Middleton Oaks Health And Rehabilitation

Based on record review, interview, observation and facility policy review the facility failed to implement the comprehensive person-centered care plan related to contracture management and splinting to prevent decline in Range of Motion (ROM) for one (1) of three (3) resident reviewed. Resident #1. Findings Included:Record review of the facility policy titled Prevention of Decline in Range of Motion revealed .3. Appropriate Care Planning, a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion .Record review of the Care Plan Report for Resident #1 revealed Focus: I have an ADL (activity of daily living) self-care performance deficit related to Stroke, Hemiplegia, and immobility putting me at risk for functional decline.Interventions: Apply splint to right ankle after breakfast. Provide passive stretch to right ankle after applying splint. Remove splint to right ankle at lunchtime. Apply splint to right ankle after supper. Provide passive stretch to right ankle after applying splint. Remove splint to right ankle at bedtime. Date initiated 8/1/25.Observation on 3/31/26 at 10:15 AM, revealed the resident's ankle splint was not in use and was lying in a chair in the resident's room.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure when the splint was last applied.An interview with the Physical Therapy Assistant (PTA) on 3/31/26 at 1:10 PM revealed the resident now had foot drop and the ankle splint could not be placed without additional therapy. PTA confirmed this was related to the splint not being applied daily as ordered.Interview with the Director of Nursing (DON) on 3/31/26 at 3:40 PM, revealed the care plan was used to inform staff how to care for the resident and verified staff failed to follow the care plan when they did not apply the ankle splint.Record review of the admission Record revealed that the facility admitted Resident #1 on 1/16/25 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side.Record review of Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 1/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating that the resident is cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve Range of Motion (ROM) and prevent further decline for one (1) of three (3) resident reviewed for ROM limitations Resident #1. Findings Included:Record review of the facility policy Prevention of Decline in Range of Motion, date reviewed/revised 11/10/2025 revealed Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Observation on 3/31/26 at 10:15 AM, revealed a foot splint lying in the chair in Resident #1's room. Resident #1's right hand was contracted into a fist with no hand roll in place.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure of the last time staff had applied the splint to her foot and stated she had never had a hand roll.Interview with Licensed Practical Nurse #1 (LPN) on 3/31/26 at 10:30 AM, revealed she did not know why the splint was in the resident's room and stated the resident was not required to wear it. She further verified the resident did not have a hand roll.Record review of the Physician Order Summary revealed physician orders dated 7/29/25, to apply a splint to the right ankle after breakfast and after supper with passive stretching following application.Record review of Occupational Therapy (OT) evaluation dated 2/1/25, revealed decreased ROM to the right upper extremity and recommendations for a resting hand splint and restorative splint and brace program upon discharge. Further review of OT evaluation dated 7/31/25, recommended continuation of the contracture management and splinting program.Record review of a Physician Order dated 4/24/25 revealed Apply splint to right hand after breakfast. Provide passive stretch to right elbow, wrist, and hand after applying splint one time a day for decrease contractures.remove the splint before dinner. Further review revealed an order dated 5/2/25 to discontinue the splint with a note per RP (responsible party) request. States it is too painful for her mom to wear.Interview with the Occupational Therapist on 3/31/26 at 12:30 PM, revealed she had not been notified that the hand splint had been discontinued and stated that a hand roll should have been initiated when the splint was discontinued. She further stated the resident's hand was now contracted into a fist.Record review of Physical Therapy (PT) Discharge summary dated [DATE], revealed the resident's right ankle ROM improved during therapy and recommended a PODUS boot (a specialized orthopedic brace designed to treat foot drop) daily up to five (5) hours.Interview with the Physical Therapy Assistant (PTA) on 3/31/26 at 1:10 PM revealed the resident now had foot drop and the ankle splint could not be placed without additional therapy. PTA confirmed this was related to the splint not being applied daily as ordered.Interview with the Director of Nursing (DON) on 3/31/26 at 3:30 PM, verified the resident had physician orders for ankle splinting daily and stated the expectation was for staff to apply the splint to prevent decline in ROM. The DON further verified the right-hand splint was discontinued without alternative interventions to prevent contracture.Record review of the admission Record revealed that the facility admitted Resident #1 on 1/16/25 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side.Record review of Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 1/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating that the resident is severely cognitively impaired.

Based on staff interview, record review and facility policy review, the facility failed to maintain complete and accurate medical records for one (1) of three (3) residents reviewed for post-operative care. This deficient practice resulted in the omission of a physician-ordered post-operative appointment from the resident's medical record and contributed to the resident missing the appointment. (Resident #3).Findings Include
Review of the facility policy titled Physician's Orders revealed Policy The center will ensure that all physician orders are accurately documented, promptly implemented, and authenticated in the resident's medical record in accordance with Center for Medicare and Medicaid (CMS) regulations and state requirements .
Record review of Resident #3's “After Visit Summary” (AVS) upon admission revealed an order for a post-operative visit on 5/6/25 at 1:00 PM with the Orthopedic Physician.
Record review of Resident #3's Order Summary Report revealed an entry for an appointment on 5/20/25 at 10:15 AM with the Orthopedic Physician, with an onset date of 5/6/25. No order was documented for the 5/6/25 post-operative appointment.
An interview with the Director of Nursing (DON) on 9/17/25 at 11:00 AM, revealed that Resident #3 did not attend the 5/6/25 orthopedic appointment because the order was not entered into the record. The DON stated it is facility practice that the admitting nurse enters all admission orders, and verified the resident was admitted on the 3–11 shift. The DON stated the 3–11 supervisor performed the admission and entered the orders, but the 5/6/25 appointment was missed. She further stated that she and the Assistant Director of Nursing (ADON) review admission orders in their clinical meeting the following day, but acknowledged they missed the order as well. The DON verified that the resident missed the 5/6/25 appointment due to the missed order.
Record review of the “admission Record” revealed that the facility admitted Resident #3 on 4/17/25 with a diagnosis of Acquired absences of left leg below the knee.

Based on staff interview, record review, facility investigation review and facility policy review the facility failed to ensure residents were free from misappropriation of property when narcotics belonging to two residents were unaccounted for two (2) of three (3) residents reviewed for misappropriation. Resident #1 and Resident #2. Findings Include
Findings Include
Findings Include
Review of the facility policy titled “Abuse, Neglect, Exploitation and Misappropriation” revised 11/16/22 revealed, “Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and or misappropriation of property…”
Record review of the facility investigation revealed that on 8/16/25 at approximately 5:15 PM, Licensed Practical Nurse (LPN) #1 identified a discrepancy on the Controlled Drug Count Sheet. The narcotic count was altered, with numbers scratched out and rewritten, resulting in a two-card difference. Review of the narcotic count sheets documented 34 cards/packages on 8/15/25, but 31 on 8/16/25 without documentation of removal. Further review revealed that the Master List Controlled Drug form for 8/3/25 through 8/15/25 was missing. The Director of Nursing (DON) identified that Resident #1's Norco 5-325 milligrams (mg) (discontinued in March 2025 but never removed from the cart) and Resident #2's Norco 7.5-325 mg were unaccounted for.
Record review of the Narcotic Count Sheet revealed the following:
On 8/15/25 during the beginning of the 11:00 PM to 7:00 AM shift, 34 packages/sheets were documented on the cart and signed by LPN #3 and LPN #4.
On 8/16/25 at the beginning of the 7:00 AM to 3:00 PM shift, the count numbers were marked out, and the number thirty-one (31) was written on the side, circled, and signed by LPN #4 and LPN #2.
On 8/16/25 at the beginning of the 3:00 PM to 11:00 PM shift, thirty-three (33) was documented as the number of packages/sheets present. This was subsequently written over as thirty-one (31), and both entries were signed by LPN #2.
Record review of the Master Narcotic List for the [NAME] Front Hall cart revealed no Master List Controlled Drug form was available for the period of 8/3/25 through 8/15/25. Additional review identified a Master List Controlled Drug form dated 8/16/25, which documented that one (1) empty card had been removed from the cart by LPN #4 on 8/16/25.
Record review of the Order Summary Report revealed Resident #1 had an order for Norco 5-325 mg from 2/17/25 through 3/19/25.
Record review of the Physician Orders revealed Resident #2 had an order for Norco 7.5-325 mg from 1/13/25 through 8/18/25.
An interview with LPN #1 on 9/17/25 at 8:40 AM, revealed that narcotics are reconciled each shift by on-coming and off-going nurses, with additions or subtractions documented and witnessed. She stated that when she reconciled the cart on 8/16/25, she observed counts scratched through and a decrease from 34 to 31 without documentation of additions or removals. She reported the discrepancy to the DON immediately.
An interview with LPN #2 on 9/17/25 at 9:04 AM, confirmed that she reconciled the narcotics with LPN #4 on 8/16/25 and verified the number was changed to 31 and circled but could not explain the discrepancy. She further stated that she sometimes did not check the Master List Controlled Drug form and acknowledged that Resident #1's discontinued narcotics remained on the cart.
An interview with the DON on 9/17/25 at 9:30 AM, revealed she was notified of the discrepancy on 8/16/25 at approximately 5:15 PM. She confirmed that narcotics were missing, and that Resident #1's discontinued Norco and Resident #2's active Norco were not accounted for. She further stated the missing Master List Controlled Drug form could not be located. She verified that LPN #4, the nurse on duty during the shift in question, refused to assist with the investigation and was suspended on 8/17/25 and terminated on 8/21/25.
An interview with the DON and Administrator on 9/17/25 at 2:30 PM, verified that a reconciliation and match back was completed on 8/16/25 of all narcotics and that corrective actions were initiated, including weekly audits implemented with continuation at least monthly and an in-service on narcotic security and misappropriation prevention.
A follow-up interview with the DON and Administrator on 9/18/25 at 8:40 AM, confirmed that the incident and investigation results were presented to the Quality Assurance Committee on 8/18/25, during which the facility policy was reviewed with no revisions made.
Based on the implementation of the facility's corrective actions on 8/16/25, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 8/18/25.
The SA validated on 9/18/25, through interview and record review that all corrective actions had been implemented as of 8/16/25, and the facility was in compliance as of 8/18/25, prior to the SA's entrance on 9/17/25.
Record review of the “admission Record” revealed that the facility admitted Resident #1 on 10/18/23 with a diagnosis of Hypertensive Disease without Heart Failure.
Record review of the “admission Record” revealed that the facility admitted Resident #2 on 6/9/23 with a diagnosis of Cerebral Infarction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11
Record review of Resident #11's care plan for pressure ulcer revealed intervention to administer treatments as ordered and monitor for effectiveness.
Record review of Resident #11's Electronic Treatment Administration Record (ETAR) revealed there were 12 days in 03/2025 with missed pressure ulcer treatments documented.
On 3/27/25 at 8:15 AM, an interview and record review with the Wound Care Registered Nurse (RN) confirmed the 12 undocumented wound treatments in the ETAR for Resident #11. She revealed that she worked Monday through Friday and had performed the wound treatments for this resident each day she worked but confirmed that accurate documentation was needed to verify that the care was done.
On 3/27/25 at 8:10 AM, during an interview the Director of Nursing (DON) confirmed that wound treatments should be documented upon completion of the care, and this was not done for 12 of Resident #11's wound treatments for this month. She confirmed the facility failed to accurately document the wound care treatment which was a part of the wound care treatment process, so therefore, the care plan was not followed.
An interview with the MDS Coordinator on 03/27/25 11:39 AM revealed she was responsible for the care plans. She confirmed the documentation was part of the treatment procedure. She confirmed the facility failed to document the treatments multiple times in the month of March for Resident #11's wound treatments, therefore the care plan was not followed.
Record review of Resident #11's admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included Pressure Ulcer of Sacral Region and Type 2 Diabetes Mellitus.
Record review of MDS Section C with ARD of 2/21/25 revealed the resident was unable to participate in the BIMS as he is rarely or never understood.
Resident #51
Record review of Resident #51's care plan revealed the resident had an ADL self-care performance deficit related to morbid obesity and immobility. One intervention listed was to check nail length and trim and clean on bath day and as necessary.
On 3/25/25 at 11:20 AM, during an observation and interview Resident #51 revealed he wanted his toenails to be trimmed. An observation of the resident's feet revealed his big toe nail on his right foot was extending approximately three-fourths (3/4) inch from the tip of the nailbed and the left big toe nail was extending approximately one-half (1/2) inch from the tip of the nailbed. All other toenails were approximately one-third (1/3) inch long from the tips of each nailbed, jagged and uneven.
On 3/26/25 at 10:25 AM, an interview and observation with the Director of Nursing (DON)confirmed that Resident #51's foot and nail care had not been done. She confirmed the facility failed to maintain the resident's toenails within a safe and comfortable length and as the resident preferred. She stated the care plan was a guide for the residents' care. She confirmed the facility failed to implement this resident's care plan for ADL's.
During an interview with the MDS Coordinator on 03/27/25 at 11:39 AM, she confirmed the care plan for Resident #51's ADL care which included to check nail length and trim and clean on bath days and as necessary was not followed.
Record review of Resident #51's admission Record revealed the facility admitted the resident on 1/13/25. Diagnoses included Complete Lesion at T2-T6 Level of Thoracic Spinal Cord, Peripheral Vascular Disease, Lymphedema, and Need for Assistance with Personal Care.
