Every finding on record at Willowbrooke Court Skilled Care Center - Edgewater

Based on observation, interview and record review, the facility failed to follow standardized recipes to ensure that food was appetizing, palatable, and flavorful that could potentially affect any resident who may request Chicken Noodle soup with their meals. This practice could affect 18 out of 19 residents residing on the 3rd floor, certified section. The findings included: Review of the facility's Standardized Recipe for preparation and serving of Chicken Noodle Soup noted the following: 6-ounce Chicken Base 3 gallons Tap Water Chopped Celery, Onion, Carrots 1 lb. [pound] 8 ounces Cooked Pulled Chicken Meat Poultry Seasoning, Black Pepper 1 Pound Dry Egg noodles Combine water, base vegetables, spices and chicken to a boil. Simmer 30 min [minutes]. Add Noodles and simmer until tender about 15 minutes and maintain at > [greater than] 140 F [Fahrenheit] for 4 hours. Yield = 50, 6-ounce portions. 1. During the Resident Council Meeting conducted by the surveyors on 12/12/23 at 10:30 AM, it was noted that the 7 residents in attendance stated soups (Chicken Noodle Soup) was runny, watered down, non-appetizing, and does not taste good on a regular basis. The residents also stated that the facility serves Chicken Noodle Soup for every lunch and dinner. During the review of the approved menu for the 12/12/23 lunch menu, it was noted that a 6-ounce portion of Chicken Noodle Soup was to be served to all Regular, Mechanical Soft, Pureed, and Therapeutic Diets (CHO, Renal). During the observation of the lunch meal in the First Floor Satellite / Dining Room Kitchen on 12/12/23 at 12 PM, it was noted that the Chicken Noodle Soup was located on the steam table. Observation of the soup noted that the soup contained only chicken broth and tiny particles of chicken. No noodles were located with the soup. Interview with the Dietary Manager (DM) stated that it is usual serving practice that there is a separate container of pasta and chicken pieces. The pasta and chicken are combined with the chicken broth when a resident orders a serving of Chicken Noodle Soup. The DM stated that the pasta is held separately because if it is put into the soup mixture prior to serving it results in large portions of blown-up pasta pieces. Further observation noted that DM called the main kitchen to have pasta and chicken sent to the satellite kitchen. It was noted that the main kitchen had to prepare the pasta and chicken and it took over 30 - 45 minutes for the pasta and chicken to be sent to the satellite kitchen. The 20 residents seated in the dining room were noted to sit and wait the 30-45 minutes for the soup and were noted to become agitated with the lunch meal service. At 12:45 PM, the pasta and noodles arrived from the main kitchen for the soup service. The surveyor tasted the pasta and noted it to be well undercooked and semi hard. The soup ingredients were combined for each soup portion and served to the residents. The CDM (Certified DM) stated to the surveyor that the serving of the soup for the third-floor residents is the same procedure. On 12/13/23 at 9:00 AM, an interview was conducted with the Main Kitchen Culinary Director (CD) it was stated that the soup ingredients of chicken broth, cooked pasta, and chicken pieces are kept separately because of Kosher request from the residents. The surveyor said to the Culinary Director (CD) that there are no resident requests who reside in the nursing home for Kosher or Kosher style foods. The CD then corrected himself and stated that the Kosher requests are from the Independent Living residents and not the facility residents. The CD further stated that the soup for the facility residents should have been prepared according to the standardized recipe with all ingredients combined during the preparation of the soup. At the request of the surveyor, the CD submitted the standardized recipe for the preparation of the Chicken Noodle Soup. Following the review with the CD, it was noted that the method of preparation and serving of the soup was not followed. A review of the facility's diet census for 12/11/23 noted that the issues could potentially affect 18 out of 19 residents on the 3rd floor, certified section who may make a request for Chicken Noodle soup during meals.

Based on observation, record review and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety potentially for 18 out of 19 residents residing on the 3rd floor, certified section. The findings included: Review of the facility's Culinary Services Manual - Policies and Procedures: Cleaning and Sanitation Issued: ,d+[DATE], Revised: ,d+[DATE], documented, in part, the following: Procedure: (b) The Culinary and Nutrition Services management team is responsible for developing written daily cleaning schedules. (c) The manager initiates the cleaning schedule and supervises employee comp, to the schedule. (d) All cleaning tasks will be checked nightly to ensure the meet ACTS standards. (f) Heavy duty monthly and semi-annual cleaning projects must also be scheduled and documented by the management staff. During the kitchen observation tour conducted on [DATE], it was noted that Cleaning and Sanitation Policies and Procedures were not followed as evidenced by the following: 1. During the initial kitchen / food service observation tour conducted on the main kitchen accompanied with the Culinary Director (CD) and Certified Dietary Manager (CDM) on [DATE] at 8:50 AM, the following was noted: (a) Walk-in Freezer #1 was noted to have food that was not properly dated and covered. Further observation noted that a 5-gallon container of ice cream was not covered and the contents of the container were open to air; 1 case of cookie dough contents was open to the air; and 1 case of croissants was open to the air. The CD stated that the products were not properly covered, and would discard all 3 food products. (b) Walk-in Freezer #1 was noted to have large areas of frozen water like droplets on the refrigeration unit and the ceiling area. The surveyor discussed with the CD that the freezer unit is not operating properly and requested the unit be evaluated. (c) Walk-in Freezer #2 was noted to have unlabeled and non-dated foods that were exposed to the air resulting in freezer burn. Further observation noted 3, third sized steam table pans of cooked / leftover meats, that were not labeled with a preparation date and were freezer burned. The CD stated that the frozen meats were not properly dated and covered. The CD further stated that the food products would be discarded. (d) Walk-in Refrigerator #1 was noted to have a green/black mold type substance growing around the entire unit and ceiling area. It was also noted that the tubing exterior leading to the unit was full of condensation and dripping down onto a case of fresh eggs. The surveyor discussed with the CD that there was the potential for food contamination and food borne illness. It was requested by the surveyor that all foods located beneath the refrigeration unit be moved and a refrigeration specialist be contacted to evaluate the unit. (e) Walk-in Refrigerator #1 was noted to have 2 small steam table pans that contained a mixture of Herbs (1) and a mixture of parsley spices. Further observation noted that the foods were labeled with dates that documented the expiration. The Herb mixture was dated with a facility expiration date of [DATE] and the Parsley mixture was dated with a facility expiration date of [DATE]. The CD stated to the surveyor that the foods were expired and should have been discarded by the expiration date. (f) Walk-in Refrigerator #2 was noted to have a large pan of Cole Slaw with a labeled expiration date of [DATE]. The CM stated to the surveyor that the coleslaw should have been discarded by the expiration date of [DATE]. (g) The exterior of the commercial VCM mixer/blender was noted to have large areas of dried food matter and areas of rust. The CD stated to the surveyor that the unit was not being properly cleaned and maintained. (h) Ceiling light fixture located directly above the main cooking line were noted to be not properly maintained. Specifically, 2 light fixture covers were cracked / broken. It was discussed with the CD that there was the potential for small plastic pieces of the cracked / broken fixtures to fall into food resulting in food contamination. (i) Two of two bench mounted tilt kettles were noted to have approximately 2 inches of stagnant fluid inside of each unit. The surveyor discussed with the CD that the 2 units must be dry of fluid after each cleaning to ensure food contamination does not occur. (j) The internal cavity of the commercial convection oven was noted to be heavily soiled and had a thick layer of build-up carbon. The CD stated that the unit was not properly cleaned on a regular basis. (k) The commercial grill was noted to have a thick black layer of matter on the entire bottom of the unit and on the surrounding gas fixtures. The surveyor discussed with the CD that the unit was not being properly cleaned and maintained on a regular basis. It was also discussed that the unit could potentially cause food borne illness and food contamination. (l) The exteriors of the fire extinguisher units (2) were noted to be heavily soiled and had a thick coating of black mold type matter. It was also noted the units were located on the main cooking line and were a potential source of foodborne illness and food contamination. The CD stated to the surveyor that dietary staff do not clean the units and that the maintenance department had not maintained and cleaned the units on a regular basis. (m) The exterior of the commercial floor mixture located in the cold food preparation area was noted to have large areas of dried food matter and areas of rust that were located directly above the mixing bowl. The surveyor discussed with the CD that the dried food matter and rust fall into foods being mixed each time the unit is utilized resulting in potential food borne illness and food contamination, the surveyor requested that the unit not be utilized until proper cleaning and sanitizing. (n) The exterior of the commercial bench mounted mixture located in the cold food preparation area was noted to have large areas of dried food matter and areas of rust that were located directly above the mixing bowl. The surveyor discussed with the CD that the dried food matter and rust fall into foods being mixed each time the unit is utilized resulting in potential food borne illness and food contamination, the surveyor requested that the unit not be utilized until proper cleaning and sanitizing. (o) Observation of the dish machine room area noted that the exterior of the dish machine was covered in numerous dried food particles. The surveyor discussed with the CD that the interior and exterior of the dish machine require proper cleaning and sanitizing after each use. (p) Observation of the dish machine room area noted that the resident silverware was not being washed / sanitized and held in a sanitary manner. Specifically, noted that a large container of resident silverware was being stored with the eating portion in an upright position after washing and sanitizing. The surveyor discussed with the CD that the resident silverware requires a separate wash / sanitizing with the silver eating portion on a downward position to ensure that staff handle the silverware in a sanitary manner prior to resident use. (q) Observation of the dish machine room noted that the ceiling mounted light cover and ceiling tiles (2) surrounding the light were broken and had large areas of peeling paint. Further observation noted that the light fixture and tiles surrounding the light were located directly above the 3-compartment sink. The surveyor discussed with the CD that small pieces of the plastic light cover and peeling paint were dropping directly into the 3-compartment sinks. The surveyor requested that the 3-compartment sinks not be utilized until the issues were corrected. (r) Observation of the dish machine room noted clean dish and food preparation equipment were being stored on soiled and paint peeling shelving. Specifically, 12 storage shelves were noted to have a large area of dried food matter and peeling paint. The surveyor requested of the CD to clean or purchase new shelving. (s) Observation of the dish machine room noted the walls surrounding the dish machine and 3-compartment sink were heavily soiled and had a build-up of black mold type matter. The surveyor requested of the CD to clean and sanitize the area walls immediately. Photographic Evidence Obtained for 1. (a) through (s). 2. During the observation of the lunch meal on [DATE] at 12:15 PM, food temperatures were taken by the facility's Consultant Registered Dietitian (CRD) with the use of the facility's calibrated thermometer in the satellite kitchen. The temperature testing noted that cold foods were not being held with the regulatory temperature of 41 degrees F (Fahrenheit) or below. The temperatures were recorded as follows: Chicken Caesar Salad (8 individual portions) = 46 degrees F. Sliced Turkey Sandwich ( 9 individual portions) = 46 degrees F. 3) During the observation of the breakfast meal conducted on [DATE] at 7:30 AM in the Third Floor Satellite Kitchen, accompanied with the facility's Consultant Registered Dietitian, the following were noted: (a) The wall area located above the wall-mounted storage cabinets were heavily soiled and dust laden. (b) The wall area located above the commercial microwave oven was noted to covered in a black oil type matter and was leaking down onto the oven. (c) The floor area and base board located under the steam table and serving counter was noted to be soiled, stained, and numerous areas of dried food matter. Photographic Evidence Obtained for 3. (a), (b), (c).

