**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to submit a 5 day follow up of the facility's investigation to the State Survey agency for 1 resident (Resident #1) of 4 residents reviewed. The findings include: Review of the facility's Policy titled, Resident Rights-Abuse and Crimes against, revised 6/16/2023 showed .all alleged violations .are reported .to the .state agency responsible for surveying/licensing the facility . continued review showed no procedure or process for submitting a 5 day follow up investigation, after the initial report to the State Survey agency. Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Difficulty in Walking, and Cognitive Communication Deficit, the resident discharged to the hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 1 which indicated the resident had severe cognitive impairment. The resident required assistance of one or more staff members with activities of daily living (ADL's). Review of a current care plan showed Resident #1 had the .Potential for fall or injury r/t [related to] impaired cognition, poor safety awareness .Transfer with assist as needed .Ambulation with assist as needed .Bilateral soft mats to bedside .10/6 [10/6/2023] .Recommended 24-7 caregivers. 10/23 [10/23/2023] .Dycem [non-slip material] in wheelchair at all times .10/18 [10/18/2023] .may use broada chair [specialized wheelchair] when OOB [out of bed] .Send to ER [Emergency Room] as ordered. 10/23. 10/23/2023] . review showed multiple falls with new interventions in place with each fall. Review of the facility's fall investigation showed on 10/23/2023 Resident #1 was up in his geriatric chair. Resident #1's spouse had came to the facility for a visit near dinner time and requested the resident be put in his recliner at approximately 5:40 PM. CNA A assisted the resident's wife with putting the resident in his recliner and Resident #1's spouse left sometime after dinner. At 8:28 PM, after having just walked by the residents room a few minutes earlier and seeing him in the recliner sleeping, Resident #1 was observed by CNA A lying on the floor on his right side next to his bed and the heater. A hematoma was noted on Resident #1's right forehead, the physician was notified, and orders were received to send the resident to the ER. The diagnosis from the hospital showed a Subarachnoid Hematoma (bleeding in the space between the brain and the tissue covering the brain). Continued review showed no documentation a 5 day follow up investigation had been submitted to the State Survey agency. Review of the State Survey agency INTAKE INFORMATION form showed the above incident was reported to the State Survey agency with .No 5 day follow up added . During an interview on 4/24/2024 at 11:00 AM, the Administrator stated .I checked and there was a 5 day follow up filled out, but it was never finalized so it wasn't turned in . confirming the facility failed to submit a 5 day follow up to the State Survey agency.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse was properly contained in 1 of 4 dumpsters. The findings include: Review of facility policy titled, Sanitation and Infection Control Garbage & [and] Refuse Disposal, dated 1/2016, showed .All garbage, refuse, glass, tin cans, cardboard, paper .generated within the Food and Nutrition Services department shall be disposed of in a sanitary manner . All items shall be disposed of in appropriate dumpster, food/medical waste versus recyclable materials .All parties utilizing the dumpsters for waste to prevent harborage and feeding of pests .All parties utilizing the dumpsters for waste and/ or recycling purposes are responsible for maintaining the area by ensuring that the dumpster lids are closed and the area around the dumpster is free of waste . During an observation and interview with the Certified Dietary Manager on 5/22/2023 at 11:00AM, showed 1 dumpster had a large trash bag of refuse extending ¾ out of the top of the dumpster. The Certified Dietary Manager confirmed the refuse trash bag extended out of the top of the dumpster.

