Based on observation and interview, the facility failed to ensure 1 of 3 shower rooms were clean. The findings are: On 04/15/2024 at 02:17 PM, a brown substance was smeared on the floor in the bathroom on the Medicare Hall. On 04/15/2024 at 02:19 PM, Certified Nursing Assistant (CNA) #4 walked into the shower on the Medicare Hall. She was asked, What's the brown substance on the shower floor? She stated, I'm sure it's bowel movement. On 04/17/2024 at 09:56 AM, the Director of Nursing (DON) was asked, How often should the shower room be cleaned? She stated, After use and between residents. On 04/17/2024 at 10:06 AM, the Administrator was asked, How often should the shower room be cleaned? She stated, Soils should be cleaned after every shower, and deep cleaned at the end of the day. She was asked, Should there ever be feces on the shower room floor if the shower is not in use? She stated, No it should be cleaned up as soon as the resident has left the shower room.

Based on interview and record review, the facility failed to ensure all medications were documented on the discharge summary for 1 (Resident #184) when discharging from the facility. The findings are: A review of the admission Record, indicated the facility admitted Resident #184 with a diagnosis Acute systolic (congestive) heart failure. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024 revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. On 04/17/2024 at 03:11 PM, the Administrator was asked, Did you have any residents receive the wrong medication upon discharge last month? She stated, Yes I believe her name was [Resident #184]. I don't do the discharges, but the care giver called up here and said [Resident #184] had someone else's medication and she was going to be bringing the medication back up here. I think she gave the medication to [Licensed Practical Nurse (LPN) #2] on Station 1. On 04/17/2024 at 03:39 PM, the discharge summary was reviewed. There was no documentation indicating what medications were sent home with the resident on 03/20/2024. On 04/17/2024 at 03:43 PM, the Director of Nursing (DON) was asked, What is the process for getting a residents medication ready for discharge? She stated, The nurse goes over the resident's orders then she pulls the medications. The Surveyor asked, Is there a discharge summary of all the medications that were sent home with [Resident #184]? She looked in the computer and pulled up a copy of the physician orders. She was asked, What medications were sent home with [Resident #184] that didn't belong to the resident? She stated, I'm not sure. On 04/17/2024 at 04:21 PM, LPN #2 was asked, What's the process for discharging a resident home with medication? She stated, The night shift pulled the PM meds [medications], and I pulled the AM meds. I put them all together and I put them in a bag. The Surveyor asked, Did you check the medications? She stated, No, I just put them in the bag since the night shift had already pulled them. The Surveyor asked, Why is it important that you check the medications against the physician orders? She stated, I should have. The discharge person does all the paperwork and the reconciliation form, and we just pull the meds. I just took for granted that everything was correct. The Surveyor asked, What could happen if a resident is discharged with the wrong medication? She stated, The caregiver called me and told me that [Resident #184] had the wrong medication, and she would bring them up here. She was asked, After this incident happened, were you in-serviced? She stated, Personally, no they didn't. The DON didn't know about it. I told the Administrator. It was an absolutely a freak mistake. On 04/17/2024 at 03:47 PM, the Administrator was asked, When were you made aware that the nurse had discharged [Resident #184] home with another resident's medication, and did you provide an in-service for the nurses? She stated, No I didn't. I just talked to LPN #2, and she told me that they were bringing the medications back up here.