Based on observation, interview, record review of policy & procedure review, the facility failed to properly dispose of a remaining powder medication packet for 1 of 6 sampled residents observed during a Medication Administration Observation, Resident #149; failed to ensure it maintained the resident's medication in line of sight, during a Medication Administration Observation, for 1 of 6 sampled residents observed, Resident #149; failed to properly dispose of an unsecured, expired over-the-counter (OTC) medication at the resident's bedside for 1 of 13 residents observed during an observational tour, Resident #17; and failed to ensure it properly secured medication as a 'loose' pill was observed on the dining room patio floor during a facility residents' activity. The findings included: Review of facility policy and procedure on [DATE] at 1:08 PM for 'Storage of Medications', provided by the Director of Nursing (DON), revised [DATE] for Long Term Care (LTC) Facility's Pharmacy Services and Procedures Manual, Storage and Expiration Dating of Medications, Biologicals. Applicability documented in part: .sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) .or (3) , are separated from other medications until destroyed or returned to the pharmacy or supplier 8. Facility should ensure that resident medication and biological storage areas are locked 13. Bedside Medication Storage 13.1 Facility should not administer / provide bedside medications or biologicals without a Physician / Prescriber order and approval by the Interdisciplinary Care Team and Facility administration 16. Facility should destroy or return all discontinued, outdated / expired or deteriorated medications or biologicals in accordance with Pharmacy return / destruction guidelines and other Applicable Law, . 1. On [DATE] at 9:28 AM, during a Medication Administration Pass Observation of Staff H, a Licensed Practical Nurse (LPN), for Resident #149, the LPN was observed tossing the 'remaining' [MEDICATION(S)] 4gm ,d+[DATE] medication packet (powder) into the trash bin located on the medication cart Team I Riverbend Road neighborhood Memory Care . A brief interview was conducted with the nurse on [DATE] at 9:30 AM and she was asked why she tossed this in the medication cart trash bin. Staff H stated and acknowledged that the medication packet should not have been tossed in there. 2. On [DATE] at 9:42 AM, during a Medication Administration Pass Observation of Staff H, the LPN was observed leaving both of Resident #149's eye drops and nasal spray unattended, out-of-her-line-sight and accessible at the bedside on the overbed table with the resident while she went into the bathroom to wash her hands. The nurse also acknowledged that she should not have left the medications unattended at the resident's bedside. During a brief interview conducted on [DATE] at 9:42 AM with the LPN, she was asked why she had left the two (2) medications unattended at the resident's bedside. She acknowledged that she should not have left the medications unattended. 3. On [DATE] at 10:55 AM, Resident #17's room was observed as having a used expired visible bottle of (OTC) Saline nasal spray with an expiration date of ,d+[DATE] located in his bathroom on the shelf above the toilet. The (OTC) Saline Nasal spray medication was unsecured and accessible to other residents, employees and visitors. Resident #17 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence was obtained of the used/expired bottle of (OTC) Nasal spray medication. During a brief interview with Resident #17 on [DATE] at 11 AM, Resident #17 stated, regarding the (OTC) Saline Nasal Spray medication bottle on the shelf in his bathroom above the toilet, that his wife brought in the bottle for him to use as he needs it. On [DATE] at 2:09 PM, Resident #17's room was observed as having the used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet. This was confirmed by second surveyor. On [DATE] at 10:12 AM, Resident #17's room was again observed as having a used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet On [DATE] at 2:31 PM, Resident #17's room was observed as having a used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet. [DATE] 09:41 AM Resident #17's room still observed as having a used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet. An interview was conducted on [DATE] at 10 AM with Resident #17's nurse, Staff I, LPN, regarding the (OTC) Saline Nasal spray medication bottle observed on Resident #17's bedside table and she acknowledged that the medication bottle should not have been there. A side-by-side record review was conducted with Staff J, a Registered Nurse Unit Manager (RN/UM) for the 1st and 3rd floors. The record indicated that neither Resident #17's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for him to be able to administer his own medications. There was no physician order on the Resident #17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The bottle of expired (OTC) nasal spray medication was not removed from this resident's bedside, until after surveyor intervention. 4. On [DATE] at 2:05 PM, during a resident bingo game observation conducted of the Activity Room off the main dining on the first floor, it was noted that there was a loose, unidentified white tablet on the floor in the presence of nine (9) vulnerable residents who were all seated at the Activities Bingo table. This boservation of the pill was confirmed by a second surveyor. Photographic evidence was obtained of the single, loose, unidentified white table on the Activity room floor. During an interview conducted on [DATE] at 10:20 AM with Staff J, she indicated this resident does not self-administer any of his own medications and was not assessed to be able to do so. On [DATE] at 10:45 AM, the Director of Nursing (DON) further acknowledged and recognized that the remaining packet of medication should not have been tossed into the medication cart trash bin, indicated that the nurse should not have left the resident medication unattended at the bedside, that the pill should not have been on the floor, and the (OTC) Saline Nasal Spray medication should not have been left at the resident's bedside.