Based on facility policy review, observation, and interview, the facility failed to ensure appropriate hand hygiene practices were followed during meal service on 1 of 3 hallways observed during meal service. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 1/1/2017, showed .handwashing/hand hygiene as the single most important means of preventing the spread of infection .All personnel will follow the handwashing procedure to prevent the spread of infection and disease to other personnel, residents, and visitors. Employees will perform appropriate handwashing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions and as additionally needed .When to wash hands .Before and after each resident contact .Before handling food tray or preparing food . During an observation and interview on 5/22/2023 at 12:30 PM, Certified Nursing Assistant (CNA) #2 was observed retrieving a meal tray from a meal cart without performing hand hygiene, entered a resident room, set up the meal tray for the resident, positioned the resident's overbed table, and exited the room without performing hand hygiene. Continued observation showed CNA #2 obtained a second meal tray from the meal cart, entered another resident's room, set up the meal tray, and exited the room without performing hand hygiene. Interview with CNA #2 confirmed he had failed to perform hand hygiene during the meal service. During an interview on 5/24/2023 at 9:15 AM, the Director of Nursing (DON) confirmed it was her expectation for staff to perform hand hygiene between rooms during meal tray delivery.

Based on facility policy review, observation, and interview, the facility failed to ensure kitchen equipment was maintained in good repair in 1 of 2 kitchens. The findings include: Review of the facility policy titled, Manual Can Opener Maintenance, dated 1/2017, showed .Can Opener Blade and Gears must be checked for wear quarterly .Look for wear on blade or dulling of blade and wear on gears .if wear on blade is present, blade should be replaced . During an observation and interview with the Certified Dietary Manager on 5/22/2023 at 11:00 AM, showed a can opener on the kitchen preparation table with a frayed blade which had the potential to introduce metal shards into the canned food. The Certified Dietary Manager confirmed the can opener blade was frayed and used for resident food preparation.

Based on facility policy review, observation, and interview, the facility failed to ensure expired food items were discarded and failed to ensure food was properly stored in a walk-in freezer in 1 of 2 kitchens which had the potential to affect 29 residents. The findings include: Review of the facility policy titled, Sanitation & [and] Infection Control Receiving & Storage, dated 1/2016, showed .Proper storage procedures will be utilized for all dry and refrigerated food storage .All items are dated when received to ensure correct product rotation .Items are stored a minimum of 18 inches from the ceiling . Review of the facility policy titled, Sanitation & Infection Control Labeling & Dating, dated 1/2016, showed .All foods will be appropriately wrapped, labeled and dated on food storage guidelines. Appropriate storage .and food rotation procedures are followed . All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. RTE [Ready To Eat] products once opened have a 7-day shelf life .All products are rotated using the first-in, first-out .inventory method . During an observation on 5/22/2023 at 11:00 AM, the walk-in freezer contained a 25-pound box of corn open to air; 1 box of catfish and 1 box salmon touching the ceiling in the freezer blocking sprinklers. Continued observation of the kitchen showed 1 full and ¼ loaves of bread with an expired date of 5/9/2023, 4 packs of 6 count English Muffins with an expired date of 4/30/2023. 1 of the 4 packs of English Muffins was unsealed and open to air. All food items were available for resident use. During an interview on 5/22/2023 at 11:00AM, the Certified Dietary Manager (CDM) confirmed the box of corn was unsealed and open to air, the bread had expired and was available for resident use. The CDM further confirmed the frozen boxes of food had blocked the sprinkler system in the freezer. During an observation of the kitchen on 5/24/2023 at 7:52AM, showed 1 full loaf of gluten free bread had an expiration date of 5/20/2023. The food item was available for resident use. During an interview on 5/24/2023 at 7:52 AM, the CDM confirmed the 1 loaf of gluten free bread had expired on 5/20/2023 and was available for resident use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 resident (#190) was free from significant medication errors of 5 residents observed for medication administration. The findings include: Review of the facility policy Medication Administration, undated, revealed .Medications are administered in accordance with written orders of the attending physician . Medical record review revealed Resident #190 was admitted to the