed to change her gloves and sanitize her hands when moving from soiled to clean dishware. An interview on 3/1/22 at 12:18 PM with the Nutrition Care Coordinator/ Registered Dietician (RD) revealed Dietary Aide #1 should have performed hand hygiene to avoid cross contamination by changing her gloves each time she handled soiled dishes then clean dishes. An interview on 3/2/22 at 9:05 AM with the Administrator revealed the process for avoiding cross-contamination should be to change gloves and sanitize hands between soiled and clean dish handling. An interview with the Culinary Campus Director (CCD) on 3/2/22 at 9:28 AM indicated she oversees the food for the entire campus and assures that everyone was compliant with in-services. The CCD communicated the last hand washing in-service took place in December 2021. The CCD further communicated that the DA #1 failed to change her soiled gloves, perform hand washing, and re-glove after she handled soiled dishware and before she handled clean dishware.

Based on observations, record review and staff interviews, the facility failed to discard 2 of 3 opened expired multi-dose vials of [MEDICATION(S)] in 1 of 1 medication storage room refrigerators. Findings included: An interview and observation on 03/02/22 at 03:16 PM of the refrigerator in medication room [ROOM NUMBER] with Nurse #1, revealed 2 multi-dose vials of [MEDICATION(S)] (a medication used in a skin test to help diagnose [CONDITION(S)]) was opened and available for use with an opened date recorded. One multi-dose vial was labeled as being opened on 01/01/22 and one multi-dose vial was labeled as being opened on 01/19/22. Nurse #1 revealed she was not sure how long an opened multi-dose vial of [MEDICATION(S)] could be kept but believed the medication was good for either 90 days or 6 months once opened. Review of the manufacturer instructions revealed vials in use for more than 30 days should be discarded due to possibly affecting the outcome of the [CONDITION(S)] skin test. An interview and observation with the Director of Nursing (DON) on 03/02/22 at 04:46 PM of the refrigerator in medication room [ROOM NUMBER], revealed 2 multi-dose vials of [MEDICATION(S)] was opened and available for use with an opened date recorded. One multi-dose vial was labeled as being opened on 01/01/22 and one multi-dose vial was labeled as being opened on 01/19/22. She revealed the multi-dose vials should have been discarded after 30 days and sent back to the pharmacy. Checking for expired medications was the responsibility of the nursing staff and she was not sure why no one checked the opened dates on the multi-use vials or discarded them after 30 days. The DON discarded the 2 expired multi-dose vials. An interview with the Administrator on 03/02/22 at 05:19 PM revealed nursing staff should be monitoring that all opened medications are dated and removed prior to expiration.

Based on observations and staff interviews, the facility failed to monitor produce (small oblong red tomatoes, red bell peppers, cucumbers, celery, and medium sized red tomatoes) with signs of spoilage in 1 of 2 walk in refrigerators. Findings included: An initial tour of the kitchen was completed on 1/7/2020 at 7:05 AM. The following problems were observed with food stored in one of the kitchen's walk in refrigerators: · 3 out of 5 pint size containers of small oblong red tomatoes in a cardboard flat were observed with white/ blueish fuzzy matter · 2 out of 11 red bell peppers in a clear plastic bin with no lid were observed mushy with white/ blueish fuzzy matter · 2 out of 25 green cucumbers in a clear plastic bin were observed mushy with clear fluid draining and white/ blackish fuzzy spots · 1 out of 7 stalks of celery in a clear plastic bin with no lid observed with fuzzy white/ blueish fuzzy matter · 2 out of 13 medium sized red tomatoes in a cardboard flat observed with white/ blueish fuzzy matter An interview and observation was completed on 1/7/2020 at 7:35 AM with Cook #1 who stated walk through mini inspections were completed each morning prior to starting the breakfast meal. Cook #1 explained staff checked to make sure equipment was in working order and also checked for signs of spoilage with food items. Cook #1 explained he had not completed his check this morning prior to starting the breakfast meal. Cook #1 observed the signs of spoilage with the small oblong red tomatoes, red bell peppers, green cucumbers, celery stalks, and medium sized red tomatoes. He verbalized the food items would need to be discarded. An interview was completed on 1/7/2020 at 9:52 AM with the Culinary and Nutritional Services Director (CNSD) who verbalized a walk through would be completed each morning, as well as, at closing by her culinary staff (mainly cooks or chefs). These items would generally be caught with the walk throughs and discarded. This was the intent for using the clear storage bins, so spoilage could be seen. The CNSD stated she would complete corrective action inclusive of produce items with signs of spoilage would be thrown away, remaining produce items would be cleaned/ washed, and storage bins would be cleaned. The CNSD also communicated education would be provided to the culinary staff.