Based on interview and record review, the facility failed to ensure 1 (Resident #184) did not receive medications that were not prescribed to them upon discharge. The findings are: A review of the admission Record, indicated the facility admitted Resident #184 with a diagnosis of Acute systolic (congestive) heart failure. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024 revealed Resident #184 had a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. On 04/17/2024 at 03:11 PM, the Administrator was asked, Did you have any residents receive the wrong medication upon discharge last month? She stated, Yes, I believe [the resident] name was [Resident #184]. I don't do the discharges, but the care giver called up here and said [Resident #184] had someone else's medication and she was going to be bringing the medication back up here. I think she gave the medication to [Licensed Practical Nurse (LPN) #2] on Station 1. On 04/17/2024 at 03:39 PM, the discharge summary was reviewed. There was no documentation indicating what medications were sent home with the resident. On 04/17/2024 at 03:43 PM, the Director of Nursing (DON) was asked, What is the process for getting a residents medication ready for discharge? She stated, The nurse goes over the resident's orders then she pulls the medications. The Surveyor asked, Is there a discharge summary of all the medications that were sent home with [Resident #184]? She looked in the computer and pulled up a copy of the physician orders. She was asked, What medications were sent home with [Resident #184] that didn't belong to her? She stated, I'm not sure. On 04/17/2024 at 04:21 PM, LPN #2 was asked, What's the process for discharging a resident home with medication? She stated, The night shift pulled the PM meds [medications], and I pulled the AM meds. I put them all together and I put them in a bag. The Surveyor asked, Did you check the medications? She stated, No, I just put them in the bag since the night shift had already pulled them. The Surveyor asked, Why is it important that you check the medications against the physician orders? She stated, I should have. The discharge person does all the paperwork and the reconciliation form, and we just pull the meds. I just took for granted that everything was correct. The Surveyor asked, What could happen if a resident is discharged with the wrong medication? She stated, The caregiver called me and told me that [Resident #184] had the wrong medication, and she would bring them up here. She was asked, After this incident happened, were you in-serviced? She stated, Personally no they didn't. The DON didn't know about it. I told the Administrator. It was an absolutely a freak mistake. On 04/17/2024 at 03:47 PM, the Administrator was asked, When were you made aware that the nurse had discharged [Resident #184] home with another resident's medication, and did you provide an in-service for the nurses? She stated, No I didn't. I just talked to [LPN #2], and she told me that they were bringing the medications back up here.

Based on observation and interview, the facility failed to ensure a medication cart was locked while unsupervised, and that controlled narcotics were contained in a locked and permanently affixed container. The findings are: On 04/17/2024 at 03:00 PM, the Surveyor observed the refrigerated plastic emergency kit located in the Station 1 refrigerator containing (5) 2 milligram (Mg)/1 milliliter (mL) oral Lorazepam syringes and (1) 2 Mg/1 mL injectable Lorazepam syringe was not in a locked and affixed container. Lorazepam is a controlled substance which can cause paranoid or suicidal ideation and impair memory, judgment, and coordination. Combining with other substances, particularly alcohol, can slow breathing and possibly lead to death. On 04/17/2024 at 03:13 PM, the Surveyor observed the medication cart on Station 2 to be unlocked and unattended. On 04/17/2024 at 03:14 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Is the refrigerated emergency kit containing Lorazepam in a permanently affixed and locked container? LPN #1 stated No. The Surveyor asked, Should the medication cart on Station 2 be unlocked and unattended? LPN #1 stated No, it should not be. On 04/17/2024 at 03:56 PM, the Director of Nursing (DON) confirmed the medication cart on Station 2 was left unlocked and unattended. On 04/17/2024 at 04:16 PM, the Assistant Director of Nursing (ADON) confirmed the refrigerated emergency kit containing Lorazepam was not in an affixed and locked container. On 04/17/24 at 04:27 PM, the DON reported the facility did not have a Medication Storage Policy. A document provided by Human Resources on 04/18/2024 at 08:28 AM titled, Charge Nurse Job Description showed, .responsibilities .ensure proper .storage of medications and controlled substances .

Based on observation, interview and record review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets from 1 of 1 kitchen. The findings are: 1. The menu for supper documented that the residents who received pureed diets were to receive two #8 scoops (totaling 1 cup) of pureed pimento cheese sandwich. 2. On 04/16/2024 at 05:06 PM, Dietary Employee (DE) #2 used a 4-ounce spoon to serve a single scoop (totaling 0.5 cups) of pureed pimento cheese sandwich to the residents on pureed diets, instead of two #8 scoops as specified on the menu. 3. On 04/17/2024 at 11:38 AM, the Surveyor asked DE #2 what spoon size she used to serve pureed pimento cheese and how many servings she had served to the residents who required pureed diets. DE #2 stated, I used 4-ounce spoon and gave a serving each.