facility on [DATE] with diagnoses including Fracture Right Hip, Pulmonary Emboli, and Hypertension. Medical record review of the Physician's Order dated 1/7/20 for Resident #190 revealed, .Eliquis [medication used to thin the blood] 5mg [milligram] 1 TABLET oral Two Times Daily starting 1/7/20 . Observation of medication administration on 1/7/20 at 7:40 AM, on the Magnolia Hallway, revealed Licensed Practical Nurse (LPN) #1 administering medications to Resident #190. Continued observation revealed the LPN administered Eliquis 5mg 2 tablets to Resident #190. Interview with LPN #1 on 1/7/20 at 8:30 AM, on the Magnolia Hallway, confirmed Resident #190 received Eliquis 5mg 2 tablets, during the AM medication administration. Continued interview confirmed the current physician's order was for Eliquis 5mg 1 tablet oral two times daily starting 1/7/20. Further interview confirmed a medication error had occurred. Interview with the Director of Nursing on 1/7/20 at 3:15 PM, in the conference room, confirmed the LPN had administered Eliquis 5mg 2 tablets an incorrect dosage of Eliquis to Resident #190. Continued interview confirmed a significant medication error had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to assess 1 resident (#38) for self-administration of medication of 7 residents reviewed for medication administration of 26 residents sampled. The findings include: Review of the facility policy MEDICATION- SELF ADMINISTRATION reviewed July 1, 2007 revealed .Upon admission a determination shall be made as to the capability of a Resident to self-administer medication .A Resident who is alert and oriented may self administer medication if determined capable by the Director of Health Services and ordered by the physician .The Charge Nurse will notify the resident's physician and obtain an order, if one had not already been obtained, for medications to be kept in the resident's apartment in a secure area .The Charge Nurse will monitor use of the medications and record self-administration on the Medication Administration Record .The resident's Medication Record will have an order . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Unspecified Fracture of Left Foot, Fall, Anxiety, Insomnia, and Gastroesophageal Reflux Disease. Medical record review of the admission Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Observation and interview of Resident #38 on 12/17/18 at 10:30 AM, in the resident's room, revealed the resident lying on the bed with two bottles of prescription eye drops on the nightstand at the bedside. Continued interview revealed the resident was self-administering the eye drops and was aware of the administration times. Observation of Resident #38 on 12/18/18 at 9:58 AM, in the resident's room, revealed two bottles of prescription eye drops sitting on the bedside table. Observation of Resident # 38 on 12/18/18 at 3:12 PM, in the resident's room, revealed two bottles of prescription eye drops on the over bed table. Medical record review of the Physician's Orders revealed no order for the prescription eye drops. Observation and Interview with the Assistant Director of Nursing (ADON) on 12/18/18 at 3:17 PM, in the resident's room, revealed two bottles of prescription eye drops used for Glaucoma (eye condition that can cause blindness) in the residents room. Continued interview with Resident #38 revealed the eye drops had been brought from home. Interview with the ADON on12/18/18 at 3:21 PM, at the nurse's station, confirmed the resident had no Physician's Order for the use of the eye drops. Further interview revealed no assessment had been completed for the resident to self-administer medication and keep the eye drops in her room. Interview with the Director of Nursing on 12/18/18 at 3:23 PM, at the nurse's station, revealed it is her expectation for residents to have physician's order for any medication kept in the room and for a self-administration assessment to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure POLST (physician orders life sustaining treatment ) forms were completed for 3 residents (#30, #38,and #99) of 26 sampled residents. The findings include: Review of the facility policy, Health Care Decision Making- Advance Directives, revised 12/7/16 revealed .3. The wishes of the resident are carried out according to the resident's advance health care directives and POLST form . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Displaced Fracture of the Fourth Cervical Vertebra, Anterior Cord Syndrome, Parkinson's Disease, and Repeated Falls. Medical record review of the POLST form dated 11/12/18 revealed the Physician had not signed or dated the form. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Unspecified Fracture of Left Foot, Fall, Anxiety, Insomnia, and Gastroesophageal Reflux Disease. Medical record review of the POLST form revealed the form was signed and dated by the Physician on 11/28/18. Further review revealed the date prepared was blank. Medical record review revealed resident #99 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, and Muscle Weakness. Medical record review of the POLST form revealed the POLST was blank and was not completed upon admission. Interview with the Director of Nursing (DON) on 12/18/18 at 2:07 PM, in the conference room, confirmed it is her expectation for the POLST forms were to be completely filled out, signed, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to ensure proper administration of medication for 1 resident (#3) of 7 residents reviewed for medication administration; and failed to notify the physician and complete a falls investigation after a fall for 1 resident (#26) of 3 residents reviewed for falls of a total of 26 sampled residents. The findings include: Review of the facility policy, Medication Administration, dated 3/2005 revealed .Take medication(s) .to resident .Administer medication according to specific procedure such as oral, topical, injection .Reposition resident for comfort with call light in reach . Review of the facility policy FALLS reviewed April 2015, revealed .All residents who fall must be assessed for injury .and follow-up investigation of fall .notification will be made in the following manner .Physician .If after hours notify physician by telephone, on the next business day .A Fall Investigation form must be initiated at the time of the fall by the charge nurse .The Fall Investigation should be attached to the completed Incident Report . Medical record review revealed resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Affecting Right Dominant Side, and Lack of Coordination. Observation on 12/17/18 at 9:54 AM, in the resident's room, revealed resident #3 sitting in wheelchair with 7 unidentified medications poured out on the resident's over-bed table. Continued observation revealed no other residents or facility staff was present in the resident's room. Further observation revealed no wandering residents were on the hallway close to resident's room at this time. Interview with the Licensed Practical Nurse (LPN) #1 on 12/17/18 at 9:57 AM, outside the resident's room, revealed the LPN had left the medications in the Resident's room for Resident #3 to take (self-administer). Continued interview confirmed the LPN failed to ensure the resident's medication was properly administered to the resident prior to exiting the resident's room. Interview with the Director of Nursing (DON) on 12/17/18 at 2:04 PM, in the conference room, confirmed the facility had not followed their policy to ensure medication was properly administered. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Presence of Right Artificial Knee Joint, Osteoarthritis, Muscle Weakness, and Unsteadiness on Feet. Medical record review of the discharge Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 12, indicating the resident had moderately impaired cognition. Further review revealed the resident had had one fall, with no injury. Medical record review of the facility's standing orders revealed .Falls-notify MD/NP [Physician or Nurse Practitioner] and assess for injury . Medical record review of a facility accident report dated 11/20/18 revealed the resident was lowered to the floor during a transfer from the toilet to the wheel chair with assist of 2 staff members. Further review revealed the Physician was not notified of the fall. Continued review revealed no documentation a fall investigation had been completed. Interview with the Assistant Director of Nursing on 12/19/18 at 8:27 AM, in the conference room, confirmed the facility failed to notify the Physician of the resident's fall, and failed to complete a fall investigation following the resident's incident on 11/20/18.

Based on the manufacturer's instruction review, observation, and interview, the facility failed to ensure dishes were cleaned in a sanitary manner for 34 of 52 residents on census. The findings include: Review of the manufacturer's instructions revised November 2012 revealed .Minimum Temperatures using High-Temperature Sanitizing .Two-Tank Models .Wash Tank .150 [degrees] .Final Rinse .180 [degrees] . Observation and interview of the dishwasher with the Food Service Manager (FSM) on 12/17/18 at 9:50 AM, in the kitchen, revealed the dishwasher had a washing temperature of 142 degrees and a final rinse temperature of 175 degrees. Continued interview with the FSM revealed the washing temperature should have been at 150 degrees and the final rinse temperature should have been at 180 degrees. Interview with the lead dish washer on 12/17/18 at 9:57 AM, in the kitchen revealed the dishwasher had not maintained appropriate wash and final rinse temperatures since 12/13/18. Interview with the FSM on 12/18/18 at 3:30 PM, in the conference room, confirmed the dishwasher was a high temperature two-tank model machine. Continued interview confirmed the wash and final rinse temperatures had not been properly maintained since 12/13/18 and the FSM had not been notified until 12/17/18.