Record review of Resident #51's MDS with ARD of 3/10/25 revealed the resident had a BIMS of 13 which indicated the resident was cognitively intact.
Resident #75
Record review of Resident #75's care plans initiated 2/15/24 revealed his diagnosis of gastroesophageal reflux disease (GERD) put the resident at risk for heartburn, nausea/vomiting, pain, and other gastrointestinal complications. Interventions included to give medications as ordered and observe/document/report as needed signs and symptoms of GERD including nausea/vomiting and increased gag response. Record review of the care plan for the history of an alteration in gastrointestinal status related to sigmoid colon resection revealed an intervention dated 2/15/24 to give medication as ordered.
Record review of Resident #75's Order Recap Report revealed an active order for Zofran Oral Tablet 4 milligrams (mg) by PEG (percutaneous endoscopic gastrostomy) every six hours as needed for vomiting dated 3/11/24.
Record review of Progress Note dated 10/20/24, revealed, Resident can't tolerate, starts gagging.
Record review of Resident #75's Electronic Medication Administration Report (EMAR) revealed the as needed Zofran was not given on 10/20/24.
Record review of Progress Note dated 10/28/24, revealed, Resident vomiting/gagging and can't tolerate feeding.
Record review of Resident #75's EMAR revealed the as needed Zofran was not given on 10/28/24.
Record review of Progress Note dated 2/22/25, revealed, Resident in bed, gave resident his med per PEG and flushes, as soon as I finished, he started vomiting his feeding, vomiting several times, feeding cut off at this time.
Record review of EMAR revealed the as needed Zofran medication was not given on 2/22/25.
On 3/27/25 at 9:20 AM and 10:11 AM, during interviews the DON confirmed that Resident #75 had documentation of nausea and vomiting and the ordered medication for relief of these symptoms was not administered. She stated the care plan gives the staff information for the care of each resident. She confirmed the facility failed to implement the care plan related to the administration of an ordered medication for relief or nausea/vomiting.
An interview with the MDS Coordinator on 03/27/25 at 11:39 AM, confirmed the care plan for Resident #75 related to administering medications as ordered was not followed.
Record review of Resident #75's admission Record revealed the facility admitted the resident on 3/7/24. Diagnoses included Dysphagia following Cerebral Infarction, Gastrostomy Status, Gastro-esophageal Reflux Disease, and Acquired Absence of Other Specified Parts of Digestive Tract.
Record review of Resident #75's MDS Section C with an ARD of 2/27/25, revealed a BIMS of 6 which indicated the resident had severe cognitive impairment.
Resident #12
A record review of Resident #12's Care Plan revealed that he had an ADL self-care deficit related to abnormal gait, lack of coordination, hx (history) of CVA (cerebrovascular vascular accident) with left sided hemiplegia, with interventions that included Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse .Personal Hygiene: I require extensive/substantial assistance of 1 staff with personal hygiene .
On 3/25/25 at 10:50 AM, an observation and interview revealed Resident #12's fingernails to be approximately one (1) inch long past the tips of the fingers, dirty in appearance, with a dark brown substance under the nail beds. Facial hair was noted on the chin and sides of the face that was approximately ½ (one-half) inch. Resident #12 stated, I would like to have my fingernails trimmed and would also like to be shaved.
On 3/26/25 at 10:25 AM, in an interview and observation LPN #1 confirmed Resident #12's fingernails were long, jagged, and had a brown substance under them. LPN #1 confirmed the resident needed to be shaved and should have been shaved when he received his bed bath yesterday. LPN #1 confirmed the residents' ADL care plan was not being followed and it should have been.
On 3/26/25 at 11:05 AM, during an interview the Director of Nurses (DON) confirmed the resident should have been adequately groomed, which includes shaving and nail care. The DON revealed the resident's care plan regarding his personal hygiene was not being followed, and it should have been.
A review of the admission Record revealed the facility admitted Resident #12 on 3/3/2014 with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the Left Non-Dominant Side.
Record review of Resident #12's Section C of the MDS dated [DATE] revealed a BIMS score of 11, indicating the resident has moderate cognitive impairment.
Resident #42
A record review of the Resident #42's care plan revealed I require staff assistance with ADLs related to joint pain/stiffness and impaired cognition .Interventions Eating: I am dependent on one staff to feed me my meals and snacks .
On 3/25/25 at 11:50 AM, an observation revealed Resident #42 unassisted, eating her lunch.
During an observation and interview on 3/25/25 at noon, the Assistant Director of Nurses (ADON) confirmed that Resident #42 is supposed to have a CNA (Certified Nursing Assistant) assisting her with her meals.
An observation on 3/26/25 at 8:10 AM, revealed Resident #42 was eating her breakfast in her room unassisted.
An observation on 3/26/25 at 11:50 AM, revealed Resident #42 was eating her lunch in her room unassisted.
On 3/26/25 at 2:30 PM, during an interview with Registered Nurse (RN) #2, she stated, The resident is supposed to be assisted with all her meals.
In an interview on 3/27/25 at 08:20 AM, the MDS Nurse confirmed that according to Resident #42's ADL care plan, she is to be assisted by a staff member for all meals, and if she wasn't being assisted with her meals by a staff member, then her plan of care was not being followed.
Record review of the admission Record revealed the facility admitted Resident #42 on 12/26/2023 with medical diagnoses that included Sequelae of Cerebral Infarction, Muscle Weakness and Need for Assistance with Personal Care.
Record review of the MDS with an ARD of 12/31/2024 revealed under Section GG-Functional Abilities that the resident required Substantial/maximal assistance with eating, which details The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.
Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene (Resident #5, #12, #51), wound treatment (Resident #11), staff assistance with meals (Resident #42) and treatment for nausea and vomiting (Resident #75), for six (6) of 22 resident care plans reviewed.
Findings include:
Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.
Resident #5
Record review of Resident #5's Activities of Daily Living (ADL) care plan revealed .I have the potential for an ADL self-care performance deficit r/t (related to) .impaired vision and arthritis .Interventions .Diabetic nail care weekly Friday 7-3 and Bathing/Showering: Check nail length and trim and clean on bath day and as needed. Report any changes to nurse .
On 3/25/25 at 11:16 AM and again on 3/26/25 at 10:25 AM an observation and interview of Resident #5 revealed gray facial hair that measured approximately one-fourth (1/4) an inch in length and his fingernails were one-eighth (1/8) inch in length, jagged with a brown substance underneath. Resident #5 stated that he needed a bath, a shave, and he would like his nails to be trimmed.
An interview with Licensed Practical Nurse (LPN) # 3, she confirmed that Resident #5 had an odorous smell, and a brown substance under his long nails. LPN #3 confirmed his nails needed cleaning and cut and indicated the nurses were responsible for trimming his nails because he was a diabetic.
Review of the admission Record revealed that the facility admitted Resident #5, on 1/03/2020 with a medical diagnosis that included Type 2 Diabetes Mellitus without Complications.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #5 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for three (3) of 38 sampled residents. Resident #5, #12 and #51.
The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey.
Findings include:
Review of the facility policy titled, Activities of Daily Living, dated 02/01/2022, revealed, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, care and assistance as necessary. ADL's includes bathing, dressing, grooming hygiene, toileting and eating.
Resident #5
An observation and interview on 3/25/25 at 11:16 AM and again on 3/26/25 at 10:25 AM with Resident #5 revealed the resident had numerous visible gray facial hairs that measured approximately one-fourth (1/4) in length and his fingernails on both hands were one-eighth (1/8) inch in length past the tips of the fingers, long and uneven with some sharp edges and a brown substance underneath. During an interview for both observations Resident #5 stated that he needed a bath, shaved and he would like his nails to be trimmed.
An observation and interview with Licensed Practical Nurse (LPN) # 3, she revealed that Resident #5's fingernails were the responsibility of the nurses because he was diabetic and confirmed they needed to be cleaned and cut. She admitted that the resident had an odor, and his nails had some sort of a brown substance underneath the nail beds.
Review of the admission Record revealed that the facility admitted Resident #5, on 1/03/2020 with a medical diagnosis that included type 2 diabetes mellitus without complications.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #5 was cognitively intact.
Resident #12
An observation and interview on 3/25/25 at 10:50 AM with Resident #12 revealed all of his fingernails had a dark brown substance underneath them and were long extending approximately one (1) inch long past the tips of the fingers. The resident had approximate one-half (½) long facial hair covering his chin and sides of his face. The resident admitted he wanted to be shaved and have his nails cut because it had been too long.
During an observation on 3/26/25 at 8:25 AM and again at 10:10 AM, Resident #12's appearance remained the same as the previous day.
An interview and observation on 3/26/25 at 10:15 AM Certified Nurse Aide (CNA) #1 revealed that she gave Resident #12 a bath yesterday. She confirmed that he needed to be shaved, but he did not ask her to do it, and she did not ask if he wanted it done. She stated that she doesn't cut any of the resident's nails. She confirmed the resident's fingernails were dirty and needed cutting and admitted that the CNA's are supposed to ask the nurses if residents are diabetic, but she never has.
In an interview and observation on 3/26/25 at 10:25 AM, LPN #1 confirmed that Resident #12's nails were dirty with a brown substance underneath, too long and rough. He stated the resident could cut himself with those sharp nails and possibly cause a skin infection. He revealed that the resident is a diabetic and usually the CNA's will let the nurses know when those residents need their nails trimmed. LPN #1 also confirmed the resident needed shaving and should have been shaved with his bath yesterday.
During an interview on 3/26/25 at 11:05 AM, the Director of Nurses (DON) confirmed that Resident #12 and all residents should always be groomed as needed and on bath days, that includes nails and shaving. She stated that it is not the resident's responsibility to request grooming.
Record review of the admission Record revealed the facility admitted Resident #12 on 3/3/2014 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side.
Record review of Resident #12's Section C of the MDS dated [DATE] revealed a BIMS score of 11, indicating the resident has moderate cognitive impairment.
Resident #51
During an observation and interview on 3/25/25 at 11:20 AM with Resident #51 he stated that his toenails needed trimming. An observation of the resident's feet confirmed that all of his toenails were long and jagged extending at least ½ inch past the tip of the nailbed except for the right big toe. The right big toe was approximately three-fourths (¾) inch past the nail bed.
An interview with CNA #11 on 3/26/25 at 10:10 AM revealed Resident #51 was assigned to her, and it was her responsibility to trim the fingernails and toenails who were not diabetic but confirmed that she had not trimmed Resident #51's toenails.
During an interview and observation with Resident #51 on 3/26/25 at 10:15 AM, LPN #1 confirmed that the resident needed his toenails tended to. She revealed that the resident is not diabetic and therefore the CNAs are responsible for trimming nails. During the observation LPN #1 stated the nails were long and jagged and should not look that way and they should have been trimmed long before now.
An interview and observation with the DON on 3/26/25 at 10:25 AM, confirmed the resident's toe nails needed cut. She confirmed the facility failed to maintain the resident's toenails within a safe and comfortable length and as the resident preferred.
Record review of Resident #51's admission Record revealed the facility admitted the resident on 1/13/25. Diagnoses included Complete Lesion at T2-T6 Level of Thoracic Spinal Cord, Peripheral Vascular Disease, Lymphedema, and Need for Assistance with Personal Care.
Record review of MDS with ARD of 3/10/25 revealed Resident #51 had a BIMS of 13 which indicated the resident was cognitively intact.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure necessary care and services were provided for one (1) of 38 residents (Resident #75) reviewed for PEG (percutaneous endoscopic gastrostomy) tube management and PRN (as needed) medication administration. Specifically, nursing staff failed to administer Zofran 4 mg (milligrams) PRN for vomiting/gagging on multiple documented occasions, despite physician orders and clinical indications. This failure resulted in Resident #75 experiencing vomiting and feeding intolerance, requiring cessation of tube feeding, and caused unnecessary discomfort.
Findings include:
Record review of the facility policy titled, Enteral Feedings - Enteral Nutrition Pump, with revision date of 11/12/18, revealed, Nurses administer enteral feedings when volume control is indicated and as ordered by physician.
Record review of facility policy titled, Administering Medication, dated 4/19, revealed, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame .
During the initial tour on 3/25/25 at 11:05 AM, an observation revealed Resident #75 lying in bed awake, alert and responsive, but not interviewable. He had a tube feeding of Glucerna 1.5 infusing by feeding pump at 50 milliliters per hour.
Record review of Progress Note dated 10/20/24, revealed, Resident can't tolerate, starts gagging.
Record review of Resident #75's Order Recap Report revealed an active order for Zofran Oral Tablet 4 milligrams (mg) via PEG (percutaneous endoscopic gastrostomy) tube every six hours as needed for vomiting dated 3/11/24.
Record review of Resident #75's Electronic Medication Administration Report (EMAR) revealed the as needed Zofran was not given on 10/20/24.
Record review of Progress Note dated 10/28/24, revealed, Resident vomiting/gagging and can't tolerate feeding.
Record review of Resident #75's EMAR revealed the as needed Zofran was not given on 10/28/24.
Record review of Progress Note dated 2/22/25, revealed, Resident in bed, gave resident his med per PEG and flushes, as soon as I finished, he started vomiting his feeding, vomited several times, feeding cut off at this time.
Record review of EMAR revealed the as needed Zofran medication was not given on 2/22/25.
During an interview on 3/27/25 at 8:44 AM, the Regional Director of Clinical Services stated Resident #75 had nausea and vomiting and was not given an ordered medication for the relief of the vomiting. She confirmed the facility failed to administer an ordered medication to a resident with nausea/vomiting to decrease his discomfort.