Based on observation and interview, the facility failed to ensure the 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 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets. The findings are: 1. On 04/17/2024 at 07:40 AM, a pan of pureed sausage was on the steam table. The consistency of the pureed sausage was gritty and not smooth. The Surveyor asked Dietary Employee (DE) #5 to describe the consistency of the pureed sausage. DE #5 stated, It was a little gritty. I should have pureed it a little longer. 2. On 04/17/2024 at 10:45 AM, DE #5 used a 6-ounce scoop to place 7 servings of lasagna into a blender, added beef broth and pureed. At 10:47 AM, DE #5 poured the pureed lasagna into a pan and placed it on the steam table. The consistency of the pureed lasagna was lumpy and not smooth. There were pieces of intact noodle visible in the mixture. 3. On 04/18/2024 at 07:50 AM, the Surveyor asked DE #5 to describe the consistency of pureed lasagna. DE #5 stated, I should have pureed it longer.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered, sealed, and dated, kitchen walls, door frames and baseboards were free of rotten wood, chipped walls were replaced, dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents who received food from 1 of 1 kitchen, 2 of 2 ice machines were maintained in a clean and sanitary condition and dietary staff washed their hands and changed their gloves before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 82). The findings are: 1. On 04/14/2024 at 10:15 AM, 17 individual 4 ounce (oz) containers of lemon flavor with other natural sweeter flavors added were on a shelf in the storage room. There was no received date on the box. 2. On 04/17/2024 at 03:45 PM, there was a pink residue in the interior surface of the ice machine located in the kitchen. The Surveyor asked the Dietary Supervisor to wipe the right interior side of the ice machine where pink residue was found. She used a tissue to wipe the area, which had a pinkish residue on it and the pink substance easily transferred to the tissue paper. The Surveyor asked the Dietary Supervisor to describe the residue that was on the tissue, who uses the ice machine, and how often was it cleaned. The Dietary Supervisor stated, Pinkish, and we use it in the kitchen to fill beverages served to the residents at mealtimes. 3. On 04/16/2024 at 03:46 PM, the cabinet below the deep fryer had 5 pilots, the pilots and the bottom of the cabinet which were covered with a buildup of greasy. The Surveyor asked the Dietary Supervisor how often they cleaned it. She stated, It is cleaned every week, but it has not been. 4. On 04/16/24 at 03:47 PM, Dietary Employee (DE) #1 picked up a box of gloves, pulled the gloves out of the box and placed them on his hands, contaminating them. Without washing his hands and changing gloves, he picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who received pureed diets. The Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? DE #1 stated, I should have washed my hands. 5. On 04/16/2024 at 03:49 PM, there was a pink residue in the interior surface of the ice machine located behind the nurse's station on Station 3. The Dietary Supervisor asked DE #2 to wipe the left and the right interior side of the ice machine where pink residue was found. He used tissues to wipe the areas, which had a pinkish residue on them. The pink substance is easily transferred to the tissue paper. The Surveyor asked the Dietary Supervisor to describe the residue that was on the tissue, who uses the ice machine, and how often it was cleaned. The Dietary Supervisor stated, Pinkish and the housekeeping cleans it once a week. That's the ice machine the CNAs use for the water pitchers in the residents' rooms. 6. On 04/16/2024 at 04:15 PM, an opened box of bacon was on a shelf in the refrigerator. The box was not covered or sealed. 7. On 04/16/2024 at 04:16 PM, during observation the following food items on a shelf in the freezer were not covered or sealed. a. A box of biscuits. b. A box of hamburger patties. c. A box of biscuit dough. d. A box of garlic bread. e. A box of garlic biscuits. 8. On 04/16/2024 at 04:29 PM, the following observations were made in the kitchen. a. The exit door frame from the kitchen leading to the hall was chipped, exposing the metal. b. The board against the wall of the door frame was loose. c. The bottom of the door frame was rotten, exposing the metal. d. The wall paint between the plate warmer and the steam table was peeling, exposing the cement. e. The wall on the right side of the steam table was chipped, exposing the sheet rock. f. The wall paint below the dish washing machine was peeling, exposing the cement. The area had sage color on it. 9. On 04/16/2024 at 05:02 PM, DE #1, who was on the tray line assisting with supper meal, was observed to pick up tray cards, packet of individual crackers and place them on the trays. Without washing his hands, he picked up the plates to be used in portioning the food items to be served to the residents for supper with his fingers inside of them on the trays. The Surveyor asked DE #1 what should have been done after touching dirty objects and before handling clean equipment. DE #1 stated, I should have washed my hands. 