Every finding on record at Woodruff County Health Center

Based on interview, record review, and policy review, the facility failed to ensure the environment remained free from avoidable accident hazards, and that adequate supervision was provided during transfers for one (Resident #107) of eight residents reviewed for accidents and supervision. Specifically, the facility did not ensure staff followed safe transfer procedures using a mechanical lift, which resulted in injury to the resident. The findings include: A review of Resident #107's Face Sheet revealed Resident #107 was admitted to the facility on [DATE], with diagnoses that included a fracture of the right femur leg bone, a disease caused from narrowing blood vessels reducing the blood flow to the legs and feet, and dementia. A review of Resident #107's Care Plan, revised 04/28/2025, revealed the resident required assistance with activities of daily living and was to be transferred using a mechanical lift with two-person assistance. The Closet Care Plan also contained the same intervention. A review of a facility reported incident revealed that on 05/02/2025, at 6:18 PM, Certified Nursing Assistant (CNA) #3 reported to Licensed Practical Nurse (LPN) #4 that Resident #107 had sustained two skin tears on the right leg. LPN #4 assessed the resident and questioned CNA #3, who initially could not recall how the injuries occurred. Upon further questioning, CNA #3 admitted to transferring Resident #107 alone using a mechanical lift, without the assistance of a second staff member as required by the resident's care plan and facility policy. LPN #4 suspended CNA #3 pending investigation and notified the Director of Nursing (DON), the Administrator, Medical Director, and Resident #107's family representative. During an interview on 09/17/2025 at 10:25 AM, LPN #4 recalled the incident. LPN #4 confirmed that CNA #3 had admitted to transferring Resident #107 alone and reported the skin tears but could not identify what caused them. LPN #4 stated that CNA #3 was suspended, and the appropriate parties were notified. During an interview on 09/18/2025 at 11:08 AM, the Assistant Director of Nursing (ADON) stated that CNA #3 had performed the transfer alone. The ADON stated that all staff were trained on mechanical lift procedures upon hire and annually thereafter. During an interview on 09/18/2025 at 11:35 AM, the Director of Nursing (DON) stated that staff were trained and checked off on mechanical lift skills. The DON stated that adequate staff were available at the time of the incident and that CNA #3 did not request assistance. The DON indicated the skin tears may have resulted from improper placement of the lift pad during the transfer. During an interview on 09/18/2025 at 12:01 PM, the Administrator confirmed that CNA #3 admitted to transferring Resident #107 alone. The Administrator stated that CNA #3 was terminated following the outcome of the investigation. During an interview on 09/18/2025 at 1:09 PM, CNA #3, who was hired on at the facility on 9/02/2024 and in-serviced on lift transfers on 9/05/2024, indicated she had transferred Resident #107 without a second staff member, in violation of the care plan and facility policy. CNA #3 admitted to being aware all residents requiring a lift to transfer in this facility required two staff persons yet knowingly transferred Resident #107 independently. CNA #3 stated the transfer conducted on 05/02/2025, resulted in the termination of her employment following the facility investigation. Review of a facility policy titled Safe Lifting of Residents, revised 12/01/2013, indicated that resident safety, dignity, comfort, and medical condition would be incorporated into decisions regarding lifting and moving residents. This failure to follow safe transfer procedures placed Resident #107 at risk for injury and resulted in actual harm. Review of facility documentation revealed CNA #3 had been terminated on 05/05/2025 following the facility's investigation, and that all staff had been in-serviced following the event, completed 05/12/2025. Interviews with staff verified understanding of the training.

Based on observations, interviews, record review, and facility policy review, the facility failed to implement infection control practices in accordance with Enhanced Barrier Precautions (EBP) requirements for two (Resident #1 and Resident #2) of five residents reviewed for infection control, and one (Resident #2) of one resident reviewed for trach care. Specifically, the facility did not ensure that staff put on appropriate personal protective equipment (PPE) while providing care to residents on EBP. The findings include: Resident #1 A review of an admission Record indicated that the facility admitted Resident #1 on 05/11/2024, with diagnoses which included impaired brain function caused by metabolic disturbances, end stage kidney disease, and an encounter for attention to a feeding tube placed in the stomach. A review of Resident #1's Care Plan, revised 08/15/2025, revealed Resident #1 was on EBP. The Care Plan included interventions with a start date of 05/23/2024, to require PPE [gown, gloves, etc.] and, to provide face protection [face mask, goggles, or face shield] with activities for risk of splash or spray. During observation on 09/17/2025 at 2:51 PM, this surveyor observed Registered Nurse (RN) #2 touching medication bare handed and place the pill in the medication cup during preparation of one medication for Resident #1. RN#2 was observed to perform hand hygiene, then to touch the medication cart and medication cards, contaminating their hands, prior to touching the medication bare handed. This surveyor observed RN #2 administering medication via PEG [percutaneous endoscopic gastrostomy] tube without a gown. During the interview on 09/17/2025 at 2:51 PM with RN #2, she verbalized that she should have worn a gown. RN #2 also verified that she touched a medication without any gloves when preparing medication prior to administering them to the resident. During an interview on 09/18/2025 at 10:59 AM, the ADON (Assistant Director of Nursing) verified that residents who were on dialysis or had PEG tubes should be on EBP. The ADON confirmed that when someone had a PEG tube, a staff member should wear gown and gloves. She explained that wearing PPE was to protect the resident. She confirmed that it was not appropriate to touch medication bare handed. She stated, It is infection control. If they touch a pill they should have gloves on. The ADON verified that nursing administration did medication check offs with nurses. The ADON stated, So they know to not touch medication without gloves and we in-service about enhance barrier precautions. During an interview on 09/18/2025 at 11:19 AM, the DON (Director of Nursing) verified that residents who were on dialysis or had a PEG tube should be on EBP. The DON confirmed staff should dress with mask, gown, and gloves when performing care for residents who are on EBP. She explained that EBP was to prevent infection for the residents who were at risk, and attempt to prevent rehospitalization. The DON explained that it was not appropriate to touch medication bare handed due to cleanliness. She stated that there were in-services on EBP and medication administration. During an interview on 09/18/2025 at 11:40 AM, the Administrator verified that staff kept the supply of PPE outside the resident door, and it was re-stocked daily and as needed. She confirmed that individuals with a PEG tube would be on EBP. She stated the purpose behind EBP was to protect the resident from our germs. The Administrator verified that a nurse was not supposed to touch medication bare handed. During an interview on 09/18/2025 at 2:45 PM, the Infection Preventionist (IP) verified that nurses were supposed to wear gown and gloves when caring for someone with a PEG tube. The IP explained that using infection control practices with EBP decreased the risk of infection for the residents. She explained that nursing administration did visual observations, and PPE check offs to ensure staff followed EBP. The IP verified that it was not appropriate to handle medications without wearing gloves because, you never know what kind of germs are on your hands. She verified that even after a nurse washed their hands they are to not touch the medication bare handed because, the nurse could touch medication cards and the medication cart. Resident #2 A review of Resident #2's Face Sheet revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included tracheostomy (trach) status. A review of Resident #2's Physician orders indicated daily trach care interventions which included: to cleanse the stoma daily, to change the disposable inner cannula daily, and to change the trach collar every other day. Resident #2's Physician Orders also indicated EBP precautions were ordered on 04/11/2024. On 09/17/2025 at 3:40 PM, Registered Nurse (RN) #1 was observed performing trach care for Resident #2, who was on EBP. RN #1 did not put on a gown or mask prior to initiating care. RN #1 had placed a disposable plastic barrier down on Resident #2's over the bed table which was parked to the left of the bed. The supplies were placed on top of the barrier. RN #1 stood between the table and the resident with the resident to the right side and table on the left. RN #1 gathered supplies from the table and would lean over Resident #2, who was in a supine position in the bed with head elevated at 35 degrees. RN #1's scrub top was in direct contact with the resident's bed linens while leaning over to perform trach care. RN #1's face was positioned less than an arm length away from Resident #2's face during treatment. During an interview on 09/17/2025 at 3:50 PM, RN #1, who was in-serviced on infection control 11/11/2024, stated that trach care required EBP and acknowledged that a gown should have been worn during the procedure. RN #1 confirmed that EBP was important to prevent residents from acquiring infections. During an interview on 09/18/2025 at 8:35 AM, RN #2 confirmed that EBP should be used during trach care and that training and skills checks were conducted with staff at the facility. During an interview on 09/18/2025 at 9:06 AM, CNA #15 stated that EBP was put in place to protect residents with open sites on the body. During an interview on 09/18/2025, at 11:18 AM, the ADON stated that trach care required gloves, gown, and mask under EBP. The ADON stated that breathing near the trach site without a mask would not be safe and that EBP was used to protect residents from infection. During an interview on 09/18/2025, at 11:25 AM, the DON stated that PPE should be donned outside the resident's room and that staff are required to wear gown, gloves, and mask when providing care to residents on EBP. The DON stated that EBP was used to prevent infections and rehospitalizations and that in-services were conducted to educate staff on EBP practices. During an interview on 09/18/2025, at 11:55 AM, the Administrator stated that PPE was stocked outside the rooms of residents on EBP and that charts were flagged to identify residents who require EBP. The Administrator stated that supervisors monitor staff compliance and that camera footage was reviewed to ensure adherence to infection control practices. During an interview on 09/18/2025, at 2:45 PM, the IP stated that trach care required a gown, gloves, and mask under EBP. The IP stated that staff were observed daily and received annual PPE competency checks to ensure proper donning and doffing procedures. A review of a Medication Administration in-service, dated 11/18/2024, indicated Do not touch oral medication. A review of a facility policy titled, Personal Protective Equipment, dated 09/2010, indicated When to use a mask: when performing a task that may involve the splashing of blood or body fluids into the mouth or nose. Gowns- Use gowns only when indicated or as instructed. When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident. A review of the facility's undated policy titled, Tracheostomy Care, indicated, Put exam gloves on both hands; masks and eye wear should be worn if there is a likelihood of splashes and splattering. A review of a facility policy titled, Enhanced Barrier Precautions, dated 04/20/2024, revealed, it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include device care or use of feeding tubes and tracheostomy/ventilator tube.