During interviews on 3/27/25 at 9:20 AM and 10:11 AM, the Director of Nursing (DON) stated the review of the documentation on 10/20/24, 10/28/24, and 2/22/25 revealed the resident was gagging with vomiting and he did not receive the ordered medication for nausea relief. She confirmed the facility failed to administer an ordered medication to a resident with nausea and vomiting.
Record review of Resident #75's admission Record revealed the facility admitted the resident on 3/7/24. Diagnoses included dysphagia following cerebral infarction, gastrostomy status, gastro-esophageal reflux disease, and acquired absence of other specified parts of digestive tract.
Record review of Resident #75's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment.

Based on observation, staff interview, and record review the facility failed to ensure there was a physician's order and provide catheter care to a resident with an indwelling catheter for one (1) of eight (8) residents with an indwelling catheter reviewed. Resident #439
Findings Include:
Review of the facility provided statement on letterhead dated 3/27/25 and signed by the Administrator revealed, (Proper name of the facility) does not have a specific policy for obtaining physician orders.
An observation of Resident #439 on 3/25/25 at 11:27 AM revealed he was lying in bed. His catheter drainage bag was hanging on the lower bed rail, with yellow urine visible from the hallway.
Record review of Resident #439's Order Summary Report with active orders as of 3/26/25 revealed the resident did not have an order for the urinary catheter or catheter care orders.
An interview with Licensed Practical Nurse (LPN) #3 on 3/26/25 at 2:58 PM, she indicated Resident #439 returned from the hospital on 3/21/25 with an indwelling catheter. She confirmed the resident did not have any physician orders related to the catheter. LPN #3 revealed the admitting nurse on 3/21/25 should have done a hospital return assessment and ensured the orders were put into the system. LPN #3 further indicated the facility had a stand-up meeting every day to ensure all the new orders were captured and corrected from any admissions. She confirmed the resident would not get the proper catheter care and monitoring without orders in place.
Record review of Resident #439's Progress Notes dated 3/21/25 revealed, Catheter is indwelling.
Record review of the admission Record revealed the facility re-admitted Resident #439 on 3/03/25 with a medical diagnosis that included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side.
An interview with the Minimum Data Set (MDS) Nurse on 3/26/25 at 3:06 PM revealed that when Resident #439 came back from the hospital on 3/21/25, his discharge paperwork did not mention that he had a catheter. She revealed the admitting nurse would have been responsible for contacting the physician to obtain orders. She confirmed that without the orders in place, the resident would not get the proper catheter care needed and proper monitoring for complications.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that staff received adequate education and training regarding the use and implementation of Enhanced Barrier Precautions (EBP). As a result, staff did not utilize the required personal protective equipment (PPE) during four (4) high-contact resident care activities observed, potentially putting all residents residing in the facility at risk for the spread of multidrug-resistant organisms (MDROs).
Findings include:
cross-reference F 880
Review of the facility policy titled, Enhanced Barrier Precautions, with an effective date of 9/01/22, revealed the following: Policy: Enhanced barrier precautions (EBP) are used to reduce the spread of multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high-contact resident care activities. Procedure: 4.) Educate the staff on EBP, including but not limited to: a.) use of PPE (personal protective equipment) . b.) High-contact care areas .
During observations of four (4) high-contact resident care activities, staff were not observed at any time using EBP for Residents #11, # 25, # 32, and #75.
On 3/26/25 at 8:00 AM, an observation of Resident #75 during medication pass revealed Licensed Practical Nurse (LPN) #4 administered the resident's medications via PEG (percutaneous endoscopic gastrostomy) tube without wearing a gown for EBP.
On 3/26/25 at 10:35 AM, during an observation the Wound Care Registered Nurse (RN), assisted by Certified Nursing Assistant (CNA) #5, provided wound care for Resident #11. Neither staff used enhanced barrier precautions (EBP) during the wound care procedure.
On 3/26/25 at 11:50, during an observation of wound care for Resident #32 AM with the Wound Care Nurse and CNA #5 there was no observation of the wound care nurse or CNA #5 applying a gown as part of the EBP.
On 3/26/25 at 12:15 PM, an observation of Resident #25's wound care with the Wound Care Nurse assisted by CNA #5 revealed that the care was provided without using a gown for EBP.
During an interview with the Wound Care Nurse and Certified Nurse Assistant (CNA) #5 on 3/26/25 at 12:22 PM, they confirmed they had not been in-serviced or trained on EBP.
During an interview with the Corporate Nurse on 3/26/25 at 12:30 PM, she confirmed that staff had not been educated, and the precautions had not been implemented.
During an interview with CNA #6 on 3/26/25 at 1:25 PM, she confirmed she had not been trained or had knowledge of EBP or its purpose.
During an interview with the Infection Control Nurse on 3/26/25 at 2:51 PM, she revealed that she was aware of what EBP was because she learned it in her infection control (IC) training. She also confirmed she had never received any education in the facility related to EBP and was unaware of why the facility had not educated staff or implemented the EBP practice.
During an interview with the Administrator on 3/26/25 at 3:00 PM, he revealed he was not aware that staff were not using EBP. He stated that the facility had been using EBP at one point but experienced a breakdown in its practice due to significant staff turnover in the past six months.
During an interview with the Staff Educator on 03/27/25 at 10:30 AM, she revealed she had been in her position since July of 2024 and conducts skill competencies for staff and new hires. She confirmed that EBP was not part of the education provided and stated that since her hire date, there had been no education on EBP for any staff. She also stated she was unable to locate any education on EBP prior to her hire date.
During an interview with Licensed Practical Nurse (LPN) #1 on 3/27/25 at 10:41 AM, he revealed he had been employed for over a year and confirmed he did not know what EBP was and had never been educated on it.
During an interview with CNA #9, on 3/27/25 at 10:44 AM, she confirmed she had been employed at the facility for a year. She confirmed she had never been educated on EBP and did not know what it was.
During a follow-up interview with the Administrator on 3/27/25 at 10:48 AM, he confirmed that, due to staff not being educated on EBP and the lack of documented proof of education, the facility had failed to ensure staff had the knowledge necessary to understand and implement EBP. He stated that the concern resulting from failing to educate the staff on EBP was that high-risk residents would not receive the precautions they needed.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment and staff assistance for three (3) of three (3) dining observations. Resident #42
Findings include:
Review of the facility policy titled Assistive Devices with a revision date of 10/2022 revealed under, Policy Statement .Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently.
An observation on 3/25/25 at 11:50 AM revealed Resident #42 unassisted, eating her lunch; her meal was on a regular plate, and the resident was struggling with holding her spoon. No adaptive utensil equipment was noted.
During an observation and interview on 3/25/25 at 12:00 PM, the Assistant Director of Nurses (ADON) confirmed that Resident #42 did not have her divided plate and stated that it was on her meal ticket to have one, and the resident is supposed to have a Certified Nurse Aide (CNA) assisting her with her meals also.
On 3/26/25 at 8:10 AM, an observation revealed Resident #42 eating her breakfast in her room unassisted with no adaptive utensils were noted.
On 3/26/25 at 11:50 AM, an observation revealed Resident #42 eating her lunch in her room unassisted with no adaptive utensils noted.
During an observation and interview on 3/26/25 at 12:00 PM, CNA #10 stated, I'm new, and I'm not sure if the resident requires assistance with eating.
An interview on 3/26/25 at 2:30 PM, Registered Nurse (RN) #2 stated, The resident is supposed to be assisted with all her meals, and she uses big utensils and a divided plate also.
In an interview on 03/26/25 at 2:40 PM, the Occupational Therapist (OT) revealed she was aware that the resident required a divided plate and revealed when the resident was discharged from occupational therapy last month, she had recommended for her to use adaptive built-up utensils to assist the resident in holding her spoon or fork in addition to using her divided plate.
Record review of the Physicians Orders revealed no order for the built-up utensils or the divided plate.
Record review of the admission Record revealed the facility admitted Resident #42 on 12/26/2023 with medical diagnoses that included sequelae of Cerebral Infarction, muscle weakness and need for assistance with personal care.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 12/31/2024 revealed under Section GG-Functional Abilities that the resident required Substantial/maximal assistance with eating, which details The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.

Based on staff interviews, record review, and facility policy review, the facility failed to document if wound treatments had been completed for a resident with a Stage 4 pressure ulcer for one (1) of three (3) residents with wounds reviewed. Resident #11
Findings include:
Record review of facility policy titled, Dressing Change, dated 12/6/17, revealed, A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Document in medical record.
Record review of Order Listing Report revealed an order dated 2/21/25 for wound care to stage four pressure ulcer to sacral region to clean with one-quarter (1/4) strength Dakins, pat dry with 4x4 gauze, apply collagen with silver sheet, cover with bordered dry dressing daily until healed every day shift. This order was discontinued on 3/25/25.
Record review of Electronic Treatment Administration Record (ETAR) for March 2025 revealed wound treatments for 3/1/25, 3/4/25, 3/5/25, 3/6/25, 3/7/25, 3/12/25, 3/13/25, 3/14/25, 3/16/25, 3/18/25, 3/24/25, and 3/25/25 were not documented as administered.
An interview and record review with the Wound Care Registered Nurse on 3/27/25 at 8:15 AM, revealed she worked Monday through Friday and had performed the wound treatments for Resident #11 each day she worked. A record review with the Wound Care RN confirmed there were 12 undocumented treatments in the electronic treatment administration record (ETAR) for this month. She stated she thought that she always documented her care but admitted she missed documenting multiple treatments. She stated it might be due to how it was put into the computer, behind multiple respiratory entries and she failed to see it. She stated accurate documentation was needed to verify that the care was done on each resident's record.
During an interview on 3/27/25 at 8:10 AM, the Director of Nursing (DON) confirmed that wound treatments should be documented upon completion of the care, and this was not done for 12 of Resident #11's wound treatments for this month. She stated that documenting care is part of the continuity of care and treatment. She verified that treatments should be done and documented accurately.
Record review of Resident #11's admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included Pressure Ulcer to Sacral Region and Type 2 Diabetes Mellitus.
Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/21/25 revealed that Resident #11 was rarely or never understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and policy review, the facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) for five (5) of thirty-eight (38) sampled residents (Residents #11, #25, #32, #65, and #75). Specifically, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact resident care activities (wound care and percutaneous endoscopic gastrostomy (PEG) tube handling), failed to prevent the reuse of a single-use medical device (PEG tube declogger), and failed to store a biliary drainage collection bag in a sanitary manner. These failures created an increased risk for the transmission of infectious organisms among residents requiring complex care.
Findings include:
Cross- reference F726
Review of the facility policy titled Infection Prevention and Control Program with a revision date of 10/2018 revealed under, Policy Statement: An infection prevention and control program (IPCP) Is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Review of the facility policy titled, Enhanced Barrier Precautions, with an effective date of 9/01/22, revealed the following: Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high-contact resident care activities . High-contact care activities provide opportunities for the transfer of MDROs to staff hands and clothing . High-contact care activities include: feeding tube care, wound care .
Record review of facility's letterhead revealed, This facility does not have a policy on storage of a biliary tube bag.
Resident #11
During an observation and interview on 3/26/25 at 10:35 AM, the Wound Care Registered Nurse (RN) and Certified Nursing Assistant (CNA) #5 performed wound care for Resident #11. The RN performed the wound treatment on the resident's sacral area and CNA #5 assisted. Neither staff used enhanced barrier precautions (EBP) during the wound care procedure.
During an interview on 3/27/25 at 8:15 AM, the Wound Care RN revealed she was unaware of the EBP guidelines and did not dress out during her wound care treatments. She stated she had now been in-serviced on EBP and the purpose to decrease the risk for infection.
Record review of Resident #11's admission Record revealed the facility admitted the resident on 12/7/23. Diagnoses included pressure ulcer to sacral region and type 2 diabetes mellitus.
Record review of Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 2/21/25 revealed the resident was rarely or never understood.
Resident # 32
During an observation of wound care for Resident #32 on 3/26/25 at 11:50 AM with the Wound Care Nurse and CNA #5, revealed the Wound Care Nurse or CNA #5 did not don a gown as part of the EBP.
A review of the March 2025 Treatment Record for Resident #32 revealed the following: Clean diabetic/PVD (peripheral vascular disease) right heel wound with wound cleanser, pat dry, apply collagen dressing with silver, cover with kerlix and secure with tape daily, signed off as completed on 3/26/25.
During an interview with the Wound Care Nurse and CNA #5 on 3/26/25 at 12:22 PM, it was confirmed that they did not wear any special PPE for EBP during Resident #32's wound care and that they had not been in-serviced or trained on EBP.
A review of Resident #32's admission Record revealed that he was admitted on [DATE], with a diagnosis of Type II diabetes.
During an interview with the Infection Control (IC) Nurse on 3/26/25 at 2:51 PM, she revealed that she was aware of what EBP was because she learned about it in her Infection Control training. She stated that EBP is used as an extra layer of protection between residents and staff to reduce the spread of infection for residents with open wounds and indwelling devices. She confirmed that the facility was not using EBP for any residents. She also revealed she was unaware of why the facility did not educate staff or implement EBP practice.