Based on observation, staff interview and manufacturer's information, the facility failed to clean and sanitize dishware at the recommended wash and final rinse temperatures for 11 of 11 sampled residents (Resident #s 2, 10, 15, 16, 19, 21, 35, 36, 37, 38 and 39). Findings included. 1. Dishwashing was observed on 02/15/17 at 8:47 AM in a satellite dishwashing room on Magnolia Lane. A single tank, high temperature machine was used. The manufacturer's instructions indicated the wash temperature should be 150 degrees Fahrenheit (F) and the final rinse should be 180 degrees F. Dietary Aide (DA) #1 was working in the room. The wash temperature reached 155 degrees F and the final rinse did not come on. A February temperature log included entries for wash and final rinse temperatures. All final rinse temperatures were recorded on log as 180 degrees F. On 2/15/17 at 11:45 AM the Certified Dietary Manager (CDM) said the dishwasher used a booster heater and it took a couple of runs to get the temperature up. 2. Dishwashing was observed again on 2/15/17 at 1:25 PM. Dietary Aide #2 was putting racks of dirty dishes into the machine. DA #2 said he had been washing dishes for the last fifteen minutes. Five cycles of dishwashing were observed. The temperatures were displayed as 129, 127, 128, 128 & 128 degrees. Code EE with a picture of a wrench was displayed. According to the manufacturer's information code EE meant the booster did not reach temperature after eight minutes following the initial fill. DA #2 said, Seems like water is not getting hot enough. As each rack of dishes came out of the dishwasher, Dietary Aide #3 picked up the rack, put it on a cart and took the cart into kitchen/dining area and put the dishes away, ready for use. The Director of Nurses was in the vicinity and was asked to observe the temperature and displayed reading. On 2/15/17 at 2:04 PM the Culinary Director and the CDM said a temperature probe placed inside the dish machine showed an accurate reading of hot water. She said they plan to shut the room down and rewash dishes. She said the breaker in the booster heater was not working. She said a maintenance man looked at it this morning after getting a call. They were notified before lunch. She said the machine should have been tagged out of service due to the final rinse temperature. On 2/15/17 at 3:30 the Director of Physical Plant and Physical Plant Manager said the machine is fed off of domestic water. They said if the water is not fed at 110 degrees, then the booster heater is not effective. He said they have a purchase order on a dish machine. They said they had a couple of issues with it. When we dip below 112 degrees, we have a problem with booster.

Based on observations, staff interviews and review of facility records, the facility failed to maintain 1) potentially hazardous refrigerated foods (salami, cheese and milk) within the use-by-date or manufacturer expiration date, 2) store frozen fish in a closed container and 3) serve foods using clean utensils to three (3) sampled residents (Residents #4, 6 and 36). The findings included: 1. Review of the facility document "Guide to Proper Food Storage Techniques", dated August 2010, recorded in part, "Proper food handling and storage techniques must be followed to prevent contamination and pathogen (bacteria) growth. All food items outside of the original container must be covered, labeled and dated. Expiration dates should be checked on a regular basis." Observations in the facility's kitchen on 04/14/14 from 09:00 AM until 09:11 AM revealed the following problems with foods stored in refrigerator and freezer units. An observation of refrigerator #2 and the freezer unit revealed foods and milk stored past the facility use-by or manufacturer expiration date. The items included: ? A pre-opened package containing 16 slices of American cheese, re-packaged in plastic wrap with a facility label which recorded a use by date of 04/12/14 ? A pre-opened package of approximately 1 pound of salami, re-packaged in plastic wrap, with a facility label which recorded a use by date of 04/13/14 ? Sixteen pint sized cartons of whole fat milk with a manufacturer expiration date stamp of 04/11/14 ? A 10 pound box of rainbow trout, stored open with the fish exposed to the 0 degree air of the freezer; the fish had formed ice crystals on its exterior An interview with the culinary foodservice director (CFD) on 04/14/14 at 09:00 AM revealed that dietary staff #1 and cooks were responsible for checking refrigeration units and the freezer daily. The CFD stated that expired food items should have been discarded and the rainbow trout should be have stored in a closed package. An interview with dietary staff #1 on 04/14/14 at 09:13 AM revealed he was responsible for receiving and stocking inventory. Dietary staff #1 stated he checked the refrigerator units and freezer daily for expired items. Dietary staff #1 further stated that he had already completed his morning check of the refrigerators, but missed the cheese, salami and milk. Dietary staff #1 also stated he last check the freezer on Friday (04/11/14), but could not explain the opened box of rainbow trout. 