Based on observation, record review and interview the facility failed to ensure call light was kept within reach for 01 (Resident #23) of 01 sample mix residents. The findings are: The Minimum Data Set (MDS) 5 Day with an Assessment Reference Date (ARD) of 03/20/2024 revealed resident #23 had a history of falls. Care Plan for resident #23 dated 09/07/2022 revealed the resident is blind and a risk for safety, and call light at residents' side at all times. The care plan for resident #23 also confirmed the resident's history of falls with fracture. On 05/28/24 at 12:06 PM, the Surveyor interviewed Resident #23. Resident #23 confirmed the call light should be attached on his/her chair. On 05/29/24 at 2:08 PM, the Surveyor observed Resident #23 in a wheelchair, with the call light hooked to the bed with a bedside table in between the resident and the bed. On 05/30/24 at 950 AM, the Surveyor observed Resident #23 in the resident's room without the call light in reach. It was tethered to the bed, and Resident #23 was across the room near the heat/air unit/window. Resident #23 was going to use it and reached down on the chair looking for the call light. Due to vision impairment, Resident #23 was observed unable to maneuver across the room to reach/use the call light. On 05/30/24 at 1:10 PM, the Surveyor initiated the call light per Resident #26's request (the call light was out of the resident's reach). Licensed Practical Nurse (LPN) #05 came to Resident #23's room and confirmed the call light was out of Resident #23's reach. On 05/30/24 at 1:44 PM, the Surveyor interviewed LPN #5. LPN #5 confirmed Resident #23's call light should be in reach of the resident at all times. LPN #5 confirmed call the light should be in reach for when the resident needs assistance or in case of an emergency. LPN #5 confirmed she was unsure of the call light policy. LPN #5 confirmed Resident #23 had a history of falls caused from getting up on his/her own. On 05/30/24 at 2:23 PM, the Surveyor interviewed Certified Nurse Assistant (CNA) #8. CNA #8 confirmed the call light should be in reach of Resident #23 at all times so if the resident needs something, the resident can call. CNA #8 confirmed the facility call light policy is to keep the call light in reach at all times. CNA #8 confirmed Resident #23 has a history of falls. CNA #8 confirmed the cause of the falls was the resident getting up on his/her own. The facility provided a policy titled, Call Lights: Accessibility and Timely Response, with a copyright date of 2023 documented, Policy: 1. All staff will be educated on the proper use of the resident all system, including how the system works and resident access to the call light. 3. Each resident will be evaluating for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the residents room. 7. The call light must be accessible to the resident at each toilet and bath or shower facility. The call system will be accessible to the resident lying on the floor.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 of 1 sampled resident (Resident #85). The findings are: A review of the Face Sheet revealed Resident #85 had a diagnosis of dementia. A review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2024 revealed Resident #85 scored a 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). A review of the Care Plan revealed Resident #85 required assistance with ADLs (activities of daily living) due to dementia, confusion, and behaviors. On 05/28/2024 at 12:33 PM, the Surveyor observed Resident #85 was eating a snack and licking chocolate off of the left index left finger, and both hands had long, thick, yellowing, chipped nails with a dark brown substance under them. The Surveyor asked Resident #85 if he/she would like their nails trimmed and cleaned. Resident #85 said if that was what needed to be done, he/she would not mind having it done. Then stated, They are getting a little long and dirty aren't they. On 05/29/2024 at 9:00 AM, the Surveyor observed Resident #85's nails had not been trimmed or cleaned. On 05/30/2024 at 10:15 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4 to describe Resident #85's nails. CNA #4 said that they are dark, yellow, with substance under the nails, and that they are 1 inch in length. CNA #4 then said that they needed trimmed. The Surveyor asked what could be the issue for the resident. CNA #4 said they could scratch themselves or others. On 05/30/2024 at 10:20 AM, the Surveyor asked Licensed Practical Nurse (LPN) #5 to described Resident #85's nails. LPN #5 said that they were dirty, long, approximately an inch long, yellowing, and chipped and they need clipped, filed, and cleaned definitely. The Surveyor asked what could be the issue for the resident. LPN #5 said that they could scratch themselves or could even cause an infection. A review of the policy, Care of Fingernails/Toenails revealed, Purpose The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.General Guidelines: 2. Proper nail care can aid in the prevention of skin problems around the nail bed .

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for 1 of 1 sampled resident (Resident #74). The findings are: A review of the Face Sheet revealed Resident #74 had diagnoses of type 2 diabetes mellitus, gout, and peripheral venous insufficiency. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2024 revealed Resident #74 scored a 9 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS). A review of the Physicians Orders revealed an order for Podiatry Consults as Needed. A review of the Care Plan revealed Resident #74 had required assistance with ADLs (activities of daily living) due to vascular dementia, gout in multiple sites, and osteoporosis. A review of a Foot Observation completed on 05/24/2024 revealed, that Does have thick or ingrown toenails? Yes was selected for the left and right foot. Does resident have swelling in feet? Yes was selected for the left and right foot. On 05/28/2024 at 1:55 PM, the Surveyor observed Resident #74's right foot was swollen, with cracked peeling skin, and the toenails were thick, yellow, and growing into the skin. The fourth toe had a discolored area on the right side. The left foot was observed to have cracked peeling skin, the toenails were thick, yellow, and growing into the skin, a treatment covering was observed on the fourth toe and pinky toe. The Surveyor asked Resident #74 if he/she would like anything done for their foot or if he/she were experiencing any pain. Resident #74 said my toenails need a little TLC (tender loving care), but they do not cause me any pain. On 05/29/2024 at 9:15 AM, the Surveyor observed no change in Resident #74's toenails from the day before. On 05/30/2024 at 10:45 AM, the Surveyor asked Licensed Practical Nurse (LPN) #6 if Resident #74 had a podiatry consult. LPN #6 said no Resident #74 did not. The Surveyor asked LPN #6 to describe Resident #74's toenails. LPN #6 said that they were thick, yellow, ingrown, skin was cracked with swelling, there was a blister area on the right foot, fourth toe. Then stated that they were callused, and that there was a treatment for the abrasion on the left foot, that she will go get the treatment nurse for. The Surveyor asked what could be the issue if the resident does not get proper foot care. LPN #6 said that he/she could get an infection, grow more into the skin, and cause pressure sores. On 05/30/2024 at 1:32, the Surveyor asked Certified Nursing Assistant (CNA) #7 to describe Resident #74's toenails. CNA #7 said that they needed clipped, they were thick and growing into the skin and needed some care. CNA #7 then stated that they give the Resident a bath and his/her feet often turn purple. The Surveyor asked what is the process when toenails look like that. CNA #7 said that they would let the nurse on the hall know and that they would let the wound care nurse know about the issue. The Surveyor asked what could be the problem if the resident does not get proper foot care. CNA #7 said that they could get an infection or sores. A review of the policy Care of Fingernails/Toenails revealed, Purpose The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.General Guidelines: 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 5. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc. 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections pain or if nails are too hard or too thick to cut with ease .