During an interview with the Administrator on 3/26/25 at 3:00 PM, he revealed that he was not aware staff were not using EBP. He stated that the facility had been using EBP at one point but experienced a breakdown in its practice due to significant staff turnover in the past six months.
During a follow-up interview with the Administrator on 3/27/25 at 10:48 AM, he confirmed that concerns from failing to educate and implement EBP is that high-risk residents would not receive the necessary precautions.
Resident #25
Record review of Resident #25's Order Listing Report revealed an order dated 12/27/24, Cleanse unstageable pressure ulcer to tip of left great toe with wound cleanser or NS (normal saline), pat dry with 4 × 4 gauze, paint with betadine and cover with bordered gauze dressing q (every) Monday, Wednesday and Friday.
An observation of Resident #25's wound care with the Wound Care Nurse assisted by CNA #5 on 3/26/25 at 12:15 PM revealed that the care was provided without using a gown for EBP.
An interview with both the Wound Care Nurse and CNA #5 on 3/26/25 at 12:20 PM confirmed they did not dress out in a gown for EBP during Resident #25's wound care. They both revealed they had no knowledge of these precautions and indicated they had not been in-serviced or had any training on the subject.
An interview on 3/26/25 at 12:25 PM with CNA #2 and CNA #6 confirmed neither had been trained nor had knowledge of EBP.
An interview with the Regional Director of Clinical Services (RDCS) on 3/26/24 at 12:30 PM revealed the facility was currently working on getting EBP into place and confirmed staff had not been educated, and the precautions had not been practiced at the facility. She confirmed the purpose of using EBP was to protect the residents from infection.
Record review of the admission Record revealed the facility admitted Resident #25 on 9/15/23 with a medical diagnosis that included metabolic encephalopathy.
Resident #75
An observation of Resident #75 during medication administration on 3/26/25 at 8:00 AM revealed Licensed Practical Nurse (LPN) #4 attempted to flush the resident's PEG tube with water, but the tube was clogged. LPN #4 retrieved an opened package off the bedside table and indicated it was a peg tube declogger. The opened package was undated, and she inserted the declogger inside the resident's peg tube multiple times. Afterward, she rinsed the de-clogger and placed it back into the package. She administered the resident's medications via PEG tube without wearing a gown for EBP.
Review of the Bionix Enteral Feeding Tube Declogger manufacturer's instructions online revealed single use and discard after using.
An interview with LPN #4 on 3/26/25 at 8:47 AM confirmed the manufacturer's instructions revealed the tube declogger was for single use and revealed reusing the declogger placed Resident #75 at risk for infection. LPN #4 confirmed she did not wear a gown to administer the medications and indicated she had not been trained or had any in-services on using EBP.
On 3/26/25 at 3:21 PM, an interview with the RDCS with the Director of Nursing (DON) in attendance revealed the staff should not be using feeding tube de-cloggers and voiced there were other alternatives to handle a clogged tube.
Record review of the admission Record revealed the facility admitted Resident #75 on 3/07/24 with medical diagnoses that included sequelae of cerebral infarction and gastrostomy status.
Resident # 65
During an observation on 3/25/25 at 11:05 AM of Resident #65 revealed he was lying in bed with a biliary drain connected to a drainage bag. The biliary drainage collection bag with a brown, foamy substance was lying on the floor visible from the doorway.
During an observation and interview on 3/26/25 at 10:07 AM with LPN) #2, it was confirmed the biliary drainage collection bag should not be on the floor. She further confirmed that the bag being on the floor was an infection control issue. She stated, the floor is the nastiest place!
During an interview on 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) it was confirmed the that the biliary drainage collection bag should not have been on the floor as that is an infection control concern that could lead to an infection to the resident.
Record review of Order Summary Report confirmed Resident #65 had orders related to a biliary drain with start date 2/28/25.
Record review of admission Record revealed the facility admitted Resident #65 on 3/9/25 with medical diagnoses that included Malignant Neoplasm of Pancreas, and Obstruction of Bile Duct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident/staff interview and record review, the facility failed to ensure a resident's medications were not left unattended in the resident's room for one (1) of 38 sampled residents. Resident #28.
The scope/severity for this deficiency was increased to E due to previous citation on the last annual recertification survey.
Findings include:
Record review of a statement on the facility's letterhead dated 3/27/25 and signed by the Administrator revealed, (Proper name of the facility) does not have a specific policy for unattended medication.
During an observation and interview on 3/25/25 at 10:45 AM, a small bag of intravenous (IV) fluids with a vial of medication attached to the bag was observed from the open doorway, lying on Resident #28's bedside table. The resident confirmed it was her antibiotic medication, and the nurse needed to restart her peripheral IV before administering it.
During an observation on 3/25/25 at 1:37 PM with Registered Nurse (RN) #1, confirmed the presence of the IV antibiotic medication on the bedside table. RN #1 acknowledged that the medication should not have been left unattended, as another resident might have accessed it with the door open to the hallway.
During an interview on 3/25/25 at 2:30 PM with the RN Supervisor confirmed that leaving the IV medication unattended was inappropriate and that it posed a risk of access by another resident.
During an interview on 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) confirmed the medication should not have been left on the bedside table.
A record review of the admission Record for Resident #28 revealed that she was admitted to the facility on [DATE] with a diagnosis of polyneuropathy, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus.
A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #28 is cognitively intact.

Resident #439
An observation of Resident #439 on 3/25/25 at 11:27 AM revealed he was lying in bed and had a urinary catheter drainage bag hanging on the lower bed rail that contained yellow urine and was visible from the hallway.
An observation on 3/26/25 at 10:23 AM from Resident #439's doorway revealed he was lying in bed interacting with visitors. His catheter drainage bag was hanging on the lower bed rail without a privacy cover, and yellow urine was visible.
An observation and interview with LPN # 3 on 3/26/25 at 10:25 AM confirmed Resident #439 did not have a privacy cover on his urinary drainage bag and stated, It's a dignity issue if they do not have a cover on their bag.
Record review of the admission Record revealed the facility re-admitted Resident #439 on 3/03/25 with a medical diagnosis that included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side.
Resident #65
An observation on 3/25/25 at 11:05 AM revealed Resident #65 had a urinary catheter bag attached to the left side of the bed without a privacy cover and was half full of light-yellow colored urine. This observation also revealed that the resident had a biliary drain leading to a drainage bag that had a foamy, brown colored substance. Both the biliary drainage bag and the urinary catheter bag were visible from the doorway.
Observation and interview on 3/26/25 at 10:07 AM with Licensed Practical Nurse (LPN) #2 confirmed that both the urinary catheter bag and the biliary drainage bag should have a privacy cover. She stated it is a dignity issue.
An interview on 3/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) confirmed the urinary catheter bag and biliary drainage bags should have had a privacy cover and that it is a dignity issue.
Record review of Resident #65's admission Record revealed the facility admitted the resident on 3/9/25 with medical diagnoses that included Malignant Neoplasm of Pancreas, Unspecified.
Based on observation, staff interview, and facility policy review, the facility failed to honor a resident's right to be treated with dignity and respect as evidenced by improper feeding practices and failure to cover biliary and urinary catheter drainage devices with privacy covers for three (3) of 93 residents residing in the facility. Resident #57, #65, and #439
The scope and severity of this deficiency was increased to E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey.
Findings Include:
Record review of the facility policy titled, Policies and Procedure with a revision date of 9/19/2017 revealed Subject; Catheterization, Male and Female Urinary .Foley bag to be covered by a privacy bag to preserve dignity of resident .
Review of the typed statement on facility letterhead, signed by the Administrator and dated 3/27/25 revealed, (Proper name of the facility) does not have a specific policy for privacy bags for biliary drainage tubes.
Resident #57
An interview with the Regional Director of Clinical Services (RDCS) on 3/27/25 at 11:04 AM revealed the facility did not have a policy related to providing dignity while assisting a resident with meals.
On 3/25/25, at 12:25 PM, an observation of Resident #57 revealed Certified Nursing Assistant (CNA) #8 was standing over Resident #57 while he was in bed, feeding him his lunch meal.
During an interview with CNA #8 on 3/26/25 at 11:04 AM, she confirmed that she was standing over Resident #57 feeding him. She reported that sometimes she sits to feed him but often feeds him while standing at bedside.
During an interview with the Nursing Educator on 3/26/25 at 11:08 AM, she stated that Resident #57 should be fed while sitting in a chair at bedside. She stated standing over him would be a dignity issue.
Review of the admission Record revealed that the facility admitted Resident #57 on 11/04/22 with a medical diagnosis that included Unspecified Sequelae of Cerebral Infarction.

Based on observation, staff interview, and facility policy review, the facility failed to provide accommodation of needs for a residents call light not being within reach for two (2) of three (3) survey days. Resident #71
Findings Include
The facility provided a statement on letterhead signed by the Administrator and dated 3/27/25, (Proper name of the facility) does not have a specific policy for Call Lights.
Resident #71
An observation of Resident # 71 on 3/25/25 at 11:25 AM revealed he was lying in bed. Further observation revealed his call light was hanging over a small picture on the wall, and the end of the call button was on the floor behind a bedside dresser. The resident did not have access to his call light.
An observation on 3/26/25 at 10:43 AM of Resident #71 revealed he was sitting in a chair in his room. His call light was unreachable and hanging over a small picture on the wall with the end of the call button on the floor behind a beside dresser.
An observation and interview with Licensed Practical Nurse (LPN) #3 on 3/26/25 at 10:47 AM revealed Resident #71 knew how to use the call light if he needed something. She confirmed the call light was unreachable. LPN #3 stated, I'm on them all the time about keeping the call lights in reach; I find them on the floor and all over the place. She confirmed anything could happen to the resident, such as falling or choking, and he would not have access to call for help.
An interview with Certified Nursing Assistant (CNA) #8 on 3/26/25 at 10:55 AM confirmed Resident #71's call light should be in reach, so the resident could call staff if he required something. She revealed if the light was not in reach the resident could fall, or something could happen, and he would not be able to get help.
Record review of the admission Record revealed the facility admitted Resident #71 on 9/11/23 with a medical diagnosis that included but was not limited to Parkinson's disease with Dyskinesia.

Resident #47
Upon entering Resident #47's room on 3/25/25 at 10:55 AM, a foul pungent smell was noted. An interview at this time with Resident #47 she stated that the toilet was not flushing and that she had told the staff about it. An observation revealed the toilet was full of a brown liquid and a brown substance that was approximately 10 inches from the top of the rim of the toilet seat.
An interview on 3/25/25 at 11:00 AM, Housekeeper #1 revealed the toilet in Resident #47's room had been stopped up on and off for quite some time. She stated that they just go in and clean around the bottom of the base of the toilet and try to plunge it. She admitted that the staff report it all the time to maintenance. She revealed this had been a problem on and off for about a month and confirmed the resident's room smelled bad from the stopped-up toilet.
In an interview on 3/25/25 at 11:10 AM, the Administrator (ADM) confirmed the stopped up smelly toilet was not a homelike environment and should have been taken care of.
During an interview on 3/25/25 at 11:25 AM, the Maintenance Supervisor confirmed Resident #47's toilet being stopped up had been an ongoing issue and he was not sure what else to do. He revealed that they find all kinds of stuff in the toilet because they think the resident in the adjoining room has been putting wipes in the toilet. He confirmed it has been an ongoing issue.
Record review of Resident #47's admission Record revealed the facility admitted Resident #47 on 5/17/2024 with medical diagnoses which included Dementia, and Generalized Anxiety Disorder.
Record review of Resident #47's MDS with an ARD of 2/14/25 revealed a BIMS score of 7 which indicated the resident had severe cognitive impairment.
Resident #22
An observation on 03/25/25 at 03:29 PM of Resident # 22's room revealed an approximate 18-inch section of trim with jagged, sharp edges sticking out of the top section of her dresser.
An interview on 03/26/25 at 10:14 AM with Certified Nurse Assistant (CNA) #3 confirmed that Resident #22's dresser had an approximate 18-inch section of trim with jagged, sharp edges sticking out of the top section. She stated the resident could cut herself or get herself in the eye. She stated she wasn't sure how long the dresser had been in that condition.
An interview on 03/26/25 10:36 AM with the Maintenance Supervisor, he stated that he was not aware of loose trim on Resident #22's dresser. He confirmed the resident could get scratched or hit her face on it. He revealed after review of the maintenance log that he was unable to find any documentation for the broken equipment.
An interview on 03/26/25 at 10:47 AM with the Assistant Director of Nursing (ADON) revealed she was not aware of the loose trim on the dresser and confirmed it needed to be fixed.
Record review of Resident #22's admission Record revealed the facility admitted the resident on 9/15/22 with medical diagnoses that include Need for Assistance with Personal Care.
Resident #28
An observation and interview on 03/25/25 10:45 AM for Resident # 28 revealed that the resident's approximate 18-inch auscultating fan, located at the head of the bed, had a large buildup of a gray substance on the fan blades and fan guard. The resident mentioned that she had asked for the fan to be cleaned, but it had not been done yet and that she had not been using it because it was dirty
An observation and interview on 03/26/25 at 10:05 AM with the Housekeeping Supervisor confirmed that Resident #28's fan was covered in lint and dust. She stated she thinks maintenance is responsible for cleaning these type items. She stated this could cause allergies.
An interview on 03/26/25 10:36 AM with the Maintenance Supervisor, he stated that the CNAs are responsible for cleaning resident's personal items.