10. On 04/16/2024 at 05:09 PM, DE #2, who was on the tray line assisting with the supper meal, picked up cartons of supplements, cans of soft drinks, ice cream cartons and placed them on the trays. Without washing his hands, he picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents at the supper meal. At 05:14 PM, the Surveyor asked DE #2 what should you have done after touching dirty objects and before handling clean equipment. DE #2 stated, I should have washed my hands. 11. On 04/16/2024 at 08:00 AM, DE #3 opened a cabinet and placed clean bowls in it. Without washing her hands, she picked up bowls to be used in portioning the food items to be served to the residents for lunch with her fingers inside of them. At 11:30 AM, the Surveyor asked DE #3 what should have been done after touching dirty objects and before handling clean equipment. DE #3 stated, I should have washed my hands. 12. On 04/17/2024 at 10:25 AM, DE #5 placed 15 servings of brownie into a blender, then removed a gallon of milk from the refrigerator. DE #5 removed the lid from the gallon of milk and poured some on the brownie, added 3.5 tablespoon of thickener and pureed. Without washing her hands, DE #5 picked up a bowl from the counter with her fingers inside of it to be used in portioning dessert. When DE #4 was ready to transfer pureed dessert into a bowl to be served to the residents who required pureed diets for lunch, the Surveyor immediately asked DE #5, what should you have done after touching dirty objects and before handling clean equipment? DE #5 stated, I should have washed my hands. 13. On 04/17/2024 at 11:01 AM, DE #4 opened a box of frozen bread sticks. Without washing her hands, she removed gloves from the glove box and placed them on her hands, she picked up bread sticks from the original box with her contaminated gloved hands and placed them on the trays to be baked and served to the residents for the lunch meal. 14. On 04/17/2024 at 11:33 AM, a container of baking powder was in the cabinet with an expiration date of 12/13/2023. 15. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 04/18/2024 at 07:54 AM documented, .Staff will wash hands and exposed portions of their arms: .To remove contamination after entering the kitchen, .during food preparation, .before donning gloves for working with food, and after engaging in other activities that contaminate the hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) evaluation process was completed in accordance with the State PASRR process for 1 (Resident #17) of 7 (Resident #1, R #14, R #17, R #36, R #55, R #57, and R #62) sample selected residents who had a diagnosis of a Serious Mental Disorder documented on the Mental Health Diagnosis list provided by the Administrator on 1/20/23, to ensure the resident received appropriate care and services. The findings are: 1. Resident #17 had diagnoses of Schizophrenia and Hallucinations. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/23/22 showed the Resident scored a 15 (13-15 signified cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 01/17/23 at 01:34 PM, during R #17's Electronic Record Review, a [State Designated Professional Associates] letter dated 7/23/19 showed, You MUST contact [State Designated Professional Associates] with the Resident's admission date to receive a completed PASRR packet. b. On 01/19/23 at 02:35 PM, the Surveyor requested the PASRR II for R #17 from the Administrator. c. On 01/19/23 at 02:51 PM, the Administrator provided the Surveyor a copy of the [State designated Professional Associates] letter from 7/23/19 which documented, You MUST contact [State designated Professional Associates] with the resident's admission date to receive a completed PASRR packet The Surveyor pointed to the grey box on the middle of the letter and informed the Administrator the Surveyor was requesting the completed PASRR packet that was mentioned in the grey box. d. On 01/19/23 at 03:56 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they had run a Department of Human Services (DHS) report which showed R #17 was admitted on [DATE]. The Surveyor asked if they had documentation that [State designated Professional Associates] was contacted with R #17's admission Date and received his completed PASRR evaluation from [State designated Professional Associates]. The ADON stated, We are still looking in the paper records for R #17's [named] PASRR. e. On 01/20/23 at 09:25 AM, the Surveyor asked the Administrator if the PASRR process should be fully completed for any resident with a serious mental health issue. The Administrator stated, Yes ma'am. The Surveyor asked who was ultimately responsible for ensuring the process was completed. The Administrator stated, it's between the Business Office and the Medical Records office. The Surveyor asked what information does the PASRR I and II give the facility. The Administrator stated, if they are a PASRR II, they [PASRR] tell us about the care for the mental health issues they need. The Surveyor asked what a possible negative outcome could be if the PASRR process was not completed. The Administrator stated, we do not know what type of services we need to provide. f. On 01/20/23 at 09:29 AM, the Administrator informed the Surveyor the facility did not have a PASRR policy.