2. Review of the facility policy, "Single-Use Glove Usage", revised December 2007, recorded in part, "Glove usage does not replace the need for good hand washing practices. Hands will be washed after touching your face, hair or shoes and when soiling hands." An observation of the lunch meal tray line occurred on 04/15/14 from 11:33 AM to 12:09 PM. During this observation dietary staff #2 was observed wearing gloves. At 11:48 AM, dietary staff #2 was observed to use her gloved hands to pick up a visibly soiled box of plastic wrap. The exterior of the box of plastic wrap was soiled with stains of oil and food debris. Dietary staff #2 continued the lunch meal tray line by plating slices of pumpernickel bread with her gloved hands for Residents #4 and 36. On 04/15/14 at 12:09 PM, dietary staff #2 was observed to touch the same box of plastic wrap twice. Dietary staff #2 then wiped her face using the left shoulder area of her shirt, repositioned the left shoulder area of her shirt with her left gloved hand and then rubbed both gloved hands together. Dietary staff #2 continued the lunch meal tray line without donning new gloves or performing hand hygiene. At 12:10 PM, dietary staff #2 plated pumpernickel bread for Resident #6 using her right gloved hand. Dietary staff #2 did not don new gloves or perform hand hygiene between tasks during the lunch meal tray line. An interview on 04/16/14 at 1:39 PM with dietary staff #2 revealed she supervised the 1st shift tray line. Dietary staff #2 stated she was trained to wash her hands upon coming to work, at the start of the tray line and during the tray line if her hands/gloves became soiled. Dietary staff #2 recalled that she did not don new gloves or perform hand hygiene after handling the soiled box of plastic wrap. Dietary staff #2 observed the box of plastic wrap and stated that it was visibly soiled with grease/food stains. Dietary staff #2 further stated that she should have donned new gloves and performed hand hygiene when she touched her shirt after wiping her face onto her shirt. She further stated it was her typical practice to plate bread/sandwiches with gloved hands rather than utensils to keep the bread/sandwiches from breaking apart. An interview on 04/16/14 at 1:57 PM with the nutrition services manager (NSM) revealed she oversaw the tray line. The NSM stated she was present during the lunch meal tray line on 04/15/14 and noticed dietary staff #2 handle the soiled box of plastic wrap, but did not remind dietary staff #2 to change gloves or wash her hands. The NSM stated that dietary staff should change gloves and wash hands during the tray line service if gloves became soiled before touching food served to residents.

Based on observations and staff interviews the facility failed to store foods properly, keep food preparation and service equipment clean, maintain the dish machine's final rinse cycle at a minimum temperature of 180 degrees Fahrenheit and serve cold potentially hazardous foods at temperatures of 41 degrees Fahrenheit or below. The findings included: 1. Observations in the facility's kitchen on 04/08/13 from 11:00 AM to 11:30 AM revealed the following problems with foods stored in refrigerator and freezer units: a. Observations of previously opened foods and beverages stored in kitchen refrigeration units revealed staff failed to date items when they were opened and to discard foods with expired expiration dates. The observed undated items included the following; one quart container of heavy cream, one large container of potato salad, a two (2) pound carton of liquid eggs, a container of french dressing, a pan of blue cheese dressing, one forty six (46) ounce container of grape drink concentrate and one forty six (46) ounce container of fruit punch concentrate. Further observations of foods in refrigeration storage revealed three (3) five pound containers of cottage cheese that had expired expiration dates of 04/06/13. Interview with the Assistant Dietary Manager on 04/08/13 at 11:15 AM revealed staff is responsible for checking foods in refrigeration storage every day to ensure that all opened items are dated and there are no foods with expired expiration dates. b. Observations of foods stored in the kitchen's walk-in freezer revealed the following foods were not completely closed when stored; a fifteen (15) pound box of catfish, a fifteen (15) pound box trout, a seventeen (17) pound box of dough, a fifteen (15) pound box of pastry dough and a twenty nine (29) pound box of dough. Interview with the Assistant Dietary Manager on 04/08/13 at 11:25 AM revealed dietary staff should make sure that all foods are completely closed prior to placing them into freezer storage. 