An interview on 03/26/25 at 10:47 AM with the ADON confirmed that CNAs are responsible for cleaning resident's personal items such as the fan.
Record review of Resident #28's admission Record revealed the facility admitted the resident on 7/14/22 with medical diagnoses that included Need for Assistance with Personal Care.
Record review of Resident #28's MDS with an ARD of 1/27/25 revealed a BIMS score of 15, which indicates the resident is cognitively intact.
Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide a safe homelike environment as evidenced by missing air conditioner unit cover, damaged furniture, no fitted sheets and a foul odor from a stopped-up toilet for four (4) of 93 residents residing in the facility. Residents #3, #22, #28 and #47
The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey.
Findings Include:
Review of the facility policy titled Policies and Procedures unrevised revealed under, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair.
Review of the facility policy titled, Resident/Patient Room Cleaning with a revision date of 2/1/25 revealed, (Proper Name) is committed to providing a safe, clean, and hygienic environment for residents .
Resident #3
On 03/25/25, at 11:00 AM, and again on 3/26/25, at 10:21 AM, an observation of Resident #3's room revealed his air conditioner/heating unit cover was on the floor. In an interview, Resident #3 voiced that staff were aware and they were looking for a clip.
During an interview with Licensed Practicing Nurse (LPN) # 3, she confirmed the unit cover should not be off the unit. She stated that all maintenance repairs should be reported to the maintenance supervisor.
During an interview with the Maintenance Supervisor on 3/26/25 at 10:31 AM regarding the air conditioner/heating unit cover on the floor, he reports that the staff usually contacts via text, in person, or records in the maintenance book. He reports he was unaware of the cover being on the floor in Resident #3's room. The Maintenance Supervisor confirmed the resident should have a homelike environment.
Record review of the admission Record revealed that the facility admitted Resident #3 on 11/20/23 with a medical diagnosis that included Alzheimer's Disease.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #3 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, resident interview and facility policy review, the facility failed to complete timely reporting of a resident involved accident in the facility's wheelchair lift van to the State Agency, for one (1) of four (4) residents reviewed for wheelchair transportation safety. Resident #1
Findings Include:
Review of the facility policy titled, Policies and Procedures, with a revision date of 11/16/2022, revealed . Employee Obligation . to report such information immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . to other officials in accordance with State law. Report the result of all investigations . to the State Survey Agency, with five (5) working days of the incident.
A telephone interview on 10/18/23 at 11:30 AM with the Ombudsman revealed she was not notified by the nursing facility of the incident for Resident #1 regarding his wheelchair tilting over in the wheelchair lift van during transport.
Record review of the Verification of Investigation, facility reported incident form, for Resident #1, revealed RESIDENT NAME: (Resident #1's name removed) . DATE/TIME OF OCCURRENCE: 10/05.23 @ (at) approx. (approximately) 10:30 AM . PROVIDED DETAILED DESCRIPTION OF EVENT/ALLEGATION: Resident was being transported to appointment on facility van. Resident fell backward in van during transport and hit left shoulder on floor. Seat belt remained intact throughout event. ASSESSMENT OF RESIDENT/DESCRIBE INJURY: No bruising, redness, or skin tears noted to resident post incident. Resident refused to go to emergency room (ER) to be evaluated. RESIDENT INTERVIEW SUMMARY: Resident stated that he was secured in wheelchair and when they stopped at red light and went forwards, his wheelchair tipped backward and he hit his left shoulder on the floor. He denied any other injuries or pain and refused to go to the ER to be evaluated. FIRST REPORTED BY NAME: (Certified Nurse Aide (CNA)#1 name removed), NAME/TITLE REPORTED TO: (Registered Nurse (RN) #1 (name removed), DATE REPORTED: 10/5/23, TIME REPORTED 10:35 AM . STATE AGENCY NOTIFIED: YES, CONTACT NAME: Reporting Line, DATE: 10/5/23, TIME: 10:45 AM . PRINTED NAME: (Former Director of Nursing (DON) name removed), DATE: 10/05/23.
Record review of the time stamp of the initial telephone report by the nursing facility, provided by the SA Complaint Division, revealed WIRELESS CALLER, Voice Message From: WIRELESS CALLER, 1 (662) 7691195 [DATE], 11:10 20.8 sec.
Record review of the documentation for the incident revealed DON and NP (Nurse Practitioner)/MD (Medical Director) aware and resident is his own RP (Responsible Party). MD gave orders to continue with transportation and upon return to center can follow up at the ER for an X-Ray.
An interview on 10/18/23 at 12:38 PM with CNA #1 revealed she immediately called and reported the incident of Resident #1's wheelchair tilting over during transport.
An interview on 10/18/23 at 2:09 PM with Resident #1 revealed he was sitting in the wheelchair during transport on 10/5/23, when the driver pulled off from the red light and his chair flipped over, causing him to bump his left shoulder and the left side of his head.
An interview on 10/18/23 at 3:01 PM with RN #1 revealed she did receive the initial report and witness statement from CNA #1 of the incident with Resident #1' wheelchair tilting over in the wheelchair van during a transport to an appointment, on 10/5/23 before 10:30 AM, and immediately returned to a meeting with the Administrator, the Former DON, the MD, and his NP, and informed them of the incident.
A telephone interview on 10/18/23 at 04:22 PM with the Former DON, revealed she called the report in to the State Agency (SA) hotline on 10/5/23 shortly after she was informed of the information by the RN #1 on the same day. She revealed she was not aware of why the SA reported her call recorded on 10/9/23 at 11:10 AM. She revealed she emailed her report a couple of days later and did not include findings because there were none. She noted she did not have to add a conclusion because she did not prove something went wrong. She shared she was not late calling in the initial report and was not late sending the written report.
A telephone interview on 10/18/23 at 05:07 PM with the SA Complaint Division confirmed the initial report time of 10/9/23 at 11:10 AM from the Former DON at the nursing facility. SA was allowed to listen to the initial recorded report, from the Former DON, that warranted the SA Complaint Division to need to call back for clarification of what the incident entailed, and emailed SA a copy of the time stamp for the recording of the initial report from the Former DON at the nursing facility. The SA Complaint Division also verified the Former DON's personal cell phone number that was recorded as the number the incident was called in from, provided 10/11/23 at 02:20 PM as the first submission for the final/completed written investigation, and provided 10/15/23 at 09:22 PM for a resubmission of the final/completed written investigation.
An interview on 10/18/23 at 05:20 PM with the Administrator revealed the Former DON was the one responsible, at the time of the incident, for reporting facility incidents to the SA Complaint Division, and confirmed that the Former DON did not follow the federal regulations for timely reporting of a resident involved incident in a timely manner.
Record review of the admission Record for Resident #1 revealed an admission date of 07/15/2022.
Record review of Section C of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/18/2023, for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff and resident interview the facility failed to provide a safe clean environment as evidenced by a dirty wheelchair with a torn arm rest for Resident #249 and dirty floors throughout the facility, scuffed painted areas, gouged sheetrock, broken drawers, broken window and sharp areas on resident doors for four (4) of 4 survey days.
Findings include:
An interview with the Administrator on 9/28/23 at 9:00 AM revealed the facility did not have a policy addressing a safe and clean environment.
An observation on 9/25/23 at 1030 AM, revealed blackish build up along the edges of all of the hallways at the baseboards and around the door frames of resident's room entry and bathroom doors. There are several brownish stain spots scattered along the floor of the east hall between room [ROOM NUMBER] to room [ROOM NUMBER].
Observations on 09/25/23 at 11:25 AM and 9/26/23 at 9:03 AM, revealed Resident #249 sitting in a wheelchair that had a thick brown and gray substance on the frame and the spokes of the wheels. The right vinyl armrest was tattered and torn with jagged edges exposed.
An observation on 9/25/23 at 3:30 PM, revealed the drawers under the closet in room [ROOM NUMBER] are broken, hanging down and unable to be closed.
An observation on 9/25/23 at 3:33 PM, in room [ROOM NUMBER] revealed the paint scuffed off and the wall had areas gouged out of the sheet rock behind the bed. The clothes closet cabinet had scuffed areas with missing paint and broken edges.
An observation and interview on 09/25/23 at 03:36 PM, with Resident #52 revealed the drawer under the clothes closet was broken and hanging and will not close properly. The top of the counter space on the right side of the room has paint scuffed and peeled off the top. Resident #52 stated that she would not want this in her house if she wasn't in the nursing home.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/23 revealed a Brief Interview for Mental Status (BIMS) score of nine (9 )which indicated Resident #52 had moderate cognitive impairment.
An observation on 9/25/23 at 4:00 PM, revealed the wall behind the A and B bed in room [ROOM NUMBER] below the chair rail had approximately 75% of the paint off. The chair rail was broken behind the bed with a sharp edge on it and was pulled away from the wall.
An observation and interview on 09/26/23 at 02:10 PM, with the housekeeping District Manager confirmed the dark areas on the tile in the hallways, the build up of brownish-black material against the walls and noted the build up was worse near the hand sanitizer dispensers. He stated that some of the stuff on the floor was where they put down new baseboards and left strips of adhesive. He stated that they would try to get it up. He confirmed the black colored build up in the corners at the doors should not be there. He confirmed that the building is the resident's home and the floors should not have all the spots and build up on the tiles. If the tiles could not be cleaned the only thing to do would be to replace them.
An observation and interview on 9/26/23 at 3:30 PM, the Maintenance Director confirmed the broken drawers, scuffed paint , gouged walls and loose broken chair rail should not be like that. He confirmed he would not want to live in a house with these issues. He stated that they make daily rounds, if possible, to check on things like this, but the staff should also report anything they find that needs repair.
An observation and interview on 09/26/23 at 03:35 PM, the Director of Nurses (DON) confirmed that Resident #249's wheelchair was dirty and needed to be cleaned. She stated the wheelchair was disgusting. The DON revealed that it should have been cleaned last weekend and she wasn't sure when the last time it was cleaned. She revealed she had assigned one Certified Nurses Assistant (CNA) every weekend to clean the wheelchairs and had just put that in place about a month ago because the wheelchairs were not getting cleaned. She revealed we don't have a checklist in place at this time but that is something we are working on. The DON confirmed the right armrest was torn and jagged and could cause the resident to get a skin tear and she would get that taken care of.
An observation on 9/27/23 at 8:55 AM, on the west hall of all the room doors revealed where the door frame meets the floor had a blackish build up on the floor approximately one half (1/2) to one (1) inch wide.
An interview on 9/28/23 at 8:42 AM, with the Floor Technician revealed they stripped the floors last month and he buffed the floors yesterday. He stated he thinks the stains are rust left from a few years ago when the sewer overflowed and will not come up.
During an observation and interview on 9/28/23 at 8:45 AM, with the Administrator (ADM) she revealed the floors were stained and dirty in the halls and the resident's rooms and that they needed new floors. She confirmed room [ROOM NUMBER] had paint scuffed off the closet door, room [ROOM NUMBER] clothes closet and drawers needed repair and the shelf needed to be repainted. She confirmed the gouged walls behind the beds and the broken, loose chair rail behind the bed needed fixing. She confirmed the metal plate on the door of room [ROOM NUMBER] had rough gouged areas and the metal plate corner was bent outward approximately two (2) inches. The ADM stated that the bent metal plate could possibly cut somebody. She confirmed the hole in the window in room [ROOM NUMBER] should have been fixed instead of putting tape over it and the tape no longer covered the actual hole. She stated that the building was dirty and in need of attention and updating. The ADM stated that her house did not look like this and confirmed the residents home should not look like it does.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to complete a level one (1) Preadmission Screen (PAS) for a resident admitted to the facility for 1 of three (3) residents reviewed for Preadmission Screening and Resident Review (PASARR). Resident #81.
Findings include:
Record review of the facility policy titled Preadmission Screening and Resident Review (PASARR) with a revision date of 11/08/21 revealed, Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Also revealed under, Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record .
Record review of the admission Record revealed that Resident #81 was admitted to the facility on [DATE] with medical diagnoses that included Metabolic Encephalopathy, Major Depressive Disorder, Generalized Anxiety Disorder, Pseudobulbar Affect, and Alcohol Abuse with Alcohol-Induced Psychotic Disorder.
An interview, with the Nursing Consultant on 9/26/23 at 11:00 AM revealed the facility did not complete a Level 1 Preadmission Screen for Resident # 81, and therefore a Level II had not been done.
An interview with the Admission's Coordinator on 9/26/23 at 11:02 AM, revealed she was responsible for the PASARRs. She confirmed that a Level I was not done when Resident #81 was admitted to the facility. She revealed that the purpose of the PASARR was to identify if the resident was appropriate for nursing home placement.
An interview with the Administrator (ADM) on 9/26/23 at 2:20 PM, revealed that all residents admitted to the facility should have a PAS to ensure that they are appropriate for nursing home placement and ensure they receive the care and services needed. She confirmed that Resident #81 should have had a PAS completed on admission.
An interview with the Director of Nursing (DON) on 9/28/23 at 8:40 AM revealed that Resident #81 did have some anxiety/agitation at times.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/12/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score was not obtained due to Resident #81 is rarely/never understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plans for four (4) of the twenty-eight resident care plans reviewed. Resident #32, Resident #33, Resident #57 and Resident #248.
Findings include:
Review of the facility policy titled, Policies and Procedures Subject: Plans of Care with a revision date of 09/25/2017 revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.