Based on observation, record review, and interview the facility failed to ensure that a chemical wasn't left out within the reach of the residents on the 500 Hall. The findings are: A review of the label Micro-Kill One Germicidal Alcohol wipes, stated, Keep Out of Reach of Children Caution. On 05/30/2024 at 9:00 AM, the Surveyor observed on the second shelf of the linen cart a purple top container of Micro-Kill One Germicidal Alcohol Wipes. The Surveyor observed residents and staff members going up and down the hallway, the second shelf was observed to be at waist level of the Surveyor. On 05/30/2024 at 9:30 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 if chemicals should be stored on the covered linen cart. CNA #3 stated, No, it should not be stored on here. The Surveyor asked what could happen with chemicals stored on the linen cart. CNA #3 said the residents could get hold of it and mess with it. CNA #3 further said it wouldn't be good, it has alcohol on it and says to keep out of reach of children. On 05/30/2024 at 1:43 PM, the Surveyor asked Licensed Practical Nurse (LPN) #6 if chemicals should be stored on the covered linen cart. LPN #6 said no, it's dangerous for the residents they could get hurt. LPN #6 further said most chemicals read to keep out of reach of children.

Based on observation and interview the facility failed to ensure pureed food was processed to the correct consistency to meet the needs of 4 sampled residents who had a physician's order for a pureed diet. The findings are: On 05/29/2024 at 10:30 AM, Dietary Aide #11 (DA) was observed to place two buttermilk pies into the bowl of the food processor. DA #11 added a large amount of milk into the bowl without measuring. Pie was blended. Upon lifting the lid, DA #11 verbalized the belief that the mixture was too thin. Before DA #11 achieved what was believed to be the correct consistency she had added 2 more whole pies. When asked what consistency she was attempting to achieve she described the mixture as pudding. On 05/29/2024 at 10:42 AM, eleven servings of baked beans were placed into the bowl for processing. The beans were observed to contain a large amount of liquid. After blending for a short time, DA #11 picked up a can of non-stick spray, coated a steam table pan and poured the liquified beans into the pan. On 05/29/2024 at 10:50 AM, DA #11 placed 11 scoops of boiled chicken and broth into the bowl of the food processor. The chicken mixture was blended for a small amount of time. DA #11 was observed to add 3 slices of white bread to the bowl and blend. DA #11 then added 4 more slices of white bread. DA #11 was asked to discuss the addition of bread to the protein. DA #11 described that the addition of the bread caused the meat to be smoother. When asked if the serving size was adjusted due to the addition of bread to the chicken, DA #11 quickly denied having any knowledge of allowances made. On 05/30/2024 at 12:34 PM, Certified Nursing Assistant (CNA) #9 was observed setting up a pureed tray for a resident in the dining room. The resident received his/her pureed lunch meal in a divided plate. The baked beans were observed to not hold their shape, assuming the shape of the plate compartment. The chicken/bread mixture was also observed to not hold its shape, assuming the shape of the plate compartment. CNA #10 was asked to describe the pureed chicken. As she stirred the chicken CNA #10 described the mixture as watery. When asked to describe the baked beans CNA #10 described them as watery too. CNA #10 was asked if a resident who maintained the ability to eat unassisted could feed themselves the pureed mixture. CNA #10 expressed that a resident would have difficulty feeding themselves the pureed food as it would not stay on the spoon due to it being so thin. On 05/30/2024 at 3:30 PM, the Administrator was asked to provide a policy concerning pureed diets, if one was available. The Administrator did not believe the facility had a policy but would provide one if located. No policy was forthcoming. On 05/31/2024 at 9:15 AM, the Dietary Manager was asked to describe the pureed lunch meal. The Dietary Manager described the plate as sloppy. She continued to report that the baked beans were too thin and had probably been pureed incorrectly. When ask to describe the implications of pureed food that is too thin, the Dietary Manager described a difficulty in swallowing could result.

Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 1 (Resident #48) of 1 sample mix resident. The findings are: On 05/28/2024 at 11:06 AM, the Surveyor observed Resident #48 sitting up in a specialized chair with a fall alarm attached to the chair and running behind the pillow, behind the resident's head, and attached to the resident's shirt. Review of Resident #48's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024 documented bed alarm, chair alarm not used. Resident #48's Order History did not reveal a physician's order for a chair alarm. On 05/30/2024 at 9:10 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #1 and she confirmed Resident #48 uses a chair alarm to alert staff when the resident is leaning too far forward in the specialized chair. 05/30/2024 at 9:11 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #2 and she confirmed Resident #48 uses a chair alarm due to leaning forward in the specialized chair. On 05/30/2024 at 1:15 PM, the Surveyor interviewed the MDS Coordinator, and she confirmed that if a resident has a chair alarm attached it should be documented on the MDS, and that Resident #48 did not have it documented on the MDS with an ARD of 04/19/2024. She confirmed the MDS is not accurate. A facility policy titled, Resident Assessment- RAI with a Copyright date of 2023 documented, Policy: The facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS.

Based on record review and interview, the facility failed to ensure residents individualized plan of care was revised to reflect the current needs of the resident and updated to include a chair alarm for 1 (Resident #48) of 1 sample mix resident. The findings are: On 05/28/2024 at 11:06 AM, the Surveyor observed Resident #48 sitting up in a specialized chair with a fall alarm attached to chair and running behind the pillow behind the resident's head attaching to shirt. A review of Resident #48's Care Plan dated 07/31/2023 did not reveal the resident was care planned for a chair alarm. A review of Resident #48's Order History did not reveal an order for a chair alarm. On 05/30/2024 at 09:10 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #1 and she confirmed Resident #48 uses a chair alarm to alert staff when the resident is leaning too far forward in the specialized chair. CNA #1 confirmed the resident was not care planned for a chair alarm. 05/30/2024 09:11 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #2 and she confirmed Resident #48 uses a chair alarm due to leaning forward in the specialized chair. LPN #2 confirmed the resident was not care planned for a chair alarm. On 05/20/2024, the Surveyor interviewed the MDS Coordinator, and she confirmed Resident #48 was not care planned for a chair alarm but should be in order for staff to know how to care for the resident. A facility policy titled, Resident Assessment- RAI with a Copyright date of 2023 documented, Policy: The facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS. A facility policy titled, Comprehensive Care Plans with a Copyright date of 2023 documented, Policy Explanation and Compliance Guidelines .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, record review, and interview, the facility failed to ensure a catheter was hanging below the bladder for 1 of 1 sampled resident (Resident #81). The findings are: A review of the Face Sheet revealed Resident #81 had diagnoses of neuromuscular dysfunction of bladder, chronic kidney disease, retention of urine, obstructive and reflex uropathy, and acute kidney failure. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024 revealed Resident #81 had short term memory problems and long term memory problems on a Staff Assessment for Mental Status (SAMS). A review of the Care Plan revealed Resident #81 required an indwelling urinary catheter. Approach: position bag below the bladder. On 05/28/2024 at 12:25 PM, the Surveyor observed Resident #81 sitting in the dining room with the catheter bag observed hanging above the bladder on the back of the geriatric chair. The Surveyor observed the tubing come out of the right pant leg, with the tubing running over the arm rest of the geriatric chair. On 05/30/2024 at 10:10 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4 what the proper placement for a catheter bag was. CNA #4 stated below the kidneys, usually underneath the chair. The Surveyor asked what could the issue be for the resident if a catheter bag was not properly placed. CNA #4 said that it can back up and cause health issues. The Surveyor showed CNA #4 where the catheter bag was hanging on the 05/28/2024 observation and asked if that was proper placement for a catheter. CNA #4 stated that it was not proper placement and should be lower. On 05/30/2024 at 10:16 AM, the Surveyor asked Licensed Practical Nurse (LPN) #5 what is the proper placement for a catheter. LPN #5 said below the bladder, or it won't flow right. The Surveyor asked what the issue could be for the resident if a catheter bag was not properly placed. LPN #5 stated that it could cause infections or pain. The Surveyor showed LPN #5 where the catheter was hanging on the 05/28/2024 observation and asked if that was proper placement for a catheter bag. LPN #5 said that was not proper placement for a catheter. The Surveyor asked if the catheter had an anti-reflux valve to prevent backflow. LPN #5 said that she did not know, the order just says indwelling catheter. On 05/30/2024 at 10:40 AM, the Surveyor asked the Director of Nursing (DON) if the catheters used for Resident #81 had anti-reflux valves to prevent back flow. The DON said she did not know, but to let her find out. The DON asked the Surveyor to follow her to the medical supply room to observe the catheter bags ordered. A review of the catheter bag label revealed Contents 2000 ML [milliliters] vented drainage bag with anti-reflux tower. On 05/30/2024 at 1:30 PM, the Surveyor asked the DON if the catheter bag had just an anti-reflux tower to prevent backflow from the bag into the tube or does the tubing have an anti-reflux valve to prevent backflow from the tubing into the bladder. The DON went back to the medical supply room and looked over the catheter bag and stated, No it only states that it has an anti-reflux tower. I do not see anything about an anti-reflux valve to prevent backflow into the bladder. A review of the facility policy Catheter Care, Urinary revealed, Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections .Maintaining Unobstructed Urine Flow .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