Based on interviews, record and policy review, the facility failed to ensure that antipsychotic medication had a clinical indication for use, that the ordering Prescriber had conducted a comprehensive assessment of the resident and that behaviours were adequately monitored for 1 of 5 sampled residents reviewed for the unnecessary medication (Resident #46). The findings included: A review of the facility's policy, titled, [CONDITION(S)] Medication Use, dated 12/01/2007, showed that the following: all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose and should be monitored for efficacy, risks, and benefits. It further showed that If the Prescriber orders a [CONDITION(S)] medication for the resident, the facility should ensure that the Prescriber has conducted a comprehensive assessment of the resident as documented in the clinical records. Review of the F29, a billable/specific ICD-10-CM code, revealed it can be used to indicate a diagnosis for reimbursement purposes, and was indicitive of Unspecified [CONDITION(S)] is not due to a substance or known physiological condition. Record review showed that Resident #46 was admitted to the facility on [DATE] with diagnoses to include: Heart failure, [CONDITION(S)], Depression, Cognitive Communication Deficit, and Muscle Weakness. Review of the Physicians' orders for Resident #46 showed an order for [MEDICATION(S)] ([MEDICATION(S)]) Tablet 25 milligrams and to give one tablet by mouth in the morning for Depression which was dated 06/27/22. The care plan, dated 07/14/22, showed that Resident #46 is on [CONDITION(S)] medication, and to monitor for and document any adverse reactions to the [CONDITION(S)] medications. Further review did not show that Resident #46 was provided with an antipsychotic medication for the diagnosis of Depression or [CONDITION(S)]. In an interview conducted on 08/03/22 at 8:30 AM, Staff D, Registered Nurse, stated that any monitoring for behavior is documented in the nurse's unit in a binder, titled, Monitoring Behaviors. Review of the 'Behaviors Monitoring Binder', located on the 3rd floor in the nurses' station, showed that monitoring behaviors was conducted on Resident #46 for the month to present for August 2022, but no behavior monitoring was documented for the entire month of July 2022. In an interview conducted on 08/03/22 at 8:35 AM, Staff D, Minimum Data Set Coordinator (MDS), stated that when a resident is placed on Antipsychotic medication with a diagnosis in place, Staff E, Nurse Practitioner (NP), will update the diagnosis tab in the electronic system to reflect the new diagnosis that was identified. When asked by the surveyor if Resident #46's diagnosis was updated with [CONDITION(S)], he said 'no'. Staff D further stated that if a resident is placed on Antipsychotic medication, he would initiate a care plan for behavior monitoring that may be under another section named Psychotronic medication. He would also identify the diagnosis with the antipsychotic medication under the [CONDITION(S)] medication section of the care plan. An interview was conducted on 08/03/22 at 9:00 AM with the facility's Director of Nursing (DON). The DON stated when Resident #46 was first admitted to the facility, he questioned Staff E (NP) when she prescribed [MEDICATION(S)] for diagnosis of Depression on admission. He further stated that Staff E reported that they would monitor Resident #46's behaviors and reassess him later when they get to know him better. The DON further said that he spoke to Staff F, Medical Director (MD), last night, who told him that he would update the diagnosis of Delusional [CONDITION(S)] in the medical chart for Resident #46. In an interview conducted on 08/03/22 at 9:10 AM, Staff D, Registered Nurse (RN), stated she is unfamiliar with Resident #46 and is unsure of any behaviors that he may have exhibited in the past. She further noted that she is new to the unit and was not assigned to Resident #46 in the past. In an interview conducted on 08/03/22 at 9:15 AM with Resident #46, he stated that he did not know that he was on [MEDICATION(S)] and then said, what is this medication for. When told by the surveyor that it was prescribed to him for Depression, he said: I am not depressed. Resident #46 also reported that he does not remember speaking to Staff E, the Nurse Practitioner, or that she came to see him in his room while in the facility. Review of the Pharmacy recommendation report, dated 07/05/22, showed the following: Please discontinue [MEDICATION(S)]. If medication is to continue, please clarify the diagnosis. Depression is an inappropriate diagnosis for antipsychotics. It further showed that the physician response to keep the prescription and change Resident #46's diagnosis to code F29. The Consultation report did not include the date that Staff F (MD) wrote the answer and did not have his signature. A review of the Minimum Data Set (MDS), dated [DATE], showed that Resident #46 had a Brief Interview of Mental Status (BIMS) score of 14, which is cognitively intact. A review of Section E of the MDS for behaviors showed that Resident #46 did not exhibit any behavior symptoms. Section N of the MDS showed that Resident #46 was receiving Antipsychotic medication in the last 7 days. A review of the progress note, dated 07/14/22, completed by Staff E, showed that the following: 'Resident #46 is evaluated for evaluation of indication for [MEDICATION(S)] 25 mg at bedtime as it is indicated for Depression. The patient was noted to have nighttime dilutional thinking behaviors. It further showed that [MEDICATION(S)] is used for the management of delusional thinking patterns. Therefore the appropriate diagnosis is F 29.' Further review of Resident #46's medical chart did not show any psychology evaluation to this progress note that was written on 07/14/22. A review of the admission records did not show that Resident #46 was ever on [MEDICATION(S)] prior to this or that he had a prior diagnosis of [CONDITION(S)]. A review of the Consultation report by the Pharmacy,, dated 06/30/22 showed that the Pharmacist recommended discontinuing [MEDICATION(S)] for the diagnosis of Depression. Staff F, Medical Director, declined the recommendation stating that Resident #46 is new to the facility and will have a Psych evaluation. This information was provided to the surveyor on 08/04/22, which was the last day of the survey.

Based on interview, record review and observation the facility failed to prevent 1 of 1 sampled residents reviewed for elopement, Resident #1, from exiting the facility to outside of the facility unsupervised. The findings included: The facility's Policy and Procedures Manual has a subject titled Elopement/Wandering Risk Assessment, issued 04/03 and last revised 03/21, that defines Elopement as When a cognitively impaired resident leaves the community without following the community policies and procedures for signing out. According to the facility's investigation, Resident #1, an elderly female with a Brief Interview of Mental Status (BIMS) of 04, indicating cognitive impairment, was found on the sidewalk adjacent to the facility at the intersection where the sidewalk meets the employee parking lot. Resident #1 was found in her wheelchair at 4:41 PM by Licensed Practical Nurse (LPN) Staff A, who was leaving after her shift, which was 7:00 AM to 3:00 PM. Staff A stated she stopped her vehicle and called the first-floor nursing station to report that she found the resident outside. On 07/05/22 at 9:49 AM, a facility tour was conducted with the Director of Physical Plant Services. During the tour an observation was made of the area outside of the building where Resident #1 was located at the time of the elopement. The door where Resident #1 allegedly exited led to a sidewalk that terminated approximately 10 feet from the door. The sidewalk ended adjacent to a small grassy plot of land on the right and a locked gate that led to an enclosed patio on the left. The Director of Physical Plant Services explained that the gate on the left was permanently locked and could not be bypassed. The surveyor, with the assistance of the Director of Physical Plant Services, used a wheelchair to try and re-enact the elopement as described in the investigation report. Once outside the building it was determined that the only way to get from the sidewalk that reached a dead-end to the sidewalk where Resident #1 was found was to cut across the grass. It was noted at the time that the grass had a slight slope downward and one could not maneuver a wheelchair down the slope while seated on the wheelchair as the wheelchair stopped once the front wheels went onto the grass. The only way to cross the grass was to push the wheelchair over the terrain. Once on the sidewalk one could reseat themselves in the wheelchair and propel along the sidewalk to where Resident #1 was found. On 07/05/22 at 10:24 AM, an interview was attempted with Resident #1. Resident #1 was alert to self only and denied ever wheeling herself through the halls using a wheelchair. Resident #1 was observed in he wheelchair at that time as she moved slowly and aimlessly around the room. Resident #1 was not easy to understand because she did not have a clear thought pattern where she rambled when she spoke, she spoke softly and some of her words sounded like gibberish. Resident #1's room was located closest to the nurses' station diagonally across the hall from the dining room/activities area. The door where she allegedly exited was accessible by crossing through the dining room and making a left turn. This would be the most direct root for Resident #1 to take. At the back of the dining room there is smaller area, separated from the main dining area by a low wall with an entryway from the main dining area. This location was used for activities. The area had two doors for access to a fenced, outdoor patio. The doors had wander guard type sensors that would cause the door to lock and an alarm to sound if a person with a sensor was within 3 feet of the door at the same time as the door was being opened or the person wearing the sensor attempted to let themselves out the door. There was a gate at the backend of the patio that was locked and could only be opened with a key code. The gate opened to the parking lot and allowed direct access to the sidewalk where Resident #1 was found. The distance from the gate to the sidewalk was approximately 10 feet. The distance along the sidewalk to where Resident #1 was found was approximately 30 to 50 feet. On 07/05/22 at 12:04 PM, an interview was conducted with the Director of Rehabilitation Services. The Director of Rehabilitation Services stated Resident #1 had been placed back into rehabilitation services because Resident #1 had just returned from the hospital on 06/06/22. The Director of Rehabilitation Services provided documentation regarding the Occupational Therapy Plan. The Occupational Therapist (OT) documented improvements in transferring for toileting as well as upper body and lower body dressing. The OT documented that the resident was motivated and had improved sitting balance, which allowed for improvements in transfers and dressing. The OT documentation expressed that Resident #1 stated that she wanted to walk. The OT therapy assessment showed that Resident #1 was at a high risk for falls, documented as 4 times as likely to have 2 or more falls in 6 months. The OT also documented that Resident #1 had poor self-safety awareness with impaired standing balance. On 07/05/22 at 1:19 PM, an interview was conducted with the Activities Director. She showed a document from a former employee where that employee identified himself as a witness of the elopement. The document had a statement from the former employee that he heard the alarm and went to reset the alarm but could not remember the code. He also had written that he tried to open the doors but was unable to do so. He wrote that he went back to his office to do documentation but then he went outside with the nurse when he heard that there was a resident outside. He wrote that he did not look for the resident when the alarm went off. On 07/05/22 at 2:22 PM, a telephone interview was conducted with the Registered Nurse (RN), who was the interim Director of Nursing (DON) at the time of the elopement. She stated that during her investigation she noted that it did not seem feasible to her that Resident #1 eloped in the manner that was described by staff. She stated that the door alarm was reported to have been activated at 4:41 PM, which is the same time the call was received from Staff A the LPN who found Resident #1 when Staff A was leaving from work. The former DON stated that she and the Administrator tried to re-enact how Resident #1 exited the building and proceeded to where she was found. The former DON stated that it took her almost 5 minutes to take the most likely path from exiting through the doors, down the sidewalk, across the grass to the other section of sidewalk, and on to the site where Resident #1 was found. The former DON stated that the grass was too resistant to propel down the slight slope while sitting in the wheelchair. The former DON stated that the facility had the volume of the alarms raised after the event. On 07/05/22 at 3:24 PM, an interview was conducted with LPN Staff A who was the nurse who discovered Resident #1 outside on the sidewalk. Staff-A stated that Resident #1 was unsteady on her feet but would use the wheelchair as a walker. She stated that Resident #1 was exhausted and sweaty when resident #1 was found. She stated she was leaving at around 5:00 PM when she saw Resident #1 in her wheelchair on the sidewalk near the loading dock. She stated the weather was hot. She stated she stopped her car and got out. She then called the 1st floor nurse's station to let them know that Resident #1 was out there. She stated that she waited with Resident #1 until the on-duty staff came to retrieve Resident #1. LPN Staff A stated that she gave her statement over the phone and also emailed her statement to the Administrator. According to LPN Staff A Resident #1 was exit seeking. The nurse stated that the staff uses the back doors to go upstairs from the 1st to 3rd floors. This would require using the code to unlock the doors. On 07/05/22 at 3:57 PM, an interview was conducted with Staff B an LPN. Staff B was the nurse who took the call at the first floor nurses station, where she was informed by Staff A about Resident #1 being found outside the facility. Staff B stated that she was working in one hallway and when she was on her way up the hallway she heard the phone a the nurses' station ringing. When she answered the phone she was told by Staff A that Resident #1 was outside on the sidewalk. The nurse stated she called out to everyone that Resident #1 was outside on the sidewalk. Staff B stated she then proceeded out to the patio, opened the gate and walked to where she saw Resident #1. She stated that Resident#1 was her normal baseline and did not appear sweaty. The nurse stated that the resident did not have slurred speech. She stated that the exit doors had a very low tone, and she did not hear it. She noted that the glass side door (outer door) was ajar and not closing as it should. On the next day she reviewed the events with the DON and ADON. At that time, she informed the DON and ADON that the door was not closing properly. This was investigated and fixed the next day. Staff B stated that when Resident #1 starts talking about going back to New York they redirect her away from doors. They redirect using activities she likes, such as puzzles and movies. Staff B stated that she was not aware of any other attempts for Resident #1 to leave the premises. Staff B stated that she rechecked Resident #1's security band for function when Resident #1 re-entered the building after checking Resident #1 for injury and mental status. Staff B stated that Resident #1 did not have any physical injuries and was alert and oriented to self. On 07/05/22 at 4:52 PM, an interview was conducted with Staff C, a Registered Nurse, who was working the afternoon Resident #1 eloped. Staff C stated that she was in a different resident's room providing a medication and when she went into the hallway, she saw an activities person pushing buttons on the door code to try and stop the alarm. Staff C stated she went down the hall to enter the code to silence the alarm. Staff-C stated that the alarm was sounding but it was not very loud. Staff C stated she heard the other nurse call out that Resident #1 was outside before she reached the Activities person to turn off the alarm. At that time, Staff C stated she turned around and went back to the nurses' station without turning off the alarm. Staff C stated she went with Staff B to retrieve Resident #1. Staff C stated that Resident #1 did not look dehydrated, and she was speaking normally. Staff-C stated that she did not feel Resident #1 was ill or suffering from heat exhaustion.