Resident #33
Record review of Resident #33's Activities of Daily Living (ADL) care plan revealed, Focus: I have an ADL self-care performance deficit r/t (related to) Cardiac Dx (Diagnosis), HX (History) of CVA (Cerebral Vascular Accident), Aphasia, Cognitive Communication deficit, and Muscle Weakness . Interventions .Personal Hygiene .I require extensive assistance x 1-2 staff for personal hygiene .shaving.
An observation, on 09/25/23 at 11:35 AM, revealed Resident #33 lying in bed. This observation revealed the resident is non-verbal but acknowledged when he was spoken to and was able to respond by shaking his head to yes or no questions. Resident #33's facial hair was approximately one-half (1/2) inch long on his chin, above his mouth, and on the sides of both cheeks. The resident shook his head no when asked if he liked the facial hair to be that long. Resident #33 shook his head, yes when he was asked if he would like to be shaved.
An observation, on 09/26/23 at 08:10 AM, revealed Resident #33 remains unshaven. Resident #33 nodded his head yes; acknowledging that he would like to be cleaned up and shaven.
An interview and observation, on 09/26/23 at 11:25 AM, with Certified Nurse Aide (CNA) #2 revealed she is assigned to the resident, and he got a bed bath today. Observation of Resident #33 lying in bed revealed the resident remained unshaven. CNA #2 revealed well I didn't give him a full bed bath I just did his peri-care. CNA #2 revealed she wasn't sure if she was supposed to shave him or not, but that shaving was part of grooming. CNA #2 confirmed that the resident's facial hair was long, and he needed to be shaved. When the resident was asked if he would like to be shaved, the resident shook his head yes.
An interview and observation on 09/26/23 at 11:30 AM, CNA #1 revealed a shower or bed bath consisted of haircare and shaving the men. CNA #1 asked the resident if he would like to be shaved, and he shook his head yes while touching his face. CNA #1 confirmed that it looked like it had been a long time since he was shaved and she wasn't sure when the last time was.
An observation and interview on 09/26/23 at 11:45 AM, the Director of Nurses (DON) asked Resident #33 if he would like to be shaved and the resident shook his head yes. The DON confirmed that the resident looked like he hadn't been properly groomed in a while and stated, We are having a grooming problem in the facility. The DON revealed when the CNAs are giving him a bed bath they should be asking if he wants to be shaved too.
A record review of Resident #33's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Specified Sequelae of Cerebral Infarction, Aphasia following Nontraumatic Subarachnoid Hemorrhage, and Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting right dominant side.
Resident #57
Record review of Resident #57's ADL care plan revealed, Focus: I have an ADL Self-care performance deficit r/t (related to) Dementia, Schizoaffective Disorder-Bipolar type, DM (Diabetes Mellitus) with Neuropathy, and Anxiety. Interventions . Bathing/Showering: I am dependent on 1-2 staff for bathing/showering .Personal hygiene .I require extensive assistance and sometimes total assistance from 1 staff for personal hygiene.
An interview and observation on 09/25/23 at 11:30 AM, revealed Resident #57's facial hair was approximately 1/2 inch to his chin and on the sides of his face. Hair was approximately one (1) inch on his neck area. Resident #57 revealed he likes to be shaven and has mentioned it before to the staff, but it doesn't do any good. He revealed he couldn't remember the last time he was shaven.
An observation and interview on 09/26/23 at 08:30 AM, revealed Resident #57 lying in bed, he remained unshaven. He revealed they said they were going to get to me today and stated I sure hope they do.
An observation and interview on 09/26/23 at 10:50 AM, revealed Resident #57 remains unshaven. The resident revealed they told me a while ago that they were going to come back and shave me. I'm still waiting though.
An interview and observation on 09/26/23 at 10:55 AM, with CNA #2 revealed she was assigned to the resident today and confirmed that the resident had long facial hair on his chin, cheeks, and neck, and she was supposed to do personal care which included shaving. She revealed she wasn't sure when he was last shaved since she is only part-time.
An observation and interview on 09/26/23 at 11:35 AM, the DON confirmed that Resident #57's facial hair was long, and he needed to be shaved. The DON stated that he refuses sometimes The Resident stated, I don't refuse at all to be shaved they just don't offer to shave me.
A record review of Resident #57's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder, Bipolar type, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, and Vascular Dementia.
A record review of Resident #57's MDS revealed an ARD of 6/28/23 and in Section C a BIMS score of 10 which indicates the resident has a moderate cognitive impairment.
Resident #248
Record review of Resident #248's ADL care plan revealed, Focus: I have an ADL self-care performance deficit r/t impaired balance, Limited mobility, Limited ROM (range of motion) due to humerus fracture, multiple pubis fractures, and hx of multiple healing rib fractures .Interventions .Personal Hygiene routine: I required extensive assistance x 1 staff with my personal hygiene and oral care daily and PRN .Bathing/Showering: I am dependent on 1-2 staff assistance with my bed baths and or showers 3x week and PRN due to weakness and tremors.
An observation and interview on 09/25/23 at 03:25 PM, with Resident #248 revealed him lying in bed with facial hair approx. 1/2 inch (in) long to his chin and sides of his face. He revealed several weeks ago a girl in therapy shaved me, I haven't been shaved since then. He revealed he hasn't had a shower since he has been here and he thinks if he got a shower, it would make him feel a lot better.
Record review of Resident #248's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Parkinson's Disease, Unspecified Nondisplaced Fracture of Surgical Neck of Right Humerus, Muscle Weakness, and Need for assistance with personal care.
An observation and interview on 09/26/23 at 08:20 AM Resident #248 facial hair approx. 1/2 in. long to his chin and sides of his face. The resident revealed he hasn't received a shower but would like one.
An observation on 09/26/23 at 11:15 AM, revealed Resident #248 remains unshaven.
On 09/26/23 at 11:55 AM, an observation and interview of Resident #248 with the DON present revealed the resident with facial hair approximately 1/2 inch long to his chin, and sides of his face. He revealed he doesn't remember how long it's been since he was shaved but it was in therapy. He revealed he has not had a shower since he has been here but has only had a bed bath. The DON confirmed that the resident had long facial hair and stated, it looks like it's been a while since he was shaven. Resident #248 revealed he would like to be shaved at least every other day.
An interview on 09/26/23 at 01:18 PM, the DON revealed she believed the resident 100%, if he says he hasn't had a shower then she can guarantee he is being truthful. The DON revealed we are having a grooming problem here in the facility. I will make sure this gets taken care of today.
A record review of Resident #248's MDS with an ARD of 09/18/23 revealed in Section C a BIMS score of 12, which indicates the resident has a moderate cognitive impairment.
An interview on 09/27/23 at 09:16 AM, the MDS Nurse revealed she is responsible for developing the comprehensive care plan. She revealed the care plan is developed so that each resident gets the appropriate individualized care they need. She confirmed that Resident #57 and Resident #248 ADL care plans don't specify shaving, but it is part of grooming and personal hygiene. She revealed the plan of care for Resident #33, Resident #57, and Resident #248 were not being followed.
An interview on 09/27/23 at 04:54 PM, the DON revealed the purpose of a care plan is to establish a plan of care for each individual resident. She confirmed the care plans for Resident #33, Resident #57, and Resident #248 were not being followed.
Resident #32
Record review of Resident #32's Care Plan revealed the Focus: Nail Care:check nails weekly on Tuesday and PRN (as needed) and trim when necessary.
An observation on 09/25/23 at 2:05 PM, of Resident #32 revealed long fingernails that measured three-eights (3/8) inch (in.) in length with a brown substance underneath. The resident's right hand was contracted, with the fingers turned inward toward the palm.
An interview on 9/26/23 at 11:35 AM with the DON confirmed that Resident # 32's nails were long and needed cleaning and cutting.
An interview with the MDS Nurse on 9/27/23 at 8:30 AM, confirmed that staff did not follow Resident #32's care plan for nail care.
An interview with the DON on 9/27/23 at 4:55 PM, revealed that the purpose of the care plan was to establish a plan of care to provide the needed care for the resident. She confirmed that staff did not follow the care plan for Resident #32 related to nail care.
Record review of the admission Record revealed Resident #32 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Vascular Dementia, Contracture, Unspecified Joint and Personal History of Transient Ischemic Attack.
Record review of the MDS with an ARD of 8/23/23 revealed, under section G, that Resident # 32 requires one-person physical assistance with personal hygiene. Section C revealed a BIMS score of 07, which indicates the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for four (4) of 97 residents observed during the initial tour related to nail care for Resident #32, and failure to shave Residents #33, #57 and #248 and provide a shower for Resident #248.
Findings include:
Review of the facility policy titled, Policies and Procedures Subject: Grooming Activities, with a revision date of 3/19/19, revealed Grooming activities are provided to assist the residents in meeting their physical needs as well as self-esteem needs. 2 .Grooming Activities shall include but are not limited to: Shaving, Applying Makeup, Combing hair, and Nail care.
Resident #33
An observation, on 09/25/23 at 11:35 AM, revealed Resident #33 lying in bed. This observation revealed the resident is non-verbal but acknowledged when he was spoken to and was able to respond by shaking his head to yes or no questions. Resident #33's facial hair was approximately one-half (1/2) inch long on his chin, above his mouth, and on the sides of both cheeks. When asked if he liked the facial hair to be that long Resident #33 shook his head no. Resident #33 shook his head, yes acknowledging that he would like to be shaved.
An observation, on 09/26/23 at 08:10 AM, revealed Resident #33 remained unshaven. Resident #33 nodded his head yes, acknowledging that he would like to be cleaned up and shaven.
An interview and observation, on 09/26/23 at 11:25 AM with Certified Nurse Aide (CNA) #2 revealed she was assigned to Resident #33 and he got a bed bath today. An observation of Resident #33 lying in bed revealed the resident remained unshaven. CNA #2 revealed she didn't give him a full bed bath, she only did peri-care. CNA #2 revealed she wasn't sure if she was supposed to shave him or not, but that shaving was part of grooming. CNA #2 confirmed that the resident's facial hair was long, and he needed to be shaved. When Resident #33 was asked if he would like to be shaved, the resident shook his head yes.
An interview and observation, on 09/26/23 at 11:30 AM, with CNA #1 revealed a shower or bed bath consist of haircare and shaving the men. CNA #1 asked Resident #33 if he would like to be shaved, and he shook his head yes while touching his face. CNA #1 confirmed that it looked like it had been a long time since he was shaved, and she wasn't sure when the last time was.
An observation and interview, on 09/26/23 at 11:45 AM, with the Director of Nurses (DON) confirmed Resident #33 would like to be shaved. The DON confirmed that the resident looked like he hadn't been properly groomed in a while and stated, We are having a grooming problem in the facility. The DON revealed when the CNAs are giving him a bed bath they should be asking if he wants to be shaved too.
A record review of Resident #33's admission Record revealed the resident was admitted on [DATE] with diagnoses that included Specified Sequelae of Cerebral Infarction, Aphasia following nontraumatic subarachnoid hemorrhage, and Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting right dominant side.
Resident #57
An observation and interview, on 09/25/23 at 11:30 AM, revealed Resident #57's facial hair was approximately 1/2 inch long on his chin and sides of his face and approximately one (1) inch long on his neck area. Resident #57 revealed he likes to be shaven and has mentioned it before to the staff, but it doesn't do any good. He revealed he couldn't remember the last time he was shaved.
An observation and interview, on 09/26/23 at 08:30 AM, revealed Resident #57 remained unshaven. He stated they (the staff) said they were going to get to him today. He stated, I sure hope they do.
An observation and interview, on 09/26/23 at 10:50 AM, revealed Resident #57 remained unshaven. The resident stated, They told me a while ago that they were going to come back and shave me. I'm still waiting though.
An interview and observation, on 09/26/23 at 10:55 AM, with CNA #2 revealed she was assigned to Resident #57 today and confirmed that the resident had long facial hair on his chin, cheeks, and neck, and she was supposed to do personal care which included shaving. CNA #2 revealed she wasn't sure when he was last shaved because she was only part time.
An observation and interview, on 09/26/23 at 11:35 AM, the DON confirmed that Resident #57's facial hair was long, and he needed to be shaved. The DON stated that he refuses sometimes. Resident #57 stated, I don't refuse at all to be shaved they just don't offer to shave me.
A record review of Resident #57's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified Protein-Calorie malnutrition and Vascular Dementia.
A record review of the MDS with an ARD of 6/28/23 revealed, in Section C, a BIMS score of 10 which indicated Resident #57 had moderate cognitive impairment.
Resident #248
An observation and interview, on 09/25/23 at 03:25 PM, revealed Resident #248 lying in bed with facial hair approximately 1/2 inch long on his chin and the sides of his face. He revealed several weeks ago a girl in therapy shaved him, but he has not been shaved since then. He revealed he hasn't had a shower since he has been here and he thinks if he got a shower, it would make him feel a lot better.
Record review of Resident #248's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Parkinson's disease, unspecified Nondisplaced Fracture of surgical neck of right humerus, Muscle weakness, and need for assistance with personal care.
An observation and interview, on 09/26/23 at 08:20 AM, with Resident #248 revealed facial hair that was approximately 1/2 in. long on his chin and on the sides of his face. The resident revealed he
still haven't received a shower, but would like one.
An observation, on 09/26/23 at 11:15 AM,revealed Resident #248 remains unshaven.