Based on observation, interview and record review, the facility failed to ensure an open drink was not left within the reach of the residents on the 500 Hall. The findings are: On 05/30/2024 at 9:00 AM, the Surveyor observed a covered linen cart on the 500 Hall. On the top shelf was an open drink in an aluminum can. The Surveyor observed residents and staff going up and down the hall passing by the linen cart. On 05/30/2024 at 9:30 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 if an opened drink container should be on the covered linen cart. CNA #3 said it should not be on there, a resident could get hold of it, and that won't be good. The Surveyor observed CNA #3 picking up the opened container to move it and was asked how much was left inside it. CNA #3 said it was about half full. On 05/30/2024 at 1:45 PM, the Surveyor asked the Infection Preventionist if an open drink container should be left on the covered linen cart. The Infection Preventionist said no, that is an infection risk to the residents. A facility policy titled, Policies and Practices-Infection Control revealed, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure leftover food items were used in a manner to maintain food quality, expired food item was promptly removed/discarded by the expiration or use by dates to prevent potential for bacteria growth for residents who received meals from 1 of 1 kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and cold food was maintained at or below 41 degrees Fahrenheit on pans of ice on the counter while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who received meals from the kitchen (total census: 84), as documented on a list provided by Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 10:39 AM., the following were on the spice rack in the kitchen: a. Mesquite Barbeque that did not have an opened date on the container. b. Basil leaves did not have an opened date on the container. c. A container of lemon pepper did not have an opened date. d. A container of garlic curry powder did not have an opened date or received date. e. A container of ground cinnamon did not have a received or opened date. f. A container of unseasoned meat tenderizer did not have a received date on it. 2. On [DATE] at 10:44 AM, twelve bags of hamburger buns were stored on the bread rack with no received date on them. 3. On [DATE] at 10:45 AM, an opened box of pancakes was on a shelf in the freezer. The box did not have an opened date. 4. On [DATE] at 10:56 AM, the following leftover food items were on a shelf in the refrigerator: a. A container of leftover scrambled eggs boiled eggs. b. A container of ground sausage c. A container of sausage patties. d. The Surveyor asked the Dietary Supervisor, what the leftover foods were for. She stated, We use them the next day for the pureed and the mechanical soft diets. We never throw food away here. At 11:06 AM., the Dietary Supervisor stated, The Administrator said that we don't have a policy for leftover foods. We have alternates and we give them to the residents who asked for it, because it's their choice. The Surveyor asked, Do the other residents get a leftover mixture of scrambled eggs and poached eggs and get leftover ground sausage? She stated, No, we give them fresh eggs and sausage every morning. The Surveyor asked, What happens to the residents who cannot voice their choices? She stated, I guess we don't have to serve it to them. We are going to start giving the ones on pureed and mechanical soft diets fresh eggs and sausage. 5. On [DATE] at 11:04 AM, a container of multi-mix calorie and protein supplement were on a shelf in the kitchen with an expiration date of [DATE]. 6. On [DATE] at 11:11 AM, the following were on the spice rack above the food preparation counter: a. A container of pure ground black pepper - did not have an opened or received date on the container. b. A container of garlic powder - did not have a received date on it. c. A container of nutmeg - did not have an opened date on it. 7. On [DATE] at 11:28 AM, Dietary Employee #1 took out a plate that contained tossed salad with meat and cheese from the refrigerator and placed it on the counter. At 11:32 AM, the temperature of the food when tested and read by the Dietary Employee #1 was 52 degrees Fahrenheit. 8. On [DATE] at 11:29 AM., Dietary Employee #1 used rags to remove pans that contained food items to be served to the residents for lunch and placed them on the steam table. Without washing her hands, she picked up plates to be used in portioning food to serve to the residents for lunch and placed them on the shelf on the steam table with her thumb inside the plates. 9. On [DATE] at 11:54 AM, the following were made on a shelf in the Nourishment Room Refrigerator on the 200 Hall: a. One bottle of high protein nutritional shake did not have a received date on the bottle. b. Four bottles of nutritional shakes plus did not have a received date on them. 10. On [DATE] at 11:59 AM, the following were on a shelf in the Unit refrigerator: a. A container of real mayonnaise did not have an opened or received date. b. One opened box of bologna did not have an opened date. c. An opened bag of hot dog buns did not have an opened and/or received date on the bag. 11. The facility policy titled, Policy and Procedure Manual Hand Washing provided by the Dietary Supervisor on [DATE] at 9:35 AM documented, When to wash hands .After entering the kitchen at the start of a shift and after engaging in other activities that contaminate the hands .

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 8 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/09/23. The findings are: a. On 03/08/23 at 11:32 AM, a pan of pureed lasagna was on the steam table. The consistency of pureed lasagna was lumpy. b. On 03/08/23 at 12:30 PM, the pureed dessert served to the residents on pureed diets was runny, the pureed bread was gritty, and the pureed lasagna was lumpy. The Surveyor asked Dietary Employee #2 to describe the consistency of the pureed bread served to the residents who required pureed diet. She stated, Pureed bread was gritty and was not smooth. The Dietary Supervisor stated, The pureed dessert was runny and was not pudding consistency. The pureed lasagna was lumpy. c. On 03/08/23 at 4:03 PM, Dietary Employee #2 used a #8 scoop, placed 9 servings of potato salad into a blender, and pureed. At 4:05 PM, she used a #8 scoop and transferred the pureed potato salad into 9 individual bowls. There were pieces of celery visible in the mixture. The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed potato salad. She stated, There are pieces of celery. I guess, next time it shows up on the menu, we make it without celery. d. On 03/09/23 at 7:54 AM, the pureed sausage served to the residents on pureed diets was gritty. e. On 03/09/23 at 12:22 PM, the pureed pork roast served to the residents on pureed diets was more of mechanical soft. f. On 03/09/23 at 12:27 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the pureed pork roast and pureed potatoes served to the residents on pureed diets for lunch. She stated, Pureed meat was lumpy and doesn't look like the pudding. g. On 03/09/23 at 12:28 PM, the Surveyor asked CNA #2 to describe the consistency of the pureed meat served to the residents on pureed diets for lunch. She stated, It's chopped fine, not pureed. h. On 03/09/23 at 12:29 PM, the Surveyor asked CNA #3 to describe the consistency of the pureed meat served to the residents on pureed diets for lunch. She stated, It's chopped fine not really pureed. i. On 03/09/23 at 12:30 PM, the Surveyor asked CNA #4 to describe the consistency of the pureed meat served to the residents on pureed diets for lunch. She stated, Finely chopped. j. On 03/09/23 at 12:31 PM, the Surveyor asked CNA #5 to describe the consistency of the pureed meat and pureed potatoes served to the residents on pureed diets for lunch. She stated, It's clumpy and it doesn't look pureed. It looks like mechanical soft. k. On 03/09/23 at 12:33 PM, the Surveyor asked CNA #6 to describe the consistency of the pureed meat served to the residents on pureed diets for lunch. She stated, It was basically ground up. l. On 03/09/23 at 12:40 PM., the Surveyor asked Dietary Employee #2 to describe the consistency of the pureed meat served to the residents on pureed diets for lunch. She stated, It was clumpy.