Based upon interview and record review, the facility failed to provide a signed completed copy of the Baseline Care Plan for Resident #49, to the resident/family/representative, whose closed record was reviewed for a resident who expired in the facility; and the facility failed to complete a Baseline Care Plan within the required 48 hours after admission for Resident #38, who was reviewed for Catheter Care. This affected 2 of 18 sampled residents reveiwed for care plans, Residents #49 and #38. The findings Included: 1. Resident #49 was admitted to the facility under hospices services on [DATE]. On [DATE] at 1:14 PM, while reviewing the closed record for Resident #49, who expired in the facility, it was noted that the comprehensive care plan did not address Hospice Services. On [DATE] at 1:47 PM, an interview was conducted with the Minimum Data Set (MDS) coordinator who could not find any entry in the Comprehensive Care Plan that addressed Hospice Care. It was later learned that the resident had been previously admitted to and discharged from the facility, which allowed the facility to re-instate the previously written comprehensive care plan. Resident #49 had not been in hospice at that time. On [DATE] at 2:54 PM, the Director of Nursing (DON) provided a copy of the Baseline Care Plan for Hospice services. The DON was unable to explain why Hospice Services was not included in the Comprehensive Care Plan. A review of the Baseline Care Plan revealed that the Baseline Care Plan had not been signed by staff, or by the resident/family/representative. There were no indications that the Baseline Care Plan had been provided to the resident/family/representative as required. On [DATE] at 9:11 AM, the MDS coordinator was reinterviewed. The MDS coordinator stated that she has been working at the facility for 4 months. The MDS coordinator stated that when a resident is admitted to the facility, the admitting nurse is supposed to complete the Baseline Care Plan at the time of admission and the Baseline Care Plan is supposed to be completed with 48 hours of admission. The MDS coordinator stated that any nurse can complete a Baseline Care Plan. The MDS coordinator stated that the Baseline Care Plan is placed in a physical record as well as in the Electronic Health record. The MDS coordinator confirmed that a written, signed copy is supposed to be provided to the resident / family / representative. The MDS coordinator stated that the facility has an admissions checklist that is supposed to ensure the Baseline Care Plan is completed, but she did not know who was responsible for making sure it was completed within 48 hours and provided to the resident / family / representative. On [DATE] at 9:27 AM, an interview was conducted with the Director of Nursing (DON). The DON indicated that he started with the facility on [DATE]. The DON stated that he believed the Baseline Care Plan should be started within 72 hour of admission and the facility had 14 days to complete the process. The DON was informed that the Baseline Care Plan had to be completed within 48 hours, that the initial MDS assessment had to be completed within 14 days from admission and the Comprehensive Care Plan needed to be completed within 7 days of initial assessment which is equivalent to 21 days from the admitted . When asked who was responsible to complete the Baseline Care Plan, the DON stated either the admitting nurse or the MDS coordinator. When asked about oversight of the completion of the Baseline Care Plan, the DON stated that the facility was still developing that process. On [DATE] at 10:24 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was on leave and did not return to the facility until [DATE]. The ADON stated that the DON started in [DATE]. The ADON stated that the admitting nurse is the person who should complete the Baseline Care Plan, but any nurse can complete it, but it must be done within 48 hours of admission. The ADON stated it is best for the admitting nurse to do the Baseline Care Plan at admission as the process requires asking direct questions of the resident / family / resident representative. The ADON was shown a copy of the Baseline Care Plan for Resident #49. The ADON stated she remembered the resident and she did not remember providing a copy to the resident / family / representative. 2. Resident #38 was admitted on [DATE]. Record review revealed that on [DATE], a phyisician order was placed that documented 'Catheter care every shift - catheter placed for Urinary Retention'. During further record review for Resident #38, who was observed for Catheter Care, it was noted that the Baseline Care Plan was not completed within the required 48-hour time period. Resident #38 was admitted on was [DATE], a Friday, at 23:23 (11:23 PM). The Baseline Care Plan was completed on [DATE], a Monday, at 13:27 (1:27 PM). According to the information previously provided by the ADON and the MDS coordinator in example #1 above, the Baseline Care Plan should have been completed by Sunday [DATE]. On [DATE] at 1:48 PM, an observation of catheter care was made of Staff E, a Certified Nursing Assistant (CNA), for Resident #38. Staff E stated that the care would be provided in the bathroom as this was how the care was done. Record review conducted after the observed care revealed no care plan entries to address this accommodation and change in the facility's procedures.