On 09/26/23 at 11:55 AM, an observation and interview with the DON confirmed Resident #248 had facial hair approximately 1/2 inch long on his chin, and on the side of his face. He revealed he doesn't remember how long it's been since he was shaved, but it was in therapy. He revealed he has not had a shower since he has been here but has only had a bed bath. The DON confirmed that the resident had long facial hair and stated, It looks like it's been a while since he was shaven. Resident #248 revealed he would like to be shaved at least every other day.
An interview, on 09/26/23 at 01:18 PM, with the DON revealed she believed the resident 100%. She stated, If he says he hasn't had a shower, then I can guarantee he is being truthful. The DON revealed they were having a grooming problem in the facility and would make sure this gets taken care of today.
A record review of Resident #248's MDS with an ARD of 09/18/23 revealed in Section C a BIMS score of 12, which indicated the resident had moderate cognitive impairment.
Resident #32
An observation, on 09/25/23 at 2:05 PM, of Resident #32 revealed long fingernails that measured three-eights (3/8) inch in length with a brown substance underneath. The resident revealed he would like to have his nails cut.
An interview and observation on 9/26/23 at 11:30 AM, with Certified Nurse Aide (CNA) #3 confirmed that Resident #32's nails were long and needed cleaning and clipping. She revealed that the long nails could cause skin concerns. She revealed that the aides were responsible for cleaning the nails when needed. Furthermore, she revealed they could also trim the nails if the resident was not a diabetic.
An interview, on 9/26/23 at 11:35 AM, with the DON confirmed that Resident #32's nails were long and needed cleaning and cutting. She confirmed that the long nails could result in skin concerns. She revealed the aides were responsible for cleaning and trimming the residents' nails, since he was not a diabetic.
Record review of the admission Record revealed Resident #32 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Vascular Dementia and Personal History of Transient Ischemic Attack.
Record review of the MDS with an ARD of 8/23/23 revealed, under section G, that Resident #32 requires one-person physical assistance with personal hygiene. Section C revealed , a BIMS score of 07, which indicates the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident/staff interview, record review, and facility policy review the facility failed to ensure medications were not left in the resident's room for one (1) of 28 sampled residents. Resident #4.
Findings include:
A review of the facility policy, titled 5.3 Storage and Expiration Dating of Medications Biologicals with a revision date of 08/07/23 revealed. Applicability: This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals. syringes and needles Procedure: . 3.3; Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors . #13 Bedside Medication Storage:13.1 - Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration.13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room .
An observation and interview, on 09/25/23 at 01:58 PM, revealed a Ventolin Inhaler and a Trelegy Ellipta inhaler sitting on the overbed table inside a styrofoam cup. The Resident confirmed that he uses the inhalers himself. Resident #4 confirmed that he uses the Trelegy Ellipta Inhaler one time a day and that he uses the Ventolin Inhaler sometimes two times a day and sometimes he doesn't use it at all.
A record review, for Resident #4 revealed there was no self administration medication assessment, physician orders, or care plan for self-administration of medication.
An interview, on 09/26/23 at 01:40 PM, with Licensed Practical Nurse (LPN)#1 confirmed that there was a Trelegy Ellipta Inhaler and a Ventolin Inhaler inside of a styrofoam cup sitting on Resident #4 overbed table and that it's not supposed to be there.
An interview, on 09/26/23 at 02:00 PM, with Registered Nurse (RN)#1 confirmed there was a Trelegy Ellipta inhaler and a Ventolin inhaler inside of a styrofoam cup sitting on Resident #4's overbed table and that it's not supposed to be there. RN #1 confirmed that Resident #4 had not been assessed for self-administration of medication. RN#1 confirmed that the Trelegy Ellipta inhaler is scheduled to be given at 09:00 AM daily. RN #1 confirmed that the Trelegy Ellipta Inhaler has only been signed off as given five times this month on the Medication Administration Record (MAR), and if it isn't documented as being given that it was not done. RN #1 confirmed that inhaler is being given after 03:00 PM when the Respiratory Therapist comes in. RN#1 confirmed that the order for the Trelegy Ellipta inhaler order that is scheduled for 09:00 AM should have been changed to reflect a new time, to be given after 03:00 PM but has not been changed, and that the inhalers should be locked in medication cart until medication is given. RN#1 confirmed that if a resident wandered into Resident #4's room they could get the medication and cause harm to themselves, and that Resident #4 could possibly take too much medication.
An interview, on 09/26/23 at 03:00 PM, with the Director of Nursing (DON) confirmed that the inhalers should be locked inside medication carts and that nurse should be administering them and that the nurses should have noticed the medication Resident #4 room.
A review of the admission Record for Resident #4 revealed that he was admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Hypertension, and Type Two Diabetes.
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #4 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by, missing biohazard containers in one (1) of nine (9) transmission based precaution rooms, failure to disinfect rooms that required specialized cleaning and appropriate chemicals related to a specific organism for three (3) of nine (9) resident rooms, allowing a urinary catheter bag to lie on the floor, attempting to use contaminated oxygen tubing from the floor on a tracheostomy humidifier and attempting to use a soiled washcloth during catheter care for one (1) of six (6) care observations. Resident #8, #54, #75 and #81.
Findings include:
Review of the facility policy titled, Isolation-Initiating Transmission-Based Precautions with a revised date of August 2019, revealed 3 .When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): f. Ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and g. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room.
Record review of facility's Policies and Procedures Subject: Catheter Care, Urinary, dated 9/5/17, revealed, Wash perineal area with soap and water from front to back. Rinse well and dry.
Record review of the facility policy titled Contaminated Isolation Room Cleaning with a revision date of 10/25/16 revealed, under, B. Enter the Isolation Room - To protect the facility from the patient, every effort is made to keep the bacteria in the room and isolated in the double bag procedure along with using the EPA approved solution .
Record review of facility's letterhead revealed, This facility does not have a policy on positioning and placement of catheter bags.
An interview, with Licensed Practical Nurse (LPN) #3 on 9/25/23 at 11:04 AM, revealed Resident #8 was in contact isolation due to testing positive for Candida Auris.
During an observation and interview with Certified Nursing Assistant (CNA) #7 and LPN #3, on 9/26/23 at 9:08 AM, revealed Resident #8's catheter bag was attached to the side of the bed, but the bottom third of the bag was touching the floor. CNA) #7 confirmed the catheter bag for Resident #8 was on the floor and stated that just happens when the bed is low. LPN #3 revealed the urinary catheter bag was not to touch the floor even if the bed was in low position. She confirmed this was an infection control concern that could lead to an infection to the resident.
During an interview on 9/26/23 at 2:55 PM, the Director of Nursing stated Resident #8 was admitted to the facility on [DATE], and was diagnosed with Candida Auris prior to admission and was placed in contact isolation on admission.
During an observation and interview on 9/27/23 at 10:00 AM, with CNA #4, revealed her gathering her linen and other supplies and donned her Personal Protective Equipment (PPE) since Resident #8 was in contact isolation. She obtained her soapy cleansing solution in one basin and water in another basin for her perineal/catheter care and preceded with the resident's care. She cleaned the groin area and stool was still noted to be on the washcloth. She proceeded to rinse, even though stool was still being obtained on the cloth. During the care, she noted that the resident's oxygen tubing was disconnected from the tracheostomy (trach) humidifier tubing/collar and the oxygen tubing was on the floor, so she picked the tubing up off of the floor (with dirty gloves still in place) and began to reach for trach humidifier collar tubing to reattach. The SA stopped her at this point and requested she get Respiratory Therapy to change the tubing and not place a tubing that was on the floor onto the resident's trach humidifier mist/trach collar. She then acknowledged that this could lead to an infection for the resident. Respiratory Therapy came into room and replaced oxygen tubing and repositioned the resident's head into a comfortable position. CNA #4 resumed catheter care. While providing care, she reached into the soiled linen red bag and removed a previously used wash cloth and placed it in the soapy water basin and approached the resident. SA once again stopped her and told her that cloth was from the dirty linen bag. She stated Oh no, I grabbed the wrong one. She confirmed this was a major infection control risk. She emptied the basin and got a clean basin and proceeded to make the warm soapy solution. Then once again she proceeded with care and completed care without other incident. After the catheter care, CNA #4 confirmed she messed up with infection control concerns. She stated she knows what to do, but she was nervous and was not thinking it through. She stated good infection control is needed to protect the residents and to keep germs from spreading to others.
During an interview on 9/27/23 at 10:40 AM, the Director of Nursing (DON) confirmed the facility failed to prevent the likelihood of the spread of infection by not using appropriate infection control measures during a resident's catheter care.
During an interview on 9/27/23 at 2:50 PM, the DON confirmed the cleanser for room disinfectant used by the facility did not cover the Candida Auris organism, therefore, there was a risk of spreading the infection to others.
Record review of Resident #8's Laboratory Services document dated 6/27/23 revealed the results of the axilla and groin swab for resident detected Canada Auris Deoxyribonucleic acid (DNA) detected.
Record review of Order Summary Report Physician's Order for Resident #8 dated 8/28/23, revealed with indwelling catheter and assess for catheter care every shift and as needed by Certified Nursing Assistant.
Record review of Order Summary Report for Resident #8 revealed an order dated 8/14/23 for contact isolation due to Candida Auris.
Record review of letter from the Director of Nursing, undated, revealed, (Proper name of Resident #8) was admitted on [DATE] to our facility. She admitted with a diagnosis of Candida Auris. She was immediately placed on Transmission Based Precautions with all measures put in place. However, the isolation order was not entered/transcribed until 8/14/23. Staff has implemented all TBP (Transmission Based Precautions) since admission.
Record review of admission Record for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Nontraumatic Intracerebral Hemorrhage, Tracheostomy, Type 2 Diabetes Mellitus, Stage 3 Pressure Ulcer to Sacral Region, Gastrostomy Status.
Record review of Resident #8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/31/23 revealed in Section C, Resident #8 was rarely or never understood which indicated the resident was severely cognitively impaired.
Resident #54
An observation on 09/25/23 at 10:40 AM, revealed an isolation cart outside of room Resident #54's room. There were no red barrels for disposal of linen and trash in the resident's room.
An interview with LPN #3 on 9/25/23 at 10:40 AM, revealed Resident #54 was ordered to be in contact isolation for Carbapenem Resistant Acinetobacter Baumannii (CRAB). She confirmed this resident needed red barrels in the room for disposal of used linen and trash and this resident did not have these available in his room. She stated the proper disposal of trash and proper handling of linen was needed to prevent the spread of infections. She stated she had not noticed the barrels were missing from this room and she was unsure how the staff were disposing of these items.
During an interview on 9/27/23 at 2:55 PM, the DON confirmed the facility failed to ensure the proper handling of the used linen and trash of a resident in contact isolation. She confirmed for effective infection control, it is necessary to have the proper supplies available to decrease the likelihood of the spread of infection and the facility failed to do this. She stated red barrels in the rooms were required for residents in contact isolation and she was unsure why these were not in this resident's room, but that they could have been removed for a newly diagnosed Covid-19 positive resident.
Record review of Resident #54's Order Summary Report Physician's Order dated 1/12/23 revealed an order for Isolation: Contact - CRAB - All care/medications provided in room every shift for Carbapenem Resistant Acinetobacter Baumannii.
Record review of Interdisciplinary Progress Notes, undated, revealed, Received CRAB results 11/22/22 on (proper name of Resident #54) results positive and resident was immediately placed on transmission based precautions.
Record review of Resident #54's admission Record revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included Nontraumatic Subarachnoid Hemorrhage from Unspecified Intracranial Artery.
Record review of the MDS with an ARD of 8/14/23 revealed in Section C, Resident #54 was rarely or never understood which indicated the resident was severely cognitively impaired.
An observation on 09/26/23 at 09:15 AM, outside Resident #81's room, revealed an isolation cart with personal protective equipment (PPE) inside. A small magnetic sign was attached to the outer casing of the doorway that read, Contact Precautions.
An interview on 9/26/23 at 9:30 AM with LPN #2 revealed that Resident #81 was in contact isolation for Candida Auris. She revealed that staff must dress out in a gown and gloves to provide care and perform handwashing or hand sanitizer before and after care.
An interview on 9/26/23 at 10:55 AM with Housekeeping #1 revealed that she used the cleaning solution Virex Plus to clean the surfaces and room of Resident #81 that was on contact isolation. She revealed she sprayed down the surfaces of the room including knobs, tables, side rails, bed (all surfaces) with the cleaning solution and allowed it to sit five (5) minutes before wiping it down with a clean cloth.
An interview, with the DON on 9/26/23 at 3:30 PM revealed all residents currently with a diagnosis of Candida Auris were admitted into the facility with the organism Candida Auris (C. Auris). She revealed that none of the residents have had any symptoms, and they have not had any other cases spread inside the facility. She revealed the residents were placed on contact isolation when admitted from the hospital.
An interview, with the DON on 9/26/23 at 4:45 PM, revealed that she had reached out to the Environmental Regional Manager and the Virex Plus solution was not effective against the organism, Candida Auris. She revealed that they had Sani-Cloth Germicidal Wipes at the facility that could be used for now. She confirmed that the facility had not been using the Sani-Cloth wipes and that cleaning with a disinfectant (Virex Plus) that was not effective against the organism could lead to the spread of the infection. She revealed the facility had not had any in-house outbreaks of C.Auris.