2. Observations of the facility's kitchen on 04/09/13 from 2:00 PM to 3:20 PM revealed the following food preparation equipment, food service equipment and kitchen areas were unclean: a. Observations of the kitchen's three compartment sink area revealed food preparation pans, that had been cleaned, were stacked on top of each other. Observations of ten of these stored pans revealed the interior of all of these pans were wet with accumulated water. In addition three of these pan were observed to be unclean with food debris on them. Interview with the Dietary Manager (DM) on 04/09/13 at 2:40 PM revealed food preparation pans should be clean when stored for use. The DM further explained that staff should not stack pans on top of each other in order to allow them to air dry completely. b. Observations of the interior of five (5) of five (5) meal delivery carts, that were checked for cleanliness revealed the inside of each of these carts were unclean with dried splatters and debris. Each of these carts were ready for use and contained meal trays that were set up for the evening meal. Interview with the Dietary Manager (DM) on 04/09/13 at 2:45 PM confirmed the meal delivery carts were not clean and that the carts should cleaned and sanitized by staff after each meal. c. The following food preparation and service equipment, that was ready for use, was observed to be unclean with dried substances and/or loose debris: two convection ovens, the cutting blade of a large food processor, a large mixer, a grill unit and four (4) of ten (10) dishes that were checked for cleanliness. Also, a drawer with food preparation equipment stored inside, including a can opener, scoops and a pastry cutter, was unclean with dried substances and loose food debris. Interview with the Dietary Manager (DM) on 04/09/13 at 3:15 PM revealed food preparation and service equipment should be kept clean by staff following the department's cleaning schedules and by cleaning equipment more frequently when needed. d. A kitchen hand washing area, including the area's soap dispenser, towel dispenser and sink was observed to be unclean. Interview with the facility's Dietary Manager (DM) on 04/09/13 at 3:15 PM revealed that staff was responsible for cleaning each of the kitchen's handwashing stations at least once a day. 3. Observations of the kitchen's dish machine area on 04/09/13 at 2:20 PM revealed dietary staff was actively washing dishes in dish machine and storing these dishes for use. Monitoring of the dish machine revealed that on three consecutive occasions the machine did not reach its minimum required final rinse cycle temperature of 180 degrees Fahrenheit to effectively sanitize the dishes and dishware being washed in the machine. During these observations the machine's final rinse cycle was observed to only reach temperatures of 168 degrees F., 170 degrees F., and 174 degrees F. Although, the machine was not reaching its minimum final rinse temperature of 180 degrees F. staff was observed to store the dishes and utensils that were washed in the machine for use. Review of dish machine's temperature log revealed that staff did not monitor or document the dish machine's final rinse temperature during the lunch meal of 04/09/13. Interview with the facility Dietary Manager (DM) 04/09/13 at 2:30 PM confirmed that the the kitchen's dish machine final rinse cycle needed to reach a minimum temperature of 180 degrees F. to effectively sanitize equipment being washed in the machine. The DM specified that staff should monitor the machine's final rinse temperature during each meal service, but staff failed check the machine's temperatures during the lunch meal of 04/09/13. Further interview with the DM on 04/10/13 at 12:20 PM revealed that on 04/09/13 the facility's maintenance staff increased the temperature of the dish machine's booster water heater and the machine was able to reach a minimum temperature of 180 degrees Fahrenheit during the final rinse cycle on a consistent basis. 5. Observations of the kitchen's tray line meal service on 04/10/13 12:05 PM revealed the following cold potentially hazardous foods were being served at temperatures above 41 degrees Fahrenheit: Pimento cheese sandwiches 63 degrees F. Cottage cheese 46 degrees F. Interview with the Dietary Manager (DM) on 04/10/13 at 12:15 PM confirmed potentially cold foods, including pimento cheese and cottage cheese, should be maintained at temperatures of 41 degrees or below when served from tray line.