Based on interview and record review, the facility failed to employ a qualified Social Worker with a minimum of a bachelor's degree in Social Work or a Human Services field to meet the needs of the residents. This failed practice had the potential to affect all 73 residents who resided in the facility per Resident Daily Census provided by the Administrator on 1/17/23. The findings are: a. On 01/19/23 at 08:44 AM, the Surveyor requested a copy of the Social Service Director's (SSD) Social Worker License or bachelor's degree. The HR Employee stated, SSD [named] is not licensed because of our census. The Surveyor stated the facility was licensed for 122 beds. The HR stated, I have been here since 2013, I know she does not have one. The certificate she does hold is a CNA (Certified Nursing Assistant) certificate, but that is all she has. The HR Employee produced a CNA certificate for SSD [named] with an expiration date of 1/31/25. The Surveyor asked her hire date. HR stated, SSD [named] was hired July 16, 1996. HR provided a copy of the CNA certificate. b. On 01/19/23 at 09:15 AM, the Surveyor asked the SSD if she had a social worker license or a bachelor's degree in in Social Work (SW), Human Services Sociology, Gerontology, Special Education, Rehabilitation Counseling, or Psychology. The SSD stated, no ma'am. Just a certificate in CNA and a social work class certificate. c. On 01/19/23 at 09:20 AM, the SSD provided the Surveyor a copy of her Social Service Director Training certificate dated 2/28/2020. d. On 01/19/23 at 09:28 AM, the Surveyor asked the Administrator and Director of Nursing (DON), how many beds is your facility licensed for? The Administrator stated, we are licensed for 122. The Surveyor asked if the facility's SSD had a SW license or a bachelor's degree in Social Work, Human Services Sociology, Gerontology, Special Education, Rehabilitation Counseling, or Psychology. The Administrator stated, no ma'am. The Surveyor asked if the Administrator realized that was a regulation for the SSD. The Administrator stated, when I first started working here, I was told it was by census. We are actually looking for a Licensed Social Worker and we were just told it is based on actual beds and not our census. The Surveyor asked when the Administrator was made aware of this regulation. The Administrator stated, it was November or December or January that I was notified. The Surveyor asked who she was notified by. The Administrator stated, CANC, my nursing consultant, just notified me. She's [SSD named] been doing this for 26 years. We discussed it at a stand up. The DON stated, I did put it out on 3 different social media sites lately. The Administrator stated, we put ads out today. We have a potential applicant who is a friend of mine that works for DHS (Department of Human Services) and we were going to reach out to the Ombudsman because she told us she wanted to retire. The Surveyor requested documentation of meetings for the SSD position, job postings for the SSD position, and any other documentation related to attempts at filling that position prior to the survey. e. On 01/19/23 at 11:27 AM, the DON provided a copy of a [named social] media post from the DON regarding the Social Worker position. The post was dated 01/19/23 11:00 AM and documented it was posted Just now. f. On 01/19/23 at 04:27 PM, the Surveyor requested a copy of the signed job description for the SSD from the HR Employee. The HR Employee provided a copy which documented .Qualifications .The following for more than 120 beds: A degree in Social Work or related field .

Based on observation, interview, and record review, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; foods in resident refrigerators on the halls were labeled and dated; cookware was cleaned and sanitized between uses; 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages, and to prevent potential food borne illness for residents who received meals from 1 of 1 Kitchen. These failed practices had the potential to affect 73 residents who received meal trays and beverages from the Kitchen as documented on a Diet list provided by the Administrator on 1/20/23. The findings are: 1. On 01/17/23 at 10:10 AM, during a tour of the dry storage room with the Assistant Dietary Manager (ADM) there was a plastic square container ½ [half] full of elbow pasta dated 12/16/22. The Surveyor asked the ADM if he could locate the open date on the container. The ADM stated, I'm not going to be able to do that. The Surveyor asked if the pasta should have been dated when it was removed from the original container. The ADM stated, Yes, it should. 2. On 01/17/23 at 10:18 AM, there was unopened carton of strawberry shake on the top shelf with no date. The Surveyor asked the ADM to find a date on the carton. The ADM stated, no, I cannot find one. A plastic container 1/2 full of pickles had a received date of 1/11/23. The Surveyor asked the ADM to find a date on the container. The ADM stated, it should be yesterday and he dated the container. 3. On 01/17/23 at 10:24 AM, the Surveyor asked the ADM to wipe the inside of the ice machine in the kitchen with a white napkin or white paper towel. When the ADM wiped the inside of the ice machine, there was a residue on the paper towel. The ADM stated, oh, that's not good. It was just cleaned on the 3rd [third]. It was obviously not done well. The ADM wiped the inside of the ice machine a second time and there was more residue. The ADM stated, that's really bad. the Surveyor asked the ADM to describe the residue. The ADM stated, brown and black stuff. I will get that corrected today. 