Based on observations, interviews and record review, the facility failed to revise care plans according to resident needs for dining assistance for 2 of 18 sampled residents, Resident #31 and Resident #41; and failed to revise a care plan to reflect changes to catheter care for 1 of 2 sampled residents reviewed for catheter care, Resident #38. The findings included: Review of the Centers for Medicare & Medicaid Services Resident Assessment Instrument Version 3.0 Manual, titled Care Plan Completion, dated April 2012, documented the following: Nursing homes should also evaluate the appropriateness of the Care Plan after each Quarterly assessment and modify the Care Plan on an ongoing basis, if appropriate. Review of the facility's policy titled, Meals, Serving, revised on May 2018, documented the following: Encourage residents to eat themselves, but assist as necessary. Any resident that is unable to eat himself/herself must be assisted. 1. Review of the record documented that Resident #31 was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not conducted, as Resident #31 was rarely / never understood. Review of Section G of the MDS, dated [DATE], documented that Resident #31 required limited assistance with one person physical assist for eating. Review of the Care Plan, dated 03/22/21, documented that Resident #31 had an activities of daily living (ADL) self-care performance deficit related to limited mobility, visual impairment, and cognitive deficit. It was further documented that Resident #31 required supervision set up for eating. During an observation conducted on 06/21/21 at 12:29 PM, Resident #31 was observed in the dining room, seated at a table with two other residents [one ate independently, and one ate with feeding assistance from Staff D, Certified Nursing Assistant (CNA)]. Closer observation showed that Resident #31 was not eating and that she was dipping her fingers into her bowl of soup. At 12:40 PM, Resident #31's uneaten soup was removed from the table. It was further noted that she had not received any feeding assistance from staff. A lunch plate that contained a hotdog, sauerkraut, and baked beans was then placed on the table in front of Resident #31. Resident #31 did not eat and was observed poking her hotdog bun with her fingers and ripping it into small pieces, leaving them on her plate. At 12:56 PM, Resident #31 had still not eaten her lunch. At this time, Staff D had finished feeding Resident #31's tablemate and began feeding Resident #31 her lunch. Resident #31 did not receive feeding assistance from staff until 16 minutes after her lunch was delivered. At 1:09 PM, Resident #31 had consumed about 50% of her lunch plate. Resident #31 had not eaten her lunch until she received feeding assistance from Staff D. During an observation conducted on 06/23/21 at 12:06 PM, Resident #31 was observed in the dining room, seated at a table with a resident that was receiving feeding assistance. Closer observation showed that Resident #31 did not have any food in front of her and that she was rolling up her placemat watching her tablemate eat their lunch. At 12:24 PM (18 minutes later), a bowl of soup was placed in front of Resident #31. Closer observation showed that she was dipping her fingers into her bowl of soup and running her fingers along the edge of her bowl. At 12:26 PM, Staff B, CNA, sat next to Resident #31 and provided feeding assistance with her with her soup. During an interview conducted on 06/23/21 at 2:11 PM, the MDS Coordinator stated that she was responsible for completing sections A, B, G, GG, H, I, J, L, M, N, P, and part of O of the MDS assessment. She stated that in order to determine a resident's functional abilities for Section G, she 'would use the look back report for the past 7 days, follow the rule of three, refer to the previous MDS assessment, and observe the resident on a daily basis.' She further stated that if there was a discrepancy, she would question the staff. When asked about limited assistance with one person physical assist for eating, she stated that she would expect for staff to guide utensils into the resident's mouth or to place cups into the resident's hands. She further stated that if a resident required feeding assistance from staff they would be marked as extensive assistance or total dependence in Section G of the MDS assessment. During an interview conducted on 06/24/21 at 9:47 AM, Staff D and Staff B stated that they were usually in the dining room during meal times and that they were familiar with Resident #31. They stated that Resident #31 did not eat much food and that she required cueing during meals. The surveyor informed them that Resident #31 was observed dipping her fingers into her food, rolling up her placemat, and leaving her food uneaten when left to eat independently at meal times. Staff D and Staff B stated that Resident #31 ate better when she was cued or provided with direct feeding assistance from staff members. 2. Review of the record for Resident #41 documented that he was readmitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the MDS, dated [DATE], showed that Resident #41 had a BIMS of 03, which indicated that he was severely cognitively impaired. Review of Section G of the MDS showed that Resident #41 required limited assistance with one person physical assist for eating. Review of the Care Plan, dated 04/29/21, documented that Resident #41 had an ADL self-care performance deficit related to weakness, recent altered mental status, and hospitalization . It was further documented that Resident #41 required assistance with meals. Closer review showed that there were no interventions specific to eating. During an observation conducted on 06/22/21 at 8:16 AM, Resident #41 was seated in the dining room with a bowl of oats in front of him. Closer observation showed that Resident #41 was not eating and was falling asleep at the dining table. At 8:33 AM, Staff C, Registered Nurse, sat down next to Resident #41 and fed him spoonfuls of his oats. Resident #41 did not receive feeding assistance from staff until 17 minutes later. At 8:41 AM, Resident #41 had consumed about 75% of his oats. Resident #41 had not eaten his oats until he received feeding assistance from Staff C. At this time, the bowl of oats was removed from the table, Staff C left Resident #41 to provide feeding assistance to another resident in the dining room, and a breakfast tray was placed in front of Resident #41. At 8:44 AM, Staff C walked back over to Resident #41 and provided verbal encouragement to eat. Resident #41 ate one spoonful of his breakfast and then stopped eating. At 8:58 AM, Resident #41 had consumed less than 25% of his breakfast meal. At this time, Staff B sat next to Resident #41 and began feeding him his breakfast. Resident #41 did not receive feeding assistance from staff until 17 minutes after his breakfast plate was delivered. At 9:08 AM, Resident #41 had consumed about 50% of his breakfast. Resident #41's intake increased when he was provided with feeding assistance from Staff B. During an interview conducted on 06/24/21 at 9:14 AM, Staff C stated that she usually worked in the dining room when the facility required her assistance and that she was familiar with Resident #41. According to her, Resident #41 was able to eat independently but sometimes required cueing. The surveyor informed her that Resident #41 was observed falling asleep at the table and consuming little to none of his meal when left to eat independently at meal times. Staff C stated that Resident #41 required cueing during meals and that at times, he would need staff to feed him. She further stated that Resident #41 would sometimes even ask for staff to feed him his meals. 3. The facility policy, titled, 'Catheter Care, Indwelling', last revised 03/15, in the Procedure section stated the following: Under 4. Catheter care can be given during the AM or PM care as follows: a. Assist the resident into a supine position. Resident #38 was admitted on [DATE]. Record review revealed that on 10/23/20, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/23/21 at 1:48 PM, an observation of catheter care was made of Staff E, a Certified Nursing Assistant (CNA), for Resident #38. Staff E stated that the care would be provided in the bathroom as this was how the care was done. Catheter care was provided while the resident was standing. Record review conducted after the observed care revealed there were no care plan entries to address or revise this accommodation, the resident's preference to stand in the bathroom and change in the facility's procedures.

Based on observation, record review and interview, the facility failed to practice appropriate infection prevention and control and failed to ensure negative factors that may impact skin integrity and wound healing treatment were prevented during wound care observation for 1 of 1 sampled resident, Resident #24, reviewed for wound care. The findings included: Review of Resident #24 clinical record documents an initial admission to the facility on [DATE] with a readmission on 04/26/21 with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident Minimum Data Set (MDS) quarterly assessment dated [DATE] documents the resident Brief Interview Mental Status (BIMS) score of 8 indicating a moderate cognitive impairment. Review of Resident #24 clinical record documents a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Wound Care and Dressing Changes, revised on 08/11, documents, hand washing must be completed before and after removing a soiled dressing, before applying the new dressing . On 06/23/21 at 11:11 AM, observation revealed Staff F, a Licensed Practical Nurse, wheeling Resident #24 down the hallway to her room. Observation revealed the resident wheelchair did not have a footrest and her feet were touching the floor. The resident was wearing a pair of yellow non-skid socks. During an interview, Staff F was asked if the residents wheelchair had footrests and stated that she had to check with the therapy department and added that the resident propels herself around the unit in her wheelchair. On 06/23/21 at 11:12 AM, wound care observation performed by Staff F for Resident #24 was conducted. Staff F walked into the resident's room with her wound care supplies, disinfected the table, performed hand hygiene, donned gloves, placed a barrier over the table and stated that the right side of the table was her clean field, and the left side was her dirty side. Observation revealed the resident was sitting in her wheelchair. Staff F then lifted up the resident's right foot from the floor, removed her yellow nonskid socks, and her right heel dressing dated 06/22/21. Continued observation revealed the resident holding her right leg up on the air with her right heel wound open to air and no barrier pad noted on the floor. Staff F proceeded to remove her gloves, performed hand hygiene and donned gloves. Further observation revealed Resident #24 resting her right foot on the floor. Staff F lifted the resident's right foot and proceeded to clean the wound located on her heel with normal saline and with her contaminated gloves, reached the clean field to retrieve a gauze, dried the wound, reached for [MEDICATION(S)] (wound medication), and applied the [MEDICATION(S)] to the inside of the wound. Staff F continued to reach the clean field with her contaminated gloves and applied a cover dressing to the wound. Staff F then placed the same yellow non-skid sock to the resident right foot. On 06/24/21 11:39 AM, a joint interview was conducted with the Assistant Director of Nursing (ADON) and Staff F. Staff F stated that she changed her gloves, performed hand hygiene after the removal of the soiled dressing, then donned gloves, cleaned the wound, and then applied the treatment. Staff F was apprised that she did not change her contaminated gloves after she cleaned (dirty) wound. Staff F stated she did not know she has to change the gloves in between cleaning and applying the treatment. The ADON stated that Staff F had to change her gloves after she cleaned the wound, perform hand hygiene and don gloves before applying the treatment.