Based on observations, record review, and interview, the facility failed to ensure oxygen tubing was changed, dated, and stored properly for 2 (Residents #28, and #51) of 3 (Residents #28, #48 and #51) sampled residents who had physician orders for oxygen therapy, failed to ensure suction catheter and tubing were dated and contained in a bag when not in use for 1 (Resident #44) of 2 (Residents #28 and #44) who required suctioning and failed to ensure nebulizer masks were changed and dated for 1 (Resident #48) of 2 (Residents #48 and #51) sampled residents who required updrafts as documented on a list provided by Medical Records on 03/09/23 at 1:30 PM. The findings are: 1. Resident (R) #28 had diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Hypertensive Heart Disease with Heart Failure, and Tracheostomy Status. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. The Care Plan dated 01/13/23 documented, .Change O2 [oxygen] tubing and humidifier weekly on Wednesday nights. Oxygen tubing will be changed out, dated, and placed in new bag with date when he places tubing in inappropriate places . b. The Physicians Order dated 03/06/23 documented, .Change O2 tubing and humidifier weekly on Wednesday nights . c. On 03/06/23 at 6:50 PM, Resident #28 was lying in bed with O2 at 4L [liters]. The O2 tubing was not dated, the date on the humidifier bottle was 02/17/22, the humidifier bottle was empty. a. On 03/06/23 at 7:05 PM., Licensed Practical Nurse (LPN) #1 stated, The humidifier bottles should be changed weekly or when they ran out. The Surveyor asked, What is the purpose of changing the humidifier bottles and tubing? LPN #1 stated, To prevent respiratory infections. The Surveyor asked, Should an empty humidifier bottle still be in use with a date of 02/17/23? LPN #1 stated, No, I will go take care of that right now. 2. Resident #44 had diagnoses of Dysphagia and Parkinson Disease. The Annual MDS with an ARD of 01/31/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS) and did not require suctioning. The Physician's Order dated 01/27/23 documented, .May lightly suction due to increased secretions as needed . The Care Plan dated 01/30/23 documented, .May lightly suction due to increased secretions as needed . On 03/06/23 at 7:50 PM, a suction machine was on R #44's bedside table with undated tubing connected to a Yankauer suction catheter. The suction catheter was lying in the top drawer of the bedside table not bagged or dated. There was a suction catheter in a Plastic bag with no date. On 03/07/23 at 11:01 AM, a suction catheter was lying in the top drawer of the bedside table not bagged or dated. 03/08/23 at 08:44 AM, a suction catheter was lying in the top drawer of the bedside table not bagged or dated. 03/09/23 at 09:30 AM, a suction catheter was lying in the top drawer of the bedside table not bagged or dated. The facility policy titled, Suctioning the Upper Airway (Oral Pharyngeal Suctioning), provided by the Administrator on 03/08/23 at 1:20 PM documented, .Place catheter in clean dry area . The policy does not address dating the tubing/suction catheter. 3. Resident 48 had diagnoses of Unspecified Sequelae of Cerebral Infarction, Todd's Paralysis (post epileptic), Unspecified Asthma, Uncomplicated. The Quarterly MDS with an ARD of 02/15/23 documented the resident was severely impaired in cognitive skills for daily decision-making per SAMS and receives oxygen therapy. a. The Physicians Order dated 12/23/22 documented, ipratropium-albuterol solution for nebulization; 0.5 mg [milligrams]-3 mg(2.5 mg base)/3 mL [milliliter]; amt [amount]: l vial; inhalation Special Instructions: EVERY 6 HOURS AS NEEDED FOR SHORTNESS OF BREATH [DX [diagnosis]: Chronic obstructive pulmonary disease, unspecified] Every 6 Hours - PRN [as needed] . a. On 03/06/23 at 6:15 PM, a nebulizer mask was stored in a clear plastic bag with a date of 02/17/23. b. On 03/07/23 at 9:15 AM, a nebulizer mask was stored in a clear plastic bag with a date of 02/17/23. c. On 03/07/23 at 1:25 PM, a nebulizer mask was stored in a clear plastic bag with a date of 02/17/23. d. On 03/09/23 at 9:13 AM, a nebulizer mask was stored in a clear plastic bag with a date of 03/09/23. 4. Resident #51 had diagnoses of Chronic Pulmonary Embolism, Hypertensive Heart Disease without Heart Failure and Toxic Effect of Carbon Dioxide, Undetermined. The Quarterly MDS with an ARD of 12/14/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and did not receive oxygen therapy. The Physician Orders dated 04/09/18 documented, .O2 @ [at] 2L PRN shortness of breath . Change O2 tubing and humidifier weekly on Wednesday nights . The Care Plan dated 03/13/20 documented, .Administer oxygen as ordered per MD [Medical Doctor]. Observe oxygen precautions . Oxygen tubing will be changed out, dated and placed in new bag that's dated when she places it in inappropriate places b. On 03/06/23 at 7:13 PM, Resident #51's oxygen was set at 2.5 liters via nasal cannula. The oxygen tubing and the humidifier bottle were not dated. c. On 03/07/23 at 10:11 AM, Resident #51's oxygen was set at 2.5 liters via nasal cannula, the oxygen tubing and the humidifier bottle were dated 03/07/23. d. On 03/08/23 at 2:45 PM, the Surveyor asked LPN #2, When should O2 tubing, and humidifier bottles be changed out? LPN #2 stated, Normally we change it all out on Wednesday night on the night shift. The Surveyor asked, How often do you look at the tubing and bottles and check the dates? LPN #2 stated, I try to look at it each day, but most of the time, I don't have time. e. On 3/09/23 at 2:15 PM, the Surveyor asked the Director of Nursing (DON), How often should Oxygen tubing be changed? The DON stated, The O2 tubing, and humidifier bottles, suction catheters and masks are changed weekly every Wednesday night on the 11-7 shift or sooner if need be. The Surveyor asked, How often should the nurses check the O2 settings? The DON stated, Several times a shift. The Surveyor asked, What could be the result of not storing the suction catheter or mask properly? The DON stated, Well, it could cause bacteria to grow and cause a respiratory infection. The Surveyor asked, How should those items be stored? She stated, They should be dated and stored in a baggie. The facility policy titled, Oxygen Concentrator, provided by the Administrator on 03/10/23 at 8:00 AM documented, Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. 46319 46724

Based on record review, and interview, the facility failed ensure the resident and resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language they could understand and a copy of the notice was sent to the ombudsman for 1 Resident (#78) of 1 sampled resident who was transferred to the hospital. The findings are: Resident (R) #78 had diagnoses of Metabolic Encephalopathy, Chronic Kidney Disease, Unspecified and Severe Sepsis with Septic Shock. The Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 02/20/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) a. On 03/08/23 at 3:00 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Do you have a document for transfers/discharge with the reason for the transfer or discharge in writing? LPN #1 stated, We only do discharge for residents who aren't coming back. The Surveyor asked, Can you show me the document for R #78's transfer to the hospital? LPN #1 stated, It should be in the Medical Record under Resident Documents. The Surveyor asked, If it's not located there where would it be? LPN #1 stated, The family may not have signed and returned it. b. On 03/09/23 at 2:40 PM, LPN #1 stated, I figured out what you were talking about and the Social Director has those. c. On 03/09/23 at 2:44 pm., the Surveyor asked the Social Director for the transfer documents for R #78. The Social Director provided the facility, Bed Hold Policy - Transfer Notice form for R #78 with a transfer date of 02/09/23. The Surveyor asked, Where does it state in writing the reason for transferring to the hospital? The Social Director stated, It says transfer necessary for the Resident's welfare. The Surveyor asked, Is that the reason or the condition for the transfer to the hospital? The Social Director stated, We should go talk to the Administrator. d. On 03/09/23 at 3:10 PM, the Surveyor asked the Administrator, Can you show me on the Bed Hold Policy - Notice of Transfer form, where the reason for transfer is? The Administrator stated, It's right here. [pointing at the section stating Transfer necessary for Resident's welfare]. The Surveyor asked, Is that the reason for transfer. The Administrator stated, That's what we have always used since it has become a regulation, but we will make changes to it.

Based on observation, interview, and record review, the facility failed to accurately complete a Baseline Care Plan to reflect the use of Oxygen for 1 (Resident #290) of 1 sampled resident whose oxygen therapy was not on their Care Plan. The finding are: Resident (R) #290 was admitted on [DATE] and had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) received oxygen therapy. a. The Physician's Order dated 02/23/23 documented, .O2 [Oxygen] @ [at] 2L NC [2 liters per nasal canula] PRN [as needed] SHORTNESS OF BREATH, MAY REMOVE FOR ADL'S [Activities of Daily Living] .CHANGE O2 TUBING [and] HUMIDIFER WEEKLY ON WEDNESDAY NIGHTS Frequency: Once a Day on Wed [Wednesday] 11:00 PM - 07:00 AM . The Baseline Care Plan dated 02/24/23 did not address oxygen therapy. a. On 03/10/23 at 9:40 AM, the Surveyor asked the Director of Nursing (DON), Is it important for oxygen to be included on the Baseline Care Plan? The DON replied, Yes The Surveyor asked, Why is it important? The DON stated, We need to know. It effects the resident. b. On 03/10/23 at 9:45 AM, the Surveyor asked the MDS Coordinator, Who completes the Baseline Care Plans when a resident is admitted ? The MDS Coordinator replied, I do, as well as the Social Director. The Surveyor asked, Why is it important that oxygen in included in the Baseline Care Plan? The MDS Coordinator replied, Because it tells us how to take care of the resident. The Surveyor asked, What could be the outcome if it's not included? The MDS Coordinator replied, The resident could have respiratory distress, it lets us know what steps we need to take to care for them. c. On 03/10/23 at 9:50 AM, the Surveyor asked the Social Director, Do you help complete the Baseline Care Plan? The Social Director replied, Yes, I do my part, then give it to the nurse to complete the medical part. The Surveyor asked, When the resident has oxygen, do you complete that section? The Social Director replied, No, I don't do that part. I guess I need to start doing that, because if they are on oxygen, I do ask where they get their supplies, their doctors, etcetera.