4. On 01/17/23 at 10:31 AM, there was a stainless-steel rack near the fryer that contained 3/4 of a loaf of sliced wheat bread in a plastic bag with no date and 4 hamburger buns in a plastic bag with no date. The Surveyor asked the ADM to locate a date on the bags. The ADM stated, I will get it. the ADM left the kitchen and the Surveyor followed. The ADM was in the dry storage room writing dates on the bags. The Surveyor asked how he determined the dates. The ADM stated, from this box right here. (Pointing to a carboard box of loaves of bread). The Surveyor asked if the loaf and buns should have been dated when they were removed from the box. The ADM stated, yes, ma'am, they should have. It sure shows when you have a new group. 5. On 01/17/23 at 10:38 AM, the Surveyor asked the ADM to open a container of vanilla ice cream in the freezer that had a tear in the lid. The ADM opened the container and the Surveyor asked him to describe the brown and grey colored substance on top of the vanilla ice cream. The ADM stated, I have no idea what it is. The ADM discarded the vanilla ice cream in the trash. 6. On 01/17/23 at 10:52 AM, the following items were in the resident refrigerator by Nurse's Station #3: a. 1 container of peach cottage cheese with an expiration date of 1/16/23 and no name on it. b. A plastic tray with 5 pieces of various types of pie and cheesecake, covered by a torn piece of aluminum foil and no name or date on it. c. A plastic container full of pineapple chunks dated 11/24/22 and R #26's name on it. d. A bottle of [named] sauce dated 10/2/22 and R #51's name on it. e. A bottle of [named soft drink] 1/2 full with no name on it. f. A rectangular plastic storage container with a red lid dated 11/26/22 with R #61's name on it. g. An oval plastic storage container with a red lid dated 12/2/22 with R #5's name on it. h. Two 4 oz [ounce] plastic bottles of orange juice with foil tops with no name or date on them. i. Two brown and black spotted bananas that were soft to the touch. j. A brown bag of fast food [named] with no name or date on it. k. One 4 oz plastic container of cranberry juice with a foil top with no name or date on it. The ADM discarded all the above listed items in the trash. 7. On 01/17/23 at 11:47 AM, the Administrator provided a policy for Use and Storage of Foods Brought to Residents by Family/Others which documented, .4. Any outside food must be stored in covered containers and labeled with the resident's name and date the food was brought into the facility. 5. Any item in its original packaging that is past its expiration date will be discarded. 6. Foods brought into the facility outside of its original container or packaging will be discarded three days after the date identified on the label . 8. On 01/19/23 at 10:36 AM, the Dietary Manager (DM) removed two pans of biscuits from the oven and placed one pan on top of the other. The bottom of the top pan was laying against some of the biscuits and touched the top surface of the bottom pan that contained biscuits. At 10:40 AM, the DM did not wash the two pans and placed new raw biscuits onto the pans. The Surveyor asked if the bottom of the pans were considered clean. The DM stated, no, oh dang, I forgot to wash the pans. The Surveyor asked if the pans should be cleaned before being used again. The DM stated, oh yeah. I'm trying to do too many things at one time. 9. On 01/19/23 at 3:06 PM, the Administrator provided a policy for Dry Food Storage which documented, .9. Opened food items will be labeled with contents and opened dates as well as stored in clean, dry, and sealed containers .11. The guideline Storage Periods: Use-by Guidelines (Policy #5.6) will be used to ensure food quality . and a policy for Safe Food Handling Practices which documented .To minimize contamination and bacteria while providing nutritious meals .all work surfaces and equipment are clean and sanitized after each use .

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #8) of 2 (Residents #8 and #49) sampled residents who had an indwelling catheter. The findings are: Resident #8 had a diagnosis of Obstructive and Reflux Uropathy. a. A physician's order dated 10/14/19 documented, Foley cath [catheter]: 16 F [French] change every day shift starting on the 27th and ending on the 28th every month . This was documented as a current, active order on the Order Summary Report dated 11/16/21. b. The Care Plan dated 4/19/21 documented, The resident has Indwelling Catheter: OBSTRUCTIVE AND REFLUX UROPATHY . c. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/18/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of one person for toilet use; was occasionally incontinent of bladder; and did not have a urinary catheter. d. On 11/15/21 at 1:03 PM, the resident was sitting on the side of her bed. Her urinary catheter drainage bag was on the floor. The resident stated she took the catheter bag out of the privacy bag when she repositioned herself and forgot to put it back in the privacy bag. e. On 11/18/21 at 10:47 AM, the MDS Coordinator was asked who was responsible for completing Section H (Bladder and Bowel section) of the MDS? She replied, Me. The surveyor asked, How long has the resident had an indwelling catheter? She replied, Since admission, The MDS Coordinator was asked if the responses of occasionally incontinent and no urinary catheter were correct on the MDS with an assessment reference date of 8/18/21. She replied, No, it is not; I will correct that.