Based on observation, record review and interview, the facility failed to correctly perform urinary catheter care for 1 of 2 sampled residents, Resident #38, with an indwelling urinary catheter, reviewed related to Urinary Catheter or UTI (Urinary Tract Infection). The findings included: The facility policy, titled, 'Catheter Care, Indwelling', last revised 03/15, in the Procedure section stated the following: Under 4. Catheter care can be given during the AM or PM care as follows: a. Assist the resident into a supine position. Under 14. If resident has a leg urine collection bag, he/she uses during the day, drain the bag every 2-3 hours following these steps: a. Wash hands with soap and water and apply clean non-sterile gloves. b. Unfasten the lower leg strap. c. Remove the cap and open the clamp. d. Drain the urine into the toilet or urine collection container. e. Close the clamp and refasten the lower leg strap. f. Remove gloves and wash hands with soap and water. Resident #38 was admitted on [DATE]. Record review revealed that on 10/23/20, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/23/21 at 1:48 PM, an observation of catheter care was made of Staff E, a Certified Nursing Assistant (CNA), for Resident #38. Staff E stated that the care would be provided in the bathroom as this was how the care was done. Record review conducted after the care revealed no Care Plan entries to address this accommodation and change in the facility's procedures. Staff E had prepared disposable wash clothes on the sink top, a towel on the towel rack, a urinal in a plastic bag and alcohol wipes prior to the observation. Staff E washed her hands and put on gloves. Resident #38 was seated on the toilet. Staff E assisted Resident #38 to a standing position. Staff E noted that Resident #38 had had a bowel movement and flushed the toilet. Staff E placed a paper towel on the floor, removed the urinal from the plastic bag and placed the urinal on the paper towel. Staff E unstrapped the lower portion of the leg bag and guided the drain bag drain into the urinal after removing the cap for the catheter drain. Staff E then emptied the urine drain bag into the urinal. Staff E wiped the drain and drain cap with alcohol pads from her uniform pocket reapplied the leg bag with a leg bag strap to Resident #38's leg. Staff E removed her gloves, washed her hands, and applied new gloves. Staff E used a disposable wash cloth wet with warm water to clean Resident 38 from his bowel movement, then proceeded to provide catheter care. Staff E used a new disposable cloth wet in the sink with warm water to perform the catheter care. Staff E washed around the resident's urinary meatus and washed downward along the tubing toward the drainage bag. Staff E then used the towel to dry the resident. Staff E assisted the resident with pulling up his pants. After placing the towel in a bag, Staff E tied up the trashed. Staff E emptied the urinal into the toilet, rinsed it with water from the sink faucet and flushed the content in the toilet. Staff E removed her gloves and washed her hands. On 06/23/21 at approximately 3:15 PM, the Catheter Care observation was discussed with Staff E and the Director of Nursing (DON) in the DON's office. The DON agreed that Staff E need to be re-educated regarding proper catheter care procedures.

Based on observations, interviews and record review, the facility failed to ensure medications were secured and failed to observe the residents' consumption of the medication for 3 of 7 sampled residents observed during medication administration observation on the facility's first and third floor units, Resident #50, #30 and #25, as evidenced by unattended medication observed on the residents' overbed table and as evidenced by leaving the residents before they consumed the medication poured into a cup of juice at his table in the dining room. The findings included: Review of the facility's policy, titled, Medication Administration and Management, revised 10/19, documents, .avoid leaving medications or chemicals unattended .observe the resident's consumption of the medications . 1. On 06/22/21 at 1:30 PM, medication administration observation was performed with Staff G, a Licensed Practical Nurse for Resident #50 on the third floor. Observation revealed Staff G retrieved a bottle of [MEDICATION(S)] eye drops, placed it on a plastic tray and walked to the resident's room. Staff G stated the resident was in the bathroom and asked for help. Staff G then placed the plastic tray with the eye drops bottle on top of the dresser and walked away from the eye drops to assist the resident who was in the bathroom. Observation revealed Staff G wheeling the resident out of the bathroom and stated there was not tissues in the room and walked out of the resident's room to the supplies room located behind the nurse's station leaving the medication unattended / unsecured. 2. On 06/22/21 at 2:16 PM, medication administration observation was performed with Staff G, LPN for Resident #30 on the third floor. Staff G proceeded to crush the resident's medication (Midodrine tablet for low blood pressure), placed it on a plastic tray, walked to the resident's room, placed the plastic tray with the medication on the overbed table next to the resident. Observation revealed Staff G walked away from the medication to the bathroom to perform hand hygiene, leaving the medication unattended. Staff G returned to resident bedside and proceeded to check the resident's feeding tube for patency. Observation revealed Staff G flushing the tube with 10 cc (cubic centimeter) of water, then poured the liquid medicationand the medication was not going down the tubing. Staff G attempted to unclog the tube with no success and stated she will ask for help. She then poured the medication back into a cup and placed it on the table. Observation revealed Staff G walked out of the resident's room to the nurse's station to look for the supervisor leaving the resident medication unattended on the table. 3. On 06/23/21 at 8:28 AM, medication administration observation was performed with Staff F, a Licensed Practical Nurse for Resident #25 on the first third floor. Observation revealed Staff F retrieved the resident's Polyethylene [MEDICATION(S)], a powdery medication to relieve constipation, packet. She stated that the resident preferred to take the powdery medication mixed in apple juice with his breakfast. Observation revealed Staff F walked to the dining room across from the nurse's station to Resident #25, who was sitting with another resident. Staff F proceeded to pour the medication into the Resident #25's 4 - 6 ounces of apple juice and she stirred it. Continued observation revealed the resident drank half of the amount of the juice mixed in with his medication and placed the cup back on the table. Staff F then walked away from the resident before he had completely consumed his medication. On 06/23/21 at 2:28 PM, an interview was conducted with the Director of Nursing (DON) who stated that during medication administration, the nurse should see if the resident is ready to take the medications, if they have to help the resident, they have to go back to the cart and secure the medications in the cart. He stated that the residents' medication have to be on their view at all the time; if they are in the bathroom, they do not know what is happening outside in the room. On 06/24/21 at 10:42 AM, an interview was conducted with Staff G. She stated that she always keeps the residents' medications with her, but that she was very nervous and did not realize she left Resident #50 and #30's medications unattended in their room. On 06/24/21 at 11:20 AM, a joint interview was conducted with Staff F and the Assistant Director of Nursing (ADON). Staff F acknowledged that she left Resident #25 in the dining room before he consumed his medication on 06/23/21. During the interview, the ADON stated the nurses are supposed to stay with the resident until they take the medication to ensure that they take it.

Based on observation, interview, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to require direct care staff to change and store their N95 masks per CDC guidelines which affected 55 current residents in the facility. The findings included: An interview was conducted with the Administrator and the Director of Nurses (DON) on 12/23/20 at 11:00 AM regarding infection control. The DON revealed that the facility had an increased number of resident and staff COVID-19 positive cases in the past 3 days and tested all residents and staff today. The interview continued with the DON regarding personal protective equipment (PPE) and revealed the direct care staff are wearing N95 filtering facepiece respirator (FFR) masks and face shields. They were instructed to change the N95 mask if it gets soiled or once a week. The administrator and DON also revealed that they are not requiring the direct care staff, except the COVID-19 unit staff, to leave their face shields and masks in the facility when they leave the building at the end of their shift. Current CDC guidelines documented, Strategies for Optimizing the Supply of N95 RespiratorsUpdated Nov. 23, 2020 reveal the CDC recommends limiting the number of donnings for an N95 FFR to no more than five per device. During times of crisis, [MEDICATION NAME] limited re-use while also implementing extended use can be considered. If limited re-use is practiced on top of extended use, caution should be used to minimize self-contamination and degradation of the respirator. If no manufacturer guidance is available, a reasonable limitation should continue to be five total donnings regardless of the number of hours the respirator is worn. Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings page reviewed 03/27/20 reveal the CDC recommends to Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified.

Based on observation and interview, it was determined that the facility failed to ensure and provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable dining area; and to ensure a safe environment and the proper operation of the bathroom emergency call bell system for 1 of 1 sampled resident (Resident #20). The findings included: 1. During the observation of the breakfast meal in the first floor main dining room on 10/08/19 at 9:05 AM, the following were noted: a) Two residents and two family members were noted to be seated at one of the dining room tables. The residents and family members finished the breakfast meal and all exited the dining room at the same time. Further observation noted that Resident #19 was brought into the dining room at 10 AM. It was noted that the table and chairs were not cleaned and sanitized prior to seating Resident #19 at the soiled table. b) At 10 :15 AM, it was noted that an activity had begun in the dining room without all 9 dining room tables and chairs being cleaned and sanitized after the breakfast meal. It was further noted that numerous residents, staff (2) and family visitors (2) were seated at tables that were noted to be soiled from the breakfast meal. c) Two (2) of the nine dining room tables were set with clean silverware, linen napkin, and placemats without the tables being cleaned and sanitized after the breakfast meal. Following the observation, the surveyor discussed the issue with the Dining Room Manager. The manager stated that there has been a problem with the Activities Department starting group activities without the food service department having the opportunity to properly clean the dining area after meals. 2. During routine observations conducted of the room of Resident #20 on 10/07/19, it was noted that the bathroom call light cord was wrapped around the wall hand rail numerous times. An attempt to activate the bathroom call light by pulling the string noted that the wrapping of the cord around the hand rail made the emergency call light inoperative for use. Additional observations of the bathroom of Resident #20 were conducted on 10/08/18 at 9 AM, 12 PM, and 1:30 PM. Each observation noted that the cord remained wrapped around the hand rail. On 10/08/19 at 1:30 PM, the surveyor requested the Director of Nursing (DON) accompany the surveyor to the room of Resident #20. The DON confirmed the surveyor's findings and stated that the emergency call light was inoperable. Interview with the DON at the time of the observation noted to state that the resident is cognitively impaired, but is continent and uses the commode in the bathroom independently and does not require assistance from nursing staff. It was further discussed that the call light was inoperable in the bathroom and could not be utilized by the resident for possible fall and/or other accident incident. Review of the clinical record of Resident #20 noted an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly MDS (minimum data set), dated 08/07/19, documented a BIMS (brief interview for mental status) score of 3 (indicates severe Cognitive Impairment) and Extensive assistance with toilet use. Review of Assessment for Bowel & Bladder Program, dated 06/30/19, documented the resident requires assistance to the bathroom. Photographic evidence was obtained.