Based on observation, interview and record review, the facility failed to ensure the placement of the Percutaneous Endoscopic Gastrostomy (PEG) tubing before attempting to administer medication for 1 (Resident #1) of 1 sampled resident who was observed during medication administration. The findings are: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/3/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and received 51% (percent) or more calories and 501cc (cubic centimeters) per day through a PEG tube. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . flush PEG tube with 60 ml [milliliter] H2O (water) before and after meds every shift . check tube placement by aspirating stomach contents every shift . check tube placement by auscultating air passage every shift . [MEDICATION(S)] tablet 20 mg [milligrams] . 1 tablet gastric tube . one an evening; 05:00 PM . b. The Care Plan with a revised date of 09/23/21 documented, . Problem . Nutritional Status . Approach . Check placement of tube before each flush or feeding . c. On 4/11/22 at 4:10 PM, Registered Nurse (RN) #1 prepared Residents #1's medications. RN #1 crushed the [MEDICATION(S)] tablet 20 mg and added it to an unmeasured amount of water. She filled 2 more cups with an unmeasured amount of water. She sat the cups on the residents over bed table and set the feeding pump on hold. She unclamped the feeding tube from the PEG port. She did not check for placement. She attached the syringe to the Y port of the feeding tube. She poured the medication and the water into the syringe. The syringe was not draining into the feeding tube. She kept twisting and pinching the tubing to try to clear the tubing and allow the fluid to drain in the tube. She poured the solution from the syringe attached to the feeding tube back into the cup and sat the cup on the over bed table and walked out. d. On 4/11/22 at 4:30 PM, RN #1 asked Licensed Practical Nurse (LPN) #1 to check the residents feeding tube. The two nurses entered the resident's room. The cup with the medication and water and 2 other cups are still setting on the overbed table. RN #1 pulled up the water and medication into a 60cc syringe. She attached the syringe to the feeding tube. She tried to push the fluids into the feeding tube. She withdrew the syringe from the feeding tube and squirted the contents back into the cup. She reattached the empty syringe to the feeding tube and tried to aspirate gastric contents. She could not insert fluids through the tube or aspirate gastric contents from the feeding tube. She threw the cups into the trash. e. On 4/11/22 at 4:40 PM, RN #1 entered the resident's room. LPN # 2 entered the room. She used a stethoscope to check for placement. She could not insert 30cc of air through the feeding tube and could not aspirate gastric contents through the feeding tube. She said, It looks like it is stopped up at the Y port. She left the room and returned with a new Y port. She disconnected the Y port from the residents feeding tube and discarded it. She inserted the new Y port to the feeding tube. She used the stethoscope and checked for placement. She inserted 30cc of air and said, I heard it. f. On 4/11/22 at 4:45 PM, RN #1 set the medication up again. She poured the crushed medication into a cup and filled it with an unmeasured amount of water. She filled 2 more cups with an unmeasured amount of water. She opened the cap to the Y port, attached the syringe and poured in the medication and 50cc of water. She then added another 20cc of water. She then poured in 80cc of water, then 60cc of water, then 50cc of water and then another 60cc of water for a total of 320cc of water. g. On 4/13/22 at 11:08 AM, the DON was asked, Should you check for placement prior to administering medication? She said, Yes. h. A facility policy titled, Administering Medications through and Enteral Tube, provided by the DON on 4/12/22 at 1:12 pm documented, . Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Steps in procedure .17. Unclamp tubing. 18. Confirm placement of feeding tube. 19. If you suspect improper tube positioning do not administer feeding or medication. Notify the Charge Nurse or Physician. 20. Check gastric residual volume to assess for tolerance of enteral feeding. 21. When correct tube placement . have been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount) . 22. Remove the syringe and clamp tubing . 23. Dilute the crushed or split medication with 15-30 ml sterile or purified water (or prescribed amount). 24. Reattach syringe (without plunger) to the end of the tubing. 25. Administer medication by gravity flow. A. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. B. Open the clamp and deliver medication slowly. C. Clamp tubing (or begin flush) before the tubing drains completely . 27. When the last medication begins to drain from the tubing, flush the tubing . prescribed amount of water . 28. Quickly clamp the tubing when the flush is complete. Remove the syringe .

Based on observation of the 5:00 PM medication pass on 04/11/22, record review and interview the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #10 and #11) of 6 residents observed during the medication pass, resulting in medication errors. Medication errors were made by Registered Nurse (RN) #1 of 2 (RN #1 and Licensed Practical Nurse (LPN) #1) nurses observed administering medications. The medication error rate was 16%, based on observation of 25 medications administered and a total of 4 errors detected. The findings are: 1. Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = [equal] 2.4 GMS [grams]; oral . Twice a day; 08:00 AM, 05:00 PM . [MEDICATION(S)] capsule; 5OO mg [milligrams]; amt: 1 capsule; oral Special Instructions: FOR 10 DAYS . three times a day; 08:00 AM, 12:00 PM, 05:00 PM . [MEDICATION(S)] Sprinkles . capsule, delayed [NAME] [release] sprinkle; 125 mg; amt: l capsule; oral. Special Instructions: DO NOT CRUSH GIVE WITH FOOD . Twice a Day; 08:00 AM, 05:00 PM . b. On 4/11/22 at 4:05 PM, RN #1 prepared medications for Resident #10. RN #1 crushed the [MEDICATION(S)] DR/EC (Delayed Release/[MEDICATION(S)] Coated) 1.2 gram tablet, 2 tablets, opened a capsule of 1 [MEDICATION(S)] 500 mg and poured into a clear medicine cup. She then opened 1 capsule of [MEDICATION(S)] Sprinkles and poured into the clear medicine cup with the [MEDICATION(S)]. She added the crushed content of the [MEDICATION(S)] into the cup of the other medication. She added 1 teaspoonful of applesauce and mixed together. She gave Resident #10 two bites of the mixed medications with applesauce. She walked away to throw the cup away. The RN #1 was asked to scrape the remaining ingredients of the cup into the spoon. There was visible chunks of the medication left in the cup. RN #1 was asked, Did you give all of the medication? She said, I thought I did. There was approximately 1/2 teaspoonful left in the clear medicine cup when RN #1 threw the cup in the trash. b. The package insert for [MEDICATION(S)] DR/EC documented, . Precautions . For tablet, delayed release products: Swallow whole. Do not break/chew/crush/dissolve. Take at the same time(s) daily as directed. Take with food. Take at the same time every day . c. The Prescription Order provided by the DON on 4/13/22 at 11:15 AM documented, .Order description: [MEDICATION(S)] tablet, delayed release (DC/EC); 1.2 gram; amt: 2 tablets = 2.4 GMS; oral . Special Instructions: DO NOT CRUSH . 2. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Twice a day; 08:00 AM, 05:00 PM . [MEDICATION(S)] ([MEDICATION(S)]) tablet; 5mg; amt: 1 tablet; oral . Twice a day; 08:00 AM, 05:00 PM . [MEDICATION(S)] . dropperette; 0.5 %; amt: 1 drop to both eyes; .Special Instructions: WAIT 5 MINUTES BETWEEN DROPS . Twice a day, 08:00 AM, 05t00 Pf4 b. On 4/11/22 at 4:05 PM, RN #1 administered medications to Resident #11. She put [MEDICATION(S)] 2 ([MEDICATION(S)]) mg, 1 tablet and [MEDICATION(S)] 5 mg, 1 tablet. The resident was also to receive [MEDICATION(S)] ([MEDICATION(S)]) 0.5%, 1 drop to both eyes. RN #1 stated to Resident #11, The medication is not here. I will give it when the pharmacy delivers. Resident #11 said, I didn't get my eye drops this morning with the pink cap either. c. On 4/11/22 at 5:00 PM, RN #1 documented on the Medication Administration Record (MAR), .Charted date 4/11/22 06:00 PM Reasons/Comments . Not Administered: Other Comment: waiting on pharmacy to deliver . 3. On 4/13/22 at 11:06 AM, the Director of Nursing (DON) was asked, Should all of the medication be given when crushed and mixed in a cup? She said, Yes. The DON was asked, If a resident has eye drops and they are not available, should you notify the doctor? She said, Yes. The DON was asked, Did you hear me explain to the RN, that if a medication is ordered at the time of observation and it is not given you must tell me why and let me see when you administer it, or it counts as an error? She said, Yes.