Based on observation, record review, and interview, the facility failed to ensure hand rolls or gauze rolls were applied as ordered by the physician to prevent further decline in range of motion (ROM) for 2 (Resident #06, #46) of 5 (Residents #6, #11, #26, #28, #46) sampled residents who had contractures. The findings are: 1. Resident #46 had diagnoses of Cerebral Palsy and Contracture of Right Hand. The Quarterly Minimum Data Set (MDS) with an Assessment Refence Date (ARD) of 09/23/2021 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and had functional limitation in range of motion to the upper extremities on both sides. a. A physician order dated 2/3/2021 documented, .Clean right hand with Theraworx then apply gauze roll or palm pillow 3x/wk [3 times per week] for preventative care of contractures every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] . b. The Care Plan dated as revised on 10/21/2021 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] cerebral palsy, MR [Mental Retardation], NONVERBAL BUT ABLE TO MAKE NEEDS KNOWN . HAND ROLL RIGHT HAND . The resident has limited physical mobility r/t cerebral palsy, contractures . Clean right hand with Theraworx then apply gauze roll or palm pillow 3x/wk [3 times per week] for preventative care of contractures . c. On Monday 11/15/21 at 12:41 PM, the resident was lying in bed on her back. Her right hand and wrist were contracted, and no hand roll was in place. d. On 11/16/21 at 2:40 PM, the Director of Nursing (DON) was asked, Should the resident have a hand roll in place in her right hand? She stated, Yes. She was asked why and stated, Contractures. e. On 11/16/21 at 2:48 PM, Licensed Practical Nurse (LPN) #2 was asked, Should the resident have a hand roll in place in her right hand? She stated, Yes. She was asked why and stated, Helps with contractures. 2. Resident #6 had diagnoses of Alzheimer's Disease, Arthropathy, and Muscle Wasting and Atrophy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive two-person physical assistance for bed mobility and transfers, and had functional limitation in range of motion of the upper extremities on both sides. a. Physician's Orders dated 2/2/21 documented, Clean hands with Theraworx [sic] then apply gauze roll or palm pillow 3x/wk for preventative care of contractures every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] . check placement of gauze hand rolls q [every] shift . b. The Care Plan dated as revised 3/29/21 documented, The resident has an ADL self-care performance deficit r/t [related to] Alzheimer's . no hand rolls, use only gauze . c. On 11/15/21 at 12:03 PM, the resident was reclined in a geri-chair in Station One's Lounge / Dining Room. Both hands were contracted, and no gauze rolls were in place. d. On 11/16/21 at 8:32 AM, the resident was reclined in a geri-chair in Station One's Lounge / Dining Room. Both hands were contracted into closed fists with the fingers pressed against her palms, and no gauze rolls were in place. e. On 11/16/21 at 8:49 AM, LPN #1 accompanied the surveyor to Station One's Lounge / Dining Room and was asked, According to the resident's Care Plan, should she have hand rolls for her contracted hands? She stated, Yes, ma'am. She was asked how the staff knew to apply the hand rolls and stated, The Treatment Nurse applies the hand rolls to her hands. She was asked, What are the potential complications of not applying the hand rolls? She stated, Contractures could worsen. f. On 11/18/21 at 8:01 AM, the Treatment Nurse was asked, Do you apply the hand rolls to [Resident #6]? She replied, Yes, she is ordered to have gauze; she has treatments on Monday, Wednesday and Fridays. The Treatment Nurse was asked, Do the CNAs [Certified Nursing Assistants] apply the gauze? She replied, No. She was asked, Do you check her hands daily to ensure the gauze is in place? She replied, Yes, and if the CNAs give her a shower or if the gauze is missing, the CNAs are to notify me. She was asked, Do you have documentation that you check her hands for placement of the gauze? She replied, No.