Based on observations, staff interviews and record reviews that facility failed to utilize a gait belt when ambulating 1 of 3 of three sampled residents that were reviewed for falls. (Resident #44) The findings included: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's fall risk evaluation completed on 02/27/13 identified the resident as being at high risk for falls. This assessment specified that the resident was chair bound and not able to perform a gait/balance function test. A Nurse's Note dated 02/27/13 specified Resident #44 was toileted with two person assist with gait belt and required two person assistance with transfers. Review of Resident #44's Minimum Data Set (MDS) of 03/06/13 revealed he was assessed as requiring extensive dependence for transfers and had experienced a fall without injury since admission. The resident's care plan, developed on 03/13/13, specified that he required extensive assistance with mobility and transfers and had a history of [REDACTED]. review of the resident's medical record revealed [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. The note further specified that the resident sustained [REDACTED]. Observations of Resident #44 on 04/10/13 at 10:45 AM revealed that staff were assisting him to transfer and the resident appeared unsteady and required assistance to obtain his balance. On 04/10/13 at 11:50 AM an interview was conducted with Nurse #1. Nurse #1 stated that Resident #44 did experience confusion and required staff assistance with transfers and ambulation. Nurse #1 specified that Resident #44 had experienced five (5) falls since being admitted on [DATE] and the measures implemented by staff to prevent him from falling included; use a rolling walker, use of a gait belt, use of personal alarms, conducting hourly staff checks and positioning his bed lower to the ground. Nurse #1 stated the only fall experienced by Resident #44 which resulted in injury occurred on 04/09/13 when he fell while being ambulated by staff and experienced abrasions to both of his shins. Interview with Nursing Assistance (NA) #1 on 04/10/13 at 2:20 PM revealed Resident #44 required assistance with care and had experienced falls since his admission to the facility. NA #1 specified that the resident could ambulate with assistance with the use of a rolling walker and gait belt. On 04/10/13 at 2:40 PM an interview was conducted with the facility's Director of Nurses (DON). The DON confirmed that since Resident #44's admission to the facility he had experienced a total of five (5) falls. The DON stated that the facility had investigated the four (4) falls which occurred on 03/06/13, 03/08/13, 03/19/13 and 04/02/13, but had not concluded the investigation of the resident's 04/09/13 fall which resulted in injury. The DON specified that during the 04/09/13 fall Resident #44 fell to his knees while being ambulated by Physical Therapy (PT) and received 2 skin tears. The DON was unsure of the specific circumstances of this fall but would have expected staff to use a gait belt to ambulate Resident #44 and to ambulate him in an area with minimal distractions. On 04/10/13 at 3:10 PM an interview was conducted with PT #1, who ambulated Resident #44, when he fell on [DATE]. PT #1 stated that while ambulating Resident #44 he lunged toward another resident and fell to his knees. PT #1 stated as a result of this fall the resident experienced skin tears to both of his shins. PT #1 stated that when the fall occurred Resident #44 was using a rolling walker but did not have a gait belt in place. PT #1 confirmed that due to the resident's risk of falling she should have placed a gait belt on him and ambulated him in a quieter area.

Based on observations, medical record reviews and staff interviews the facility failed to accurately transcribe and document the physician order [REDACTED]. The accurate duration of IV antibiotic [MEDICATION NAME] was not documented. (Resident #50) The findings include: Resident #50 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. '[MEDICATION NAME] 2 gm (gram) IV (intravenously) q (every) 6 (hours x (times) 13 days' . Resident #50 was observed for medication administration on 3/28/12 at 11:36 AM. Licensed Nurse (LN) #1 was observed administering [MEDICATION NAME] appropriately. A further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview with LN #1 on 3/28/12 at 11:50 AM revealed that MAR indicated [REDACTED]. LN #1 also stated that two nurses always checked for the accuracy in transcriptions. The interview revealed that the medication order and MAR indicated [REDACTED]. LN #1 had not noticed the error in the entries and stated would get a clarification order. An interview with the Director of Nursing (DON) on 3/28/12 at 4:30 PM confirmed that all physician orders [REDACTED].

Based on observation, resident and staff interviews, and record review, the facility failed to hold a medication (Aspirin) as ordered for one (1) of eight (8) sampled residents (Resident #3). The findings are: Resident #3 was readmitted to the facility on [DATE] following a hospitalization for Upper [MEDICAL CONDITION]. Review of a hospital discharge summary dated 1/14/11 revealed Aspirin 81mg (which the resident had previously received) was ordered to be held and restarted every 48 hours on 1/21/11. Review of facility handwritten readmission orders [REDACTED]. Review of the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The transcription on the MAR indicated [REDACTED]. Interview with LN #2 at 10:40 AM on 1/20/11 revealed she readmitted Resident #3 on 1/14/11. LN #2 reported she copied the discharge medication orders from the discharge summary for physician signature. LN #2 revealed she transcribed the Aspirin 81mg to be given every other day until 1/21/11 and then daily. LN #2 reported she did not notice the error. LN #2 revealed the hospital discharge summary and the handwritten readmission orders [REDACTED]. Interview with the Director of Nurses (DON) at 12:25 PM on 1/20/11 revealed she was not aware the Aspirin had been administered prior to 1/21/11. The DON explained the nurses were expected to correctly transcribe medication orders from the hospital discharge summary.