Based on observation and interview, the facility failed to ensure safe and secure storage of medications on 2 (Back of South Hall and Back of North Hall) of 3 (Back of South Hall, Back of North Hall and Front of North and South Hall) medication carts and failed to ensure medications were not left in a resident's room unattended to prevent potential tampering or access by cognitively impaired, self-mobile residents. The findings are: 1. The facility policy titled, Storage of Medications, provided by the DON on 4/12/22 at 1:38 PM the documented, . Policy Statement . The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . 2. On 4/11/22 at 4:05 PM, Registered Nurse (RN) #1 prepared medications and walked into the dayroom for Resident #10. She did not lock the med cart. She administered the medications to the resident and walked back to her med cart. RN #1 was asked, Did you lock your med cart before you walked away? She said, No ma'am. 3. On 4/11/22 at 4:10 PM, RN #1 prepared Resident #1's medication ([MEDICATION(S)] 20mg (milligrams), 1 tablet) and placed it in a clear medicine cup. She placed the cup with the medication on top of the cart. She locked the cart and walked into Resident #1's room. She came back out of the room and retrieved the cup with the medication in it. She was asked, Should you leave that medication on top of your cart unlocked? She said, No. RN #1 then crushed the medication and added it to an unmeasured amount of water. She filled 2 more cups with an unmeasured amount of water. She sat the cups on the residents over bed table. She turned the feeding pump to hold. She unclamped the feeding tube and checked for placement. She attached the syringe to the Y port of the feeding tube and poured the medication and the water into a syringe. The syringe was not draining into the feeding tube. She poured the solution back into the cup and sat the cup on the over bed table and walked out. 4. On 4/12/22 at 4:10 PM, Licensed Practical Nurse (LPN) #3 prepared Resident #12's medications ([MEDICATION(S)] 1 gram, 1 tablet; [MEDICATION(S)]/[MEDICATION(S)] 25-100mg, 1 tablet; [MEDICATION(S)] 125mg, 1 tablet; [MEDICATION(S)] 500mg, 1 tablet and [MEDICATION(S)] 25mg, 1 tablet). After removing the medication from the medication cards, she left the cards on top of the medication cart and walked over to the nurse's station to administer the medications. LPN #1 was asked, Should you leave the medication cards on top of the med cart unattended? She said, No. 5. On 4/13/22 at 11:08 AM, the DON was asked, Should medications be left on the med cart unattended? She said, No. She was asked, Should the medication cart be left unlocked? She said, No.

Based on observation, record review and interview, the facility failed to ensure kitchen equipment was maintained in a sanitary manner, food was dated, and stored per manufacturer's instructions to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to effect 74 residents (Total Census: 79) who received meals from the kitchen based on a list provided by the Dietary Manager on 9/22/21. The findings are: 1. On 09/20/21 at 10:02 A.M., the following observations were made in the kitchen: a. There was a brownish sticky residue on the internal vent of the microwave. Dietary Employee #1 was asked to describe what she saw in the microwave and she said, It needs to be cleaned. When asked how often it is cleaned, the Dietary Employee #1 replied, Once a week. b. On the countertop near the microwave there was four containers of dry cereal with no date or label. Dietary Employee #1 was asked to identify the dry cereals and she said, There's Cheerios, Raisin Bran, Cornflakes, and Rice Krispies. When asked if the cereals should be dated, she said Yes. c. Across from the three compartmental sink there was a worktable with a drawer containing an unidentified black clump and food crumbs among the clean utensils. Dietary Employee #1 said, It looks like someone got in a hurry and dropped something in the drawer. 2. On 09/21/21 at 10:02 A.M., the following observations were made in the kitchen: a. There was a case, (50) of 6-ounce orange nutritional drinks with a received date of 9/2/2021 in the walk-in refrigerator. The handling instructions on the side of the individual drink documented, .Store frozen (0 F or below). After thawing, keep refrigerated. Use within 14 days after thawing. Dietary Employee #1 was asked if she knew how long the drinks had been thawed and she said, No. They should have a date showing when they were pulled out of the freezer. b. The can opener blade and holder had a gummy black substance on them. c. There was a fan sitting on a shelf above clean bowls and serving trays. The fan blades were covered with a greyish fuzzy debris. d. There was a grayish kitchen cart with clean serving trays stored on it. On the bottom shelf of the cart there was a soiled piece of paper, crumbs, and a yellowish unidentified substance near the clean trays.