An interview, with Housekeeping #2 on 9/27/23 at 8:45 AM revealed she used the Virex Plus for disinfecting the isolation rooms and allowed a 5-minute wait time for room surfaces and then wiped it down.
An interview, with Housekeeping #3 on 9/27/23 at 9:05 AM revealed she sprayed the Virex Plus solution onto a cloth and wiped down all the surfaces of the room.
An interview with the Environmental District Manager on 9/27/23 at 9:25 AM, confirmed that the Virex Plus solution was not effective against the organism Candida Auris (C. Auris). He revealed that he was not made aware that the facility had C. Auris in the building until yesterday, when this State Agent (SA) requested the Safety Data Sheet on Virex Plus. He revealed he was not sure who at the facility was responsible for reaching out to him to ensure the effective disinfectant was in the facility and being used. He revealed the facility could use the Sani-Hands and use bleach to mop. He confirmed that not cleaning with an ineffective disinfectant could lead to the spread of infection inside the facility.
An interview with the Administrator (ADM) on 9/27/23 at 9:40 AM, revealed that she had been working at the facility for three (3) weeks and was not aware of the residents residing at the facility with C. Auris until yesterday. She acknowledged that using an ineffective disinfecting cleaner could lead to the spread of infection.
An interview with the DON on 9/27/23 at 4:50 PM, revealed that she would have been the person responsible for contacting the Environmental District Manager to ensure that the facility cleaning/disinfecting products used were effective against C. Auris. She confirmed that ineffective cleaning products could lead to the spread of infection.
An interview with the Mississippi State Department of Health (MSDH) Epidemiology Division on 9/28/23 at 8:15 AM, with Pharmacist #1 regarding the facility use of Virex Plus for the organism Candida Auris revealed that Virex Plus does not kill the Candida Auris organism.
Record review of the Education In-service Attendance Record revealed a training session was conducted on 8/10/23 regarding C. Auris -isolation and revealed under, Candida auris Positive . All disinfection should be completed with an Environmental Protection Agency (EPA) registered disinfectant effective against Candida auris (List P).
Record review of the Infection Control Log from the dates of 1/01/23 through 9/27/23 revealed that Resident #81 was admitted to the facility with Candida Auris on 1/19/23.
Record review of the admission Record revealed that Resident #81 was admitted to the facility on [DATE] with medical diagnoses that included Metabolic Encephalopathy, Type 1 Diabetes Mellitus with Hyperglycemia and Generalized Anxiety Disorder.
Record review of the MDS an ARD of 7/12/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score was not conducted due to Resident #81 is rarely/never understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and facility policy review the facility failed to honor a resident's dignity as evidence by posting a sign on a resident's door concerning care for one (1) of 96 residents residing in the facility. Resident # 81
Findings include:
Record review of the facility policy titled Notice Of Privacy Practices undated, revealed under, Our Responsibilities: Our nursing facility is required to: Maintain the privacy of your health information .
An observation, of Resident #81's room door on 09/25/23 at 10:48 AM, revealed a sign posted that read, Patient to wear helmet at all times. The resident was observed sitting in a wheelchair in her room and was unable to communicate verbally.
An observation, of Resident #81's room door on 9/26/23 at 9:15 AM confirmed a sign posted that read, Patient to wear helmet at all times and three (3) identical signs posted on the walls in the resident's room that read, Patient to wear helmet at all times.
An interview on 9/26/23 at 11:08 AM, with Licensed Practical Nurse (LPN) # 2 confirmed a sign posted on Resident #81's door that read, Patient to wear helmet at all times and LPN confirmed that it should not be posted visible to the public. She revealed posting clinical information on the door was a privacy issue.
An interview with Registered Nurse (RN) #2 on 9/26/23 at 11:12 AM, confirmed the sign posted on Resident #81's door. She revealed that the sign was private care information that should not be visible to the public due to honoring residents' privacy.
An interview with the Director of Nursing (DON) on 9/26/23 at 11:40 AM, revealed Resident #81's care information should not be posted on the door and she confirmed it was a privacy concern.
Record review of the admission Record revealed that Resident #81 was admitted to the facility on [DATE] with medical diagnoses that included Metabolic Encephalopathy, Major Depressive Disorder, Generalized Anxiety Disorder, Pseudobulbar Affect and Alcohol Abuse with Alcohol-Induced Psychotic Disorder.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/12/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score was not conducted due to Resident #81 is rarely/never understood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and facility policy review, the facility failed to follow up on a grievance from Resident Council meetings related to answering call lights in a timely manner for two (2) of 10 residents in the Resident Council Meeting. Resident #39 and #66
Findings include:
Record review of facility policy titled Policies and Procedure - Subject: Complaint/Grievance, dated 11/30/14, revealed, The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution
Resident Council meeting was held with State Agency on 9/26/23 at 3:00 PM with 10 residents present.
An interview on 9/26/23 at 3:00 PM, at the Resident Council meeting revealed Resident #39 (Resident Council President) and Resident #66 had concerns that the call lights were not always answered timely. They both stated that this concern had been mentioned in previous Resident Council meetings and they did not receive a resolution or follow-up for this grievance. They also stated that it had improved in the past, but they were now having concerns again. The other eight residents attending the meeting revealed they had no concerns with their call lights being answered timely.
An interview with the Activity Director on 9/26/23 at 3:40 PM, revealed the residents had mentioned the call lights not being answered timely several times in Resident Council meetings and the department head was notified.
During an interview on 9/27/23 at 3:00 PM, the Director of Nursing (DON) confirmed she was aware of the ongoing concern of the call lights not being answered timely. She confirmed it is the facility's responsibility to follow up on all grievances and the facility failed to discuss a resolution and follow-up with the council members concerning the grievance.
Record review of Resident Council minutes dated 7/26/23, revealed, several concerns related to call lights.
Record review of Resident Council minutes dated 8/24/23, revealed a concern with call lights was mentioned.
Record review of the admission Record for Resident #39 revealed she was admitted to the facility on [DATE].
Record review of Resident #39's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.
Record review of the admission Record for Resident #66 revealed she was admitted to the facility on [DATE].
Record review of Resident #66's MDS with ARD of 8/22/23 revealed a BIMS score of 15 which indicated the resident was cognitively intact.

Based on resident and staff interviews and facility policy review, the facility failed to deliver mail to the residents on Saturday for 10 of 10 residents in Resident Council, with the potential to affect all residents.
Findings include:
Record review of Information Handbook dated 1/22, revealed, Mail: We deliver mail to your room daily with the exception of Sunday. All mail is delivered to you unopened unless otherwise authorized. The handbook also revealed, You have the right to: privacy in written and spoken communication; send and promptly receive unopened mail.
Interviews during the Resident Council meeting on 9/26/23 at 3:00 PM, with 10 residents present revealed they received their mail unopened, but did not receive it on Saturdays, because the mail was not delivered to the facility on Saturday. They stated during the week, the front office Receptionist or the Activity Director delivered the mail and packages to the residents.
An interview with the front office Receptionist on 9/26/23 at 3:35 PM, revealed on Monday through Friday, the mail was delivered from the Post Office to the facility. She stated the facility had informed the Post Office to not deliver mail on Saturdays since there was no one in the office to deliver it to the residents.
An interview, with the Activity Director on 9/26/23 at 3:40 PM, revealed the mail was delivered to the facility on Monday through Friday, but not on the weekends. She stated the Post Office does not deliver mail to the facility on Saturday.
During an interview on 9/26/23 at 3:45 PM, the Director of Nursing (DON) confirmed the facility had a Saturday mail delivery hold with the Post Office and the mail was not delivered to the facility on that day. She confirmed the facility failed to honor the residents' right to receive their mail and packages on Saturday.

Based on interview, record review and facility policy review, the facility failed to report an incident of neglect to the appropriate licensing agencies for one (1) of three (3) reportable incidents reviewed. Resident #1.
Findings include:
Record review of the facility's Policies and Procedures: Subject: Reporting Reasonable Suspicion of a Crime with revision dated 10/24/2022 revealed .Procedure: 3. Where an alleged violation of abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries will be made to the executive director, to the State Survey Agency, and to local law enforcement .
In an interview with the Administrator and Director of Nurses (DON) on 7/18/23 at 10:00 AM, the Administrator revealed that he had not reported the incident of Resident #1 not getting wound care on 7/8/23, 7/9/23 and 7/10/23 to any of the State licensing agencies. DON stated that Resident #1 is the resident that went to the wound care center on 7/11/23 and had a dressing on his wound dated 7/7/23. She stated that the wound care clinic contacted her letting her know the date on the dressing and that Resident #1 is being sent to the emergency room (ER) at the local hospital for evaluation. He stayed overnight and returned to the facility on 7/12/23. The Administrator stated they began an investigation, inserviced staff and did a Quality Assurance emergency meeting but did not report the incident. We were training a new treatment nurse, RN #2 on those days. When questioned she said she did that wound care. She finally admitted during the investigation that she didn't do the wound care.
An interview with RN #2 on 7/18/23 at 11:10 AM, she stated On 7/10/23, I did not do treatments on him (Resident #1). She then stated It was a couple (of treatments) I didn't do that Monday.
In an interview with Resident #1 on 7/18/23 at 10:45 AM, revealed that he did not have wound care performed on 7/17/23. He also confirmed that on the weekend before, his wound care was not done for four (4) days. He confirmed the dates were 7/8/23, 7/9/23, and 7/10/23.
Record review of the admission Record revealed the facility admitted Resident #1 on 8/25/22 with diagnoses including Peripheral Vascular Disease, Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity and Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, record review and policy/procedure review, the facility failed to implement the comprehensive care plan for four (4) of ten (10) residents, Resident #1, Resident #2, Resident #3, and Resident #4, as evidenced by Resident #1 did not receive wound treatments on 7/8/23, 7/9/23, 7/10/23,and 7/17/23, and Resident #2, Resident #3, Resident #4 did not receive their pressure sore treatments on 7/17/23.
Findings include:
Record review of the facility's policy/procedure for Plans of Care, last revised 9/25/2017, revealed Procedure: Develop and implement an individualized person-centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident and to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS).
An interview at 10:00 AM on 7/18/23, with the Director of Nurses (DON) and Administrator, revealed the DON stated that Resident #1 is the resident that went to the wound care center on 7/11/23 and had a dressing on his wound dated 7/7/23. She stated that the wound care clinic contacted her letting her know the date on the dressing. We were training a new treatment nurse, RN #2 on those days. She finally admitted during the investigation that she didn't do the wound care. The DON stated that care plans are supposed to be followed by all staff.
An interview with Licensed Practical Nurse (LPN) #1 on 7/18/23 at 10:30 AM, revealed there were other residents that had dressings dated for 7/16/23 and not 7/17/23 as she anticipated she would see on the morning of 7/18/23. She stated Resident #1 and Resident #2's dressings were not dated and they told LPN #1 their wound care was not done on 7/17/23. Resident #3 and Resident #4's wound dressings were dated 7/16/23.
An interview with RN #2 on 7/18/23 at 11:10 AM, revealed It was a couple (of treatments) I didn't do that Monday. I didn't tell anyone I had not done the treatments. I did not ask for help from another nurse.
Resident #1
Record review of Resident #1's care plan revealed, Focus: I have arterial ulcer to my Lateral Inferior RLE (right lower extremity), I have Arterial ulcer to my Posterior LLE (left lower extremity) .Interventions: WOUND CARE: Arterial ulcer to Lateral RLE - Cleanse with Dakins, pat dry with 4x4 gauze, cover with silvercel, Cover with ABD pad, wrap with kerlix and secure with tape daily and PRN (as needed) soiled/dislodged dressing every day shift . and WOUND CARE: Arterial Ulcer to Lateral LLE - Cleanse with Dakins, pat dry with 4x4 gauze, cover with silvercel wound bed followed by Maxsorb AG, Cover with ABD pad, wrap with kerlix and secure with tape daily and PRN soiled/dislodged dressing every day shift .
An interview with the Administrator on 7/18/23 at 10:00 AM revealed he went to visit Resident #1 this morning and Resident #1 stated his wound care was not done on 7/17/23. He then went to talk to Licensed Practical Nurse (LPN) #1 that was doing treatments on 7/18/23. She told him that when she did wound care on Resident #1 this AM that the dressing was not dated and he stated his wound care was not done on 7/17/23.
Interview with RN #2 on 7/18/23 at 11:10 AM, She stated On 7/10/23, I did not do treatments on him (Resident #1). I was the treatment nurse that day. Yes, I was the treatment nurse yesterday (7/17/23). His treatment didn't get done yesterday. I did not let anyone know. It was a lack of communication on my part.
An interview with Resident #1 on 7/18/23 at 10:45 AM, revealed that he did not have wound care performed on 7/17/23. He also confirmed that on the weekend before, his wound care was not done for four (4) days. He confirmed the dates were 7/8/23, 7/9/23, and 7/10/23.
Record review of the admission Record revealed the facility admitted Resident #1 on 8/25/22 with diagnoses including Peripheral Vascular Disease, Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity and Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact.
Resident #2
Record review of Resident #2's care plans revealed each Pressure Ulcer is care planned to administer treatments as ordered and monitor for effectiveness.
An interview with Resident #2 on 7/18/23 at 10:40 AM, she revealed that the new treatment nurse came into her room yesterday, told Resident #2 she'd be back to do her wound care and never returned. Resident #2 confirmed that her wound care did not get done yesterday