Based on observation, record review and interview, the facility failed to ensure humidification bottles were refilled promptly for 1 (Resident #26); respiratory supplies were changed weekly to prevent possible respiratory infections for 2 (Residents #26 and #19); and respiratory supplies were properly stored to prevent potential contamination for 1 (Resident #69) of 6 (Residents #7, #8, #11, #19, #26, #69) sampled residents who received respiratory services. The findings are: 1. Resident #26 had diagnoses of Solitary Pulmonary Nodule, Pulmonary Embolism, and Chronic Obstructive Pulmonary Disease (COPD). The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy while a resident. a. A physician order dated 11/3/2021 documented, .O2 [oxygen] at 2-4 L/M [liters per minute] via NC [nasal cannula] PRN [as needed for] shortness of breath or resp [respiratory] distress as tolerated, may remove for adls [activities of daily living] as needed for SHORTNESS OF BREATH / DECREASED O2 SATURATION. A physician order dated 11/9/2021 documented, .change O2 tubing, clean filter and O2 cabinet, date all tubing every Tuesday night on 11-7 [11:00 PM to 7:00 AM] shift every night shift every Tue [Tuesday] for maintenance . b. The Care Plan dated 11/11/2021 documented, .The resident has oxygen therapy r/t [related to] ineffective gas exchange . Change O2 tubing, clean filter and O2 cabinet, date all tubing every Tuesday night on 11-7 shift . c. On Monday 11/15/21 at 12:01 PM, the resident was lying in bed on her back with her eyes closed and receiving oxygen via nasal cannula. The flow meter on the oxygen concentrator was set to deliver O2 at 2.5 liters per minute. A humidification bottle dated 11/9 (11/9/2021) was connected to the concentrator but was empty. The storage bag for the tubing was dated 11/02. d. On 11/16/21 at 2:21 PM, the Director of Nursing (DON) was asked, Should humidification bottles be replaced once empty? She stated, Yes. She was asked why and stated, It helps with the airway, so they won't dry out, and it is more comfortable. She was asked, Should the plastic storage bags be replaced weekly? She stated, Yes. She was asked why and stated, Infection control. e. On 11/16/21 at 2:48 PM, Licensed Practical Nurse (LPN) #2 was asked, Should the humidification bottle be replaced once it is empty? She stated, Yes. She was asked why and stated, It keeps the nasal passages moist instead of drying out. She was asked, Should the plastic storage bags be replaced weekly? She stated, Yes. She was asked why and stated, Infection control. 2. Resident #19 had diagnoses of Obstructive Sleep Apnea and Shortness of Breath. The Significant Change MDS with an ARD of 11/01/2021 documented the resident scored 7 (0-7 indicates severe impairment) on a BIMS, received oxygen therapy while not a resident, and did not receive oxygen therapy while a resident. a. A physician order dated 11/3/2021 documented, .OXYGEN 2-4 L/M per NC PRN for shortness of breath or resp distress as tolerated. May remove for ADLs every shift related to SHORTNESS OF BREATH . b. The Care Plan dated as revised 10/29/2021 documented, .The resident has altered respiratory status / difficulty breathing r/t [related to] O2, Sleep Apnea, has CPAP [continuous positive airway pressure] but often refuses it . OXYGEN 2-4 LITERS per NC AS TOLERATED PRN . EQUIPMENT CHANGE EVERY TUES PER TAR [Treatment Administration Record] . c. On 11/15/21 at 1:14 PM, the resident was lying in bed on her back. The flow meter on the resident's oxygen concentrator was set to deliver O2 at 2 liters per minute. The storage bag for the oxygen tubing was dated 10/25. 3. Resident #69 had diagnoses of Heart Failure, Anemia, and Pneumonia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/2021 documented the resident scored 11 (8 -12 indicates moderately impaired) on a BIMS; required extensive assistance of two-plus persons with bed mobility and, transfers; had shortness of breath with exertion and when lying flat; and received oxygen therapy while a resident. a. A Physician's Order dated 10/22/21 documented, Change and date updraft tubing and nebulizer every Tuesday night on 11-7 shift every night shift every Tue [Tuesday] . Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML [milligrams per 3 milliliters] 1 application inhale orally every 8 hours as needed for Shortness of breath . b. The Initial Care Plan dated 11/11/21 documented, The resident has oxygen therapy r/t [related to] ineffective gas exchange . The resident will have no s/sx [signs/symptoms] of poor oxygen absorption through the review date . c. On 11/15/21 at 12:52 PM, the resident was sitting in her recliner, with oxygen in use via nasal cannula. The updraft mask was on the bedside table next to the nebulizer and was not in a bag or closed container. d. On 11/15/21 at 1:21 PM, LPN #1 accompanied the surveyor to the resident's room and was asked, What is the proper way to store the resident's updraft mask when it's not in use? She replied, They are to be placed in the black bags. The resident's mask still on the bedside table. The surveyor asked, Is that the proper way to store it? She replied, No, it should not be laying on the table. e. On 11/18/21 at 1:33 PM, the Director of Nursing (DON) was asked, What is the proper way to store an updraft when it is not in use? She stated, In the bag; after you do the updraft, you rinse it, clean it, make sure it is dry and store it in an appropriately dated storage bag. She was asked why and stated, Infection control; make sure you clean it and keep it clean.