Based on observation, record review and interview, the facility failed to ensure interventions were developed and implemented to reduce the potential for further falls and failed to ensure bed alarms were placed in accordance with the manufacturer's instructions to ensure staff would be promptly alerted if the resident attempted to transfer without assistance for 1 (Resident #9) of 4 (Residents #6, #9, #14, and #16) case mix residents who had a history of [REDACTED].#9, who sustained multiple rib fractures as a result of a fall on 9/8/12, and had the potential to cause more than minimal harm to 17 residents who were cognitively impaired and self-mobile, as documented on a list provided by the Director of Nursing on 9/14/12 at 10:00 a.m. The facility failed to ensure mechanical lifts on 2 of 6 halls (300 and 400 halls) were maintained in safe operating condition in accordance with the manufacturer's specifications, to reduce the potential for transfer accidents/injuries. This failed practice had the potential to affect 33 residents who used the mechanical lift for transfer according to a list provided by the Director of Nursing on 9/14/12. The facility failed to ensure hot water for resident use was maintained at safe temperatures on 4 (Halls 200, 400, 500 and 600 Halls) of 5 Halls to reduce the potential for burn injuries. This failed practice had the potential to affect 67 residents who resided on these halls, as observed during initial rounds on 9/10/12. The facility failed to ensure potentially hazardous chemicals and sharps were stored securely on 1 of 2 baths to prevent potential access by cognitively impaired self-mobile residents. The failed practice had the potential to affect 17 cognitively impaired, self-mobile residents, as documented on a list received from the Director of Nursing on 9/14/12. The facility failed to ensure oxygen tanks were secured when being stored to prevent potential tipping, puncture or fire in 1 of 1 oxygen storage room on the 300 Hall. The failed practice had the potential to affect 23 residents that resided in the facility as documented on the Census and Conditions Detail roster received from the Administrator on 9/10/12. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/12 documented the resident scored 10 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), had unsteady balance during transitions and had no falls since the prior assessment. a. The Care Plan dated 4/10/12 with a review date of 7/9/12 documented, "High risk for falls related to altered mobility secondary to weakness Resident will be without falls/injury this quarter Approaches Explain call bell/light assess resident's ability to use. Keep bed at lowest level at night. Maintain a clutter - free environment. Monitor for and document perceptual changes. Observe for decreases or loss of functional status. Observe for gait unsteadiness. Observe for s/sx (signs and symptoms) of blurred vision and vertigo. Orient resident to new surroundings..." The Fall Risk assessment dated [DATE] documented the resident's total fall risk score was 10, with a score of 10 or greater indicating a risk for falls. b. A physician order [REDACTED]. c. A physician's telephone order dated 9/5/12 documented, "UTI (urinary tract infection) Bactrim DS (double-strength) i (one) PO (by mouth) BID (twice daily) x (times) 10 days". A separate physician's telephone order dated 9/5/12 documented, "...Pt (patient) to receive skilled OT (Occupational Therapy) services 5x/wk x 4wks (5 times per week for 4 weeks) to (increase) balance, activity tolerance, strength & facilitate (increased) I (independence) with ADL's (activities of daily living)". d. An Incident/Accident Report form dated 9/7/12 at 5:45 p.m. documented, "Description of incident and treatment administered: Call to resident's rm (room) by aide... resident lying supine in floor on back in front of w/c (wheelchair). Resident states she was trying to go to bed and lost balance and fell backwards. Resident has lg (large) knot to back (left) side of head... Action taken to prevent further incidents: Res (Resident) counseled to call for assist before ambulating to reduce risk of fall. Verbalized understanding." There was no documentation of any additional interventions to reduce the potential for further falls, other than counseling the cognitively impaired resident to call for assistance. e. An Incident/Accident Report form dated 9/8/12 at 9:55 p.m. documented, "Res found yelling help on floor in her room ... laying on Rt (right) side with w/c in front of her. Res states 'I was going to the bathroom and I fell '. Res assist of 2 to sitting position AROM (active range of motion) of BUE (bilateral upper extremities) (without) diff (difficulty). Res assist to stand able to bear wt (weight) on BLE (bilateral lower extremities (without) diff or pain. Res c/o (complained of) (right) rib pain. Referred to ER (emergency room ) (at local hospital) via ambulance for evaluation ...Final disposition ...dx (diagnosed ) (with) multiple rib fx (fractures)... Action taken to prevent further incidents Bed alarm placed on bed..." A hospital Discharge Instruction form dated 9/9/12 documented, "Final [DIAGNOSES REDACTED]. f. An Incident/Accident Report form dated 9/11/12 at 12:30 p.m. documented, "Res (Resident) heard moaning loudly this nurse and CNAs (Certified Nursing Assistants) ...to res room to note res lying on back in front of closet (with) wheelchair at her side, head noted up against closet door. (no) injuries noted from this fall... res (with) BM (bowel movement) on self, stated 'I was trying to make it to bathroom.'...Final disposition Res confused this shift. Sent to ER for eval (evaluation) of mental status (changes) Return (with) dx of UTI (urinary tract infection) ...Action taken to prevent further incidents counseled res to use call light for assistance, bed alarm in place and adjusted..." g. On 9/12/12 at 5:00 p.m., the Director of Nursing (DON) was asked if the bed alarm sounded on 9/11/12 when the resident fell and the DON stated "Yeah, her bed alarm was on. When I checked the bed, it was set on monitor. It was not on hold. I do remember." The DON was asked if the alarm sounded loudly and was on the bed. The DON stated, "No, it was not, because I did look. Let me see, when I checked, it was set on monitor. After the fall - this is after the fall - I remember now; I said she has a bed alarm when she fell . The strip was under 2 layers of foam. She has 2 egg crates (textured foam mattress pads) on her bed. I can't explain this, cause about 8:30 that morning, her bed alarm was on and the bed alarm was going berserk. I don't understand why it didn't go off the second time. I know it did that morning; it's set on 1 second." The DON was asked if the alarm was tested and the DON stated, "We redid it under the sheet above the foam." The DON was asked how thick the foam was and stated, "The 1 inch egg crate, except there's 2 of them." The DON was then asked how often the alarm was checked and stated, "The nurses check them on rounds; she (the nurse) would check to see if it's set on monitor." The manufacturer's instructions for use of the Basic-Check User Manual Bed Check, received from Registered Nurse (RN) #2 on 9/12/12 at 5:55 p.m., documented, "How the Basic-Check System can work for you: The Basic-Check system consists of a control unit and a disposable pressure sensitive Sensormat. When a patient's weight is removed from the Sensormat, the control unit activates an alarm. How to use the Basic-Check System ...2. Place the Sensormat so that it will be beneath the patient's buttocks. 3. The control unit will automatically arm itself when weight is placed on the Sensormat. 4. If the patient lifts his weight off the Sensormat, the Basic-Check will immediately alarm. ...6. Test the system daily for effective operation. ...Basic-Check Inservice Review for Bed...B. Make sure all sheets and covers are pulled down to the foot of the bed. Place Sensormat 3 to 5 inches below the bend in the mattress. C. Attach the alligator clips to the fabric of the mattress, mattress piping or bed springs on both sides. You may now reposition sheets and covers. ...Important: Check for System Effectiveness Daily and/or at shift change. Always check correct positioning of Sensormat after any alarm..." h. On 9/12/12 at 8:40 a.m. and 11:45 a.m., the resident was in a low bed with the bed alarm properly placed. The call light was within reach and two visitors were at the resident's bedside. 2. On 9/12/12 at 12:10 p.m., the water temperature checks on the 600 Hall were measured by the surveyor. The water temperature was elevated in the common area bathroom on the 600 Hall at 125 degrees Fahrenheit (F). At 12:18 p.m., the water temperature in room 605 measured at 125 degrees F. At 12:20 p.m., the water temperature in room 610 was 125 degrees F. The water temperature in room 512 was 128 degrees F, in room 505 it was 128.8 degrees F and in room 507 it was 128 degrees F. The water temperature in room 606 at 12:30 p.m. was 128 degrees F. a. On 9/12/12 at 12:50 p.m., the Maintenance Director was asked if there had been any type of plumbing problems and the Maintenance Director stated, "No." The Maintenance Checklist form dated from January 2012 to September 2012, received from the Administrator at 12:50 p.m. on 9/12/12, was reviewed. The form documented water temps ranged from 119 degrees to 123 degrees F on the 6 facility halls. The area titled, "Problems Noted" documented, "OK". There was no documentation that attempts were made to adjust the temperatures or monitor them more frequently. b. On 9/12/12 from 12:55 p.m. to 1:45 p.m., the hot water tanks, random room and common area water temperatures were checked with the Maintenance Director and the facility's thermometer. At 1:00 p.m., in Room 605 the hot water temperature was 115 degrees. At 1:02 p.m., the hot water temperature in room 612 was 115 degrees and in room 606 the water temperature was 115 degrees. At 1:05 p.m., the water temperature for the facility's thermometer and the surveyor's thermometer reading was 114 degrees F in the common area bathroom on the 600 Hall. At 1:16 p.m., the water temperature in the Central Bath off of the 400 Hall was 120 degrees in the sink. At 1:17 p.m., the water temperature in room 402 was 120 degrees F and in room 412 the water temperature was 120 degrees F. At 1:22 p.m., the hot water tanks that supplied water for the 400 Hall (Elm) was set at 135 degrees F. and the tank that supplied the hot water for the 300 Hall was set at 120 degrees F. On 9/12/12 at 12:45 p.m., the Administrator was asked if there had been any burns. The Administrator stated, "No." c. On 9/14/12 at 9:00 a.m., the Maintenance Director was asked what temperature the hot water should be and stated, "110". The Maintenance Director was asked what was found when the facility had the plumber check the hot water on the previous day and stated, "They said they are going to put mixing valves on each tank to add cold water when the thermostat shows the water needs cold water added." 3. On 9/13/12 at 3:25 p.m., in the oxygen storage room there were 2 portable oxygen tanks that were not secured on the 300 hall . The tanks were standing next to the wall and out of the rack. The Maintenance Director stated, "The nurses put them in here like that." 4. On 9/13/12 at 3:40 p.m., in Central Bath Station 1, between 400 and 500 hall, the door was unlocked and there was a canvas and net bag by the door inside the room. The bag contained multiple bottles of liquid and uncovered disposable razors. There were 3 residents outside the shower room in the hallway and there was not any staff present. The items in the bag were as follows: a. Angel of Mine brand creamy baby oil 10 ounce bottle with a label that documented, "Safety tip. For external use only." b. An aerosol container of Axe deodorant 4 ounces with a label that documented, "Warnings: ...Avoid inhalation...Avoid spraying in eyes..." c. A 2.5 ounce tube of Repara skin ointment with a label that documented, "Warnings For external use only. When using this product do not get into eyes. ...If swallowed, get medical help or contact a Poison Control Center right away. " d. A 4 ounce tube of Remedy brand Calazime skin protectant with zinc oxide with a label that documented, "Warnings For External Use Only Do ...When using this product do not get into eyes. ...If swallowed, get medical help or contact a Poison Control center right away." e. A 4 ounces container of Ultrasure Antiperspirant and Deodorant with a label that documented, "Warnings For external use only...Avoid contact with eyes. In case of contact, flush thoroughly with water. Ask a doctor before use if you have Kidney Disease. ...If swallowed, contact a physician or Poison Control center right away." f. An 8 ounce spray bottle of Nightingale No Rinse Formula Perineal wash with a label that documented, "Caution: KEEP OUT OF EYES. In case of accidental eye contact DO NOT RUB EYES. Flush eyes thoroughly with water. If condition worsens or irritation persists, call a physician. If swallowed, consult a physician or poison control center..." g. A 4 ounce tube of Remedy brand Antifungal cream with a label that documented, "Warnings For External Use Only ...avoid contact with the eyes...If swallowed, get medical help or contact a Poison Control Center right away. ..." h. A 4 ounce tube of Remedy Skin Repair Cream with a label that documented, "Warnings For External Use Only ...When using this product do not get into eyes...If swallowed, get medical help or contact a Poison Control center right away." i. A 1.7 ounce tube of Elizabeth Arden Eight Hour Cream with a label that documented, "Warning: For external use only. Avoid contact with the eyes..." j. Two, 2 ounce tubes of Udderly Smooth with a label that documented, "Warning: For external use only. Avoid contact with eyes." k. Remedy brand Antifungal powder 3 ounce bottle with a label that documented, "Warning For external use only. ...If swallowed, get medical help or contact a Poison Control center..." l. 2 packets of Repara Skin ointment m. A 1.5 fluid ounce container of Silvasorb gel antimicrobial wound gel. n. A 1.7 ounce sized container of Degree antiperspirant and deodorant with a label that documented, "Warning For external use only..." o. A 4 ounce tube of Medline Remedy Dimethicone skin protectant with a label that documented, "Warnings For External Use Only...When using this product do not get into eyes. ...If swallowed, get medical help or contact a poison control center right away." p. There were 10 uncovered disposable razors with the blades exposed. q. On 9/13/12 at 3:50 p.m., the Director of Nursing (DON) was asked about the contents of the bag and stated, "They are supposed to lock this up." 5. On 7/11/12 at 3:30 p.m., the Reliant 450 Manual Mechanical Lift was observed on the 300 hall. There were no hooks on the swivel bar. The Reliant 450 Manual Mechanical Lift was observed on 400 hall. There was 1 of 4 safety clips missing. a. The Invacare electric patient lift manufacturer's manual for the Reliant 450 received from the Administrator on 7/12/12 documented on page 10 of the manual, "Regular maintenance of patient lifts and accessories is necessary to assure proper operation." On page 47 of the manual, there was an illustration of the swivel bar with the hooks and required safety clips. Page 47 of the manual documented, "Warning; After the first year of year of use, the hooks of the swivel bar and mounting brackets of the boom should be inspected every six months to determine the extent of wear. If these parts become worn, replacement must be made ...Caution: The swivel bar has three hooks on both ends to attach the sling that supports the patient during lift..." b. On 9/13/12 at 5:10 p.m., the Maintenance Supervisor stated, "I check all mechanical lifts periodically. I was not aware the clips were missing. They usually let me know if I need to work on the lifts."