Based on observation, interview, and record review, it was determined that, based on the comprehensive assessment, the facility failed to provide necessary care and services for 1 of 4 sampled residents, to ensure the resident's ability to eat independently and consume proper amount nutrition independently did not diminish (Resident #20). The findings included: During the observation of the lunch meal of 10/07/19 at 12 PM, it was noted that Resident #20 was seated in the First Floor Dining Room. Observation of Resident #20 from 12 PM through 1 PM revealed the resident to just be sitting and staring and not consuming the lunch meal. It was noted during the observation times that staff were not sitting with the resident or encouraging the resident to eat. On 10/07/19 at 1:15 PM, the resident left the dining room and consumed less than 10% of the lunch meal. A second meal observation was conducted during the breakfast meal on 10/08/19 at 9 AM in the First Floor Dining Room. Again, it was noted that the resident was just sitting, staring, at times sleeping, and not consuming any of the breakfast meal. At 9:20 AM, a nurse sat with the resident until 9:35 AM. However, there was a lack in encouraging the resident to eat. On 10/08/19 at 9:40 AM, the resident was wheeled from the dining room and noted by the surveyor to only consume half a banana and a cup of coffee. Interview with the Director of Nursing on 10/08/19 at 3 PM, to discuss the resident's nutrition status and self feeding status, confirmed that the resident requires supervision / assistance throughout the meal and to be seated when possible a the restorative eating table located in the first floor dining room area. Observation of the breakfast meal on 10/09/19 at 8:15 AM noted the resident was brought to the main Dining Room. Further observation noted that the resident was not seated at the restorative dining room table. However, the facility provided a nursing staff member to seat with the resident throughout the meal. It was noted that staff provided needed supervision / assistance and the resident remained focused throughout the meal and consumed 100% of the breakfast meal. Review of the clinical record noted the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (minimium data set assessment), dated 08/07/19, documented a BIMS (brief interview for mental status) score of 3 (indicates sever cognitive impairment) and required Limited Assisted with eating. Review of Progress Note, dated 09/30/19, documented that the resident has been noted to be having difficulty initiating feeding. Further review documented the resident was noted to be stopping in the middle of meals. The resident was moved to the Restorative table for lunch, where a member of staff assisted with feeding and the resident ate 90% of the meal. Will continue to encourage and assist the resident with meals. Review of the Nutrition Note, dated 10/08/19, documented to increase cues with meals, difficulty staying on task, and sits at restorative table at times.

Based on observation and interviews, the facility failed to provide wound care consistent with professional standards of practice to prevent potential infection for 1 of 1 sampled resident reviewed for pressure ulcers (Resident #39). The findings included: Review of Resident #39 medical record documents a re-admission to the facility on [DATE]. Review of the nursing admission assessment documents that the resident came in with a pressure wound to the sacral (coccyx) area. Review of the physician order [REDACTED]. On 10/09/19 at 11:09 AM, an interview was conducted with Staff A Licensed Practical Nurse. She stated that Resident #39 was readmitted to the facility from the hospital with the sacrum wound. Staff A stated that Staff B Unit Supervisor will assist during Resident #39 wound care observation. On 10/09/19 at 11:15 AM, observations during wound care for Resident #39, revealed Staff A performed handwashing, donned gloves, placed a drape over the bed table, then the wound care clean supplies over the drape. Continued observation revealed Staff A removed the soiled dressing from the wound and carried it across and above the clean wound supplies on the clean field and discarded the soiled dressing into a red bag located on top of the table. Further observation revealed Staff A performed handwashing, donned gloves and proceeded to clean the sacral wound bed (inside the wound) with a saline soaked gauze using a circular motion multiple times with the same gauze. Staff A then soaked another gauze and cleaned the wound bed twice and with the same gauze, then cleaned the wound outside area. On 10/09/19 at 11:51 AM, a joint interview was conducted with Staff A and Staff B. Staff A was apprised about cleaning the wound bed with the same gauze multiple times, and cleaning the inside and the outside of the wound with the same gauze. Staff B confirmed wound care observations concerns and stated that Staff A should have cleaned the wound bed with one stroke and discarded the gauze. Staff B stated that she should not have used the same gauze to clean the inside and outside of the wound. On 10/10/19 at 1:45 PM, during an interview, the Director of Nursing (DON) was apprised regarding Staff A wound care technique. The DON stated a wound is cleaned with a gauze, one stroke, then discard.

Based on observation and interview, it was determine that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that include: proper maintenance of refrigeration equipment, proper cleaning of food preparation equipment, maintenance of air-condition vents and lighting fixtures, and ensuring foods are held at regulatory temperatures. The findings included: During the Food Service Sanitation Tour conducted on 08/27/18 at 9:00 AM accompanied with the facility's Diet Technician, Food and Beverage Director, and Executive Chef, the following were noted: 1. Main Kitchen: (a) During the observation of walk-in refrigerator #1, it was noted the exterior wall of the unit had a heavy build-up of condensation. It was discussed with the administrative team that the condensation is a symptom of a possible problem the refrigeration unit. (b) The air-conditioning ceiling vent located above the entrance to the dry food storage unit had a heavy build-up of condensation. It was discussed with the administrative team that the contaminated condensation could potentially drip down onto foods and/or staff resulting in food contamination. (c) The food portioning scale located on the clean pot and pan storage area rack was noted to be soiled and had areas of dried food matter. It was discussed with the administrative team the scale was not being proper cleaned and sanitized after each use. (d) The commercial steam jacket tilt kettle was noted by staff that it was ready for use. Observation of the tilt kettle noted that the bottom had a build-up of black mold type matter. The survey requested that the kettle be properly cleaned and sanitized before the next use. (e) Observation of the hot holding cart noted the base of the interior had areas of dried food matter and that the unit was not being properly cleaned on a daily basis. (f) The exterior of the commercial food mixer was noted to have numerous large areas of dried food matter and peeling paint. It was discussed that use of the mixer in the soiled condition could result in food contamination. The administrative staff stated that the mixer was slated for replacement. (g) Observation of the food preparation area noted that that cook was utilizing one of the departments cutting boards. Observation of the board noted that it was heavily stained, soiled, and had deep cut grooves. The surveyor requested that the board could no longer be properly cleaned and should be discarded. (h) Observation of the dry / canned food storage room noted that the freezer jackets (2) worn by staff when working in the walk-in freezer were hanging within the clean storage room. The surveyor informed the staff the jackets were soiled and contained dried body fluids and odors and should not be stored within the clean room. (i) Observation of the dry / canned food storage room noted that 2 of 2 ceiling mounted vents were laden with black dust, and 1 of 1 ceiling light fixture was also dust laden. It was discussed with the facility's administrative team that the dust could result in food contamination and should be properly cleaned on a regular basis. (j) Observation of the dish machine room noted the following: *Soiled food preparation pots and pans were stored in the clean area of the dish room next to racks of clean drinking glasses. *Ceiling vents (2) were noted to be dust laden. *Ceiling light frame (1) was noted to be rust laden. *Ceiling light fixture over dish machine was falling from mount and peeling paint around the frame. 2. First Floor Satellite Serving Kitchen: (j) The floor of the serving kitchen was heavily worn, soiled, and had numerous areas of a black mold type build-up. (k) At the request of the surveyor, hot and cold food temperatures were taken by facility staff with the use of the facility's calibrated digital food thermometer. The finding revealed that perishable hot foods were not being held at the regulatory requirement of 135 degrees F (Fahrenheit) or above, or 41 degrees F or below. The temperatures were record as follows: *Egg Salad Sandwiches (8) = 56 degrees F *Ham Salad Sandwiches (6) = 44 degrees F *Boiled Egg (1) = 87 degrees F *Poached Eggs (7) = 98 degrees F 3. Third Floor Satellite Serving Kitchen: (l) The floor of the serving kitchen was heavily worn, soiled, and had numerous areas of a black mold type build-up.

Based on observation, record review, and interview, the facility failed to implement the care plan for 1 of 15 sampled residents, as evidenced by the facility failure to elevate Resident #22's feet and the facility failed in the application of Resident #22's treatment. The findings included: Review of Resident #22's clinical record revealed an admission date of [DATE]. Review of the Quarterly MDS (Minimum Data Set), dated 06/27/18, documented extensive assistance with one person assistance for bed mobility and transfer was requried. During an observation on 08/27/18 at 12:15 PM, Resident #22's feet were resting on the floor and not covered with ace bandages or Ted hose. During an observation on 08/29/18 at 10:05 AM, Resident #22 was sitting in the chair eating his meal with bilateral feet on the floor. Further observation showed Resident#22's feet were not covered with ace bandages or Ted hose. During medication pass on 08/29/18 at 10:53 AM in the presence of Staff G, Resident #22 was eating food and both feet were on the floor. Further observation showed both feet had plus 3 [MEDICAL CONDITION]. Further observation showed Resident #22 lacked the application of ace bandages or TED hose. Review of the physician orders, dated 07/17/18, documented an order for [REDACTED]. Review of the Careplan for Resident #22 documented the resident has [MEDICAL CONDITION] to lower extremities. Continued review documented the resident prefers to sleep in my recliner which prevents me from elevating my legs. Further review documented the last update was 06/29/18. Additional documentation was continue with current focus; goals and interventions. Continued review of the interventions included assess my lower extremities every shift and elevate my legs when I am sitting on my recliner by elevating the foot rest and placing a pillow under my legs. Additional intervention documented included resident prefers to sleep in my chair, however encourage resident to sleep in bed so I can elevate my legs. Review of the record lacked evidence of documentation of Resident #22's refusal or cueing to elevate his feet during meals. During an interview on 08/30/18 at 11:49 AM with Staff G who was providing care to Resident #22, a side by side review of the record was conducted. During the interview on 08/30/18 at 11:49 AM, Staff G acknowledged the findings. Additionally, Staff G stated Resident #22 does not use TED hose and he does not like to elevate his feet during meals.

Based on observation, interview, and review of the facility's own policy, the facility failed to ensure medication was not left unattended for 2 of 5 sampled residents during medication observation pass for Residents #22 and #56. The findings included: 1. During observation of medication pass on 08/27/18 at 11:30 AM, Staff H was observed to leave Resident #56's [MEDICATION NAME] pen unattended at the bedside table and go to the resident's bathroom. Further observation showed the medication was not in Staff H's view to be seen and Staff H proceeded to wash their hands. Continued observation showed Staff H left the bathroom and went back to Resident #56's bed side table where the medication was located. During an interview conducted at 11:40 AM, Staff H acknowledged the findings. 2. During medication pass on 08/29/18 at 10:53 AM, Resident #22 was eating his meal. Further observation showed Staff G gave Resident #22 his pills and left the bottle of eye drops unattended at the table where Resident #22 was eating his meal. Further observation showed Staff G went to the resident's bathroom and the medication was not in Staff G's view to be seen. Continued observation showed Staff G washed their hands, donned gloves, and returned to the medication at the table in front of Resident #22 for total time of 2 minutes. Further observation showed Resident #22's private duty aide was not in the room. Further review of Resident #22's record documented a BIMS (Brief Interview for Mental Status) score of 8 (moderately impaired for cognitivion). During an interview at 11:00 AM, Staff G acknowledged the findings. Review of the facility's own policy titled Medication Administration and Management documented Medication carts or medication retained in resident rooms must be locked at all times when unattended.

Based on record review and staff interview, the facility failed to monitor for behaviors related to the use of [MEDICAL CONDITION] medications for 1 of 5 sampled residents reviewed for unnecessary [MEDICAL CONDITION] medications, Resdient #46. The findings included: Resident #46 was newly admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #46 was prescribed and received, the following [MEDICAL CONDITION] medications: [REDACTED] 1) [MEDICATION NAME] Oxalate 20 mg for Depression 2) [MEDICATION NAME] 25 mg, 3 tablets at bedtime, for anxiety 3) [MEDICATION NAME] 25 mg, 1 tablet twice a day, for anxiety. A review of Resident #46's electronic health record provided no indication that Resident #46's behaviors and potential side effects were being monitored each shift since receiving the antipsychotic medication for behaviors (08/04/18). On 08/29/18 at approximately 11:00 AM, a request was made to the Director of Nursing (DON) for any documentation showing behavior, side-effect monitoring, and interventions related to the use of antipsychotic medication. On 08/29/18 at 11:30 AM, the DON returned with a Behavior / Intervention Monthly Flow Record for Resident #46. This worksheet contained no documentation related to the monitoring of behaviors / side effects. The DON acknowledged that Behavior Monitoring should have been started at the time the antipsychotic medication was prescribed (08/04/18). She stated, The Behavior Monitoring was just initiated today (08/29/18) for (Resident #46). Per interview with Pharmacist Consultant on 08/29/18 at 2:40 PM, she stated she requested clarification regarding the [DIAGNOSES REDACTED]. The Pharmacist was waiting for the physician's response.

Based on interview and record review, the facility failed to ensure that a written summary of baseline care plans and copy of medication was completed, signed and given to the resident or resident's representative within the required 48 hours for 1 of 4 newly admitted residents reviewed for baseline care plans. This affected Resident #154. The findings included: On 08/27/18 at 2:36 PM, Resident #154 was observed laying on his bed, and the left eye was covered with a black patch. The resident stated that previously he had eye surgery and vision problems. The resident appeared alert and was capable of answering questions, knew his medication, medical history and stated that he does not recall discussing his plan of care or signing any base line care plan. The resident stated that people have been in his room without telling him what is expected of him and he was getting anxious. Resident #154 was admitted [DATE] with right (R) femur fracture and history of [DIAGNOSES REDACTED], [MEDICAL CONDITION] Fibrillation, Depression, generalized anxiety, and cataract extraction/detached retina. A review of the clinical record noted a copy of a baseline care plan, dated 08/24/18, with section B for signatures of resident and representative; this section was blank/empty. The next section C for signature of staff had an electronic name for a registered nurse listed. On 08/27/18 at 2:30 PM, the resident's physician was at the nursing station preparing to visit the resident and he discussed the resident's condition stating that he has a [DIAGNOSES REDACTED]. On 08/29/18 at 2:40 PM, the 3rd floor charge nurse, Staff F, a Registered Nurse (RN), was asked about Resident #154's baseline care plan to which her name was noted; Staff F stated the baseline care plan was started by her on Resident #154's admission on 08/24/18 but after she reviewed the hospital documents, she stopped the process because she felt the resident was not able to assist with the form. When asked why a representative was not contacted, the RN stated there was no document signifying that the listed person/resident's significant other could be given Resident #154's medical history so it was left incomplete. The RN stated that the process is for the charge nurse or weekend supervisor to complete a base line care plan within 48 hours of a resident's admission, and the resident has to be offered a copy but does not have to sign. Staff F did not explain why no documentation was in the clinical record for this incompletion. On 08/29/18 at 03:28 PM, the Minimum Data Set Coordinator (MDS/RN) stated that Resident #154 did not have an assessment completed since he was transferred out and admitted to the hospital on [DATE], so a cognitive status was not done. The MDS RN stated that the baseline care plans are to be completed within 48 hours of admission and the practice is for the floor managers and/or weekend supervisors to complete the baseline care plan. On 08/30/18, the Administrator and Director of Nursing discussed the baseline care plan and stated that some of the residents do not want to discuss the plan but agreed that there was no documentation in the clinical records to communicate any attempts were made. A review of the facility's Policies and Procedures for Baseline Care Plans note under Procedure, 1 - 9, documents: 1. The licensed nurse, or designee will develop a baseline care plan in the electronic application for each resident within 48 hours of a resident's admission. 6. A written summary of the baseline care plan must be provided to the resident and/or their representative, . This summary should include: (a) initial goals of the resident (b) Summary of the resident's medications and dietary instructions.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the enteral feeding pumps are are functioning properly to ensure that that physician ordered enteral gastric feeding are followed 1 of 1 sampled residents. This affected Resident #26. The findings included: During an observation of Resident #26 on 08/29/18 at 7:45 AM, it was noted the resident was in bed with gastric tube feeding being infused. Further observation noted that [MEDICATION NAME] 1.5 infusion rate on the pump was set at 60 cc per hour. Observation noted documentation on the feeding bag that it was hung and began infusing at 60 cc/hour on 08/28/18 at 11:30 PM. Observation of the [MEDICATION NAME] bag (1500 cc) noted that only 200 cc had been infused out and 1300 cc of the feeding remained. Observation of the pump noted that volume infused was 6533 cc. It was determined that the feeding was behind at minimum 300 cc of [MEDICATION NAME] tube feeding. Interview with the medication nurse following the observation noted that she stated the gastric feeding was hung on the night shift and the pump infusion memory should have been cleared when the new feeding bag was hung and started, and this is the policy and procedure of the facility. The medication nurse confirmed the surveyors findings and that the feeding was approximately 300 cc behind according to the documented start time. Interview with the Director Of Nursing (DON) on 08/29/18 stated that the night nurse failed to clear the pump when the 11:30 PM feeding was begun infusing . The DON also stated she did not know why the feeding was 300 cc behind and had contacted the pharmacy to obtain a new gastric feeding pump on 08/29/18. The DON also stated that the resident's attending physician was also notified of the issue. Additional calculations conducted on 08/29/18 noted that the '6533 cc memory' concluded the pump was not cleared for 5 days, and the resident receives a total of only 1200 cc of [MEDICATION NAME] formula per day. This calculation was also confirmed with the DON. It was also confirmed that the 300 cc of [MEDICATION NAME] 1.5 was equal to approx 450 calories. Review of clinical record of Resident #26 on 08/29/18 noted an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of current physician orders [REDACTED].>07/25/18 - [MEDICATION NAME] 1.5 enteral nutritional feed at 60 cc/hour per peg tube via pump. Start infusion at 5 PM and continue to 20 hours and stop at 1 PM the following day. 07/31/18 - Flush peg tube with 200 cc of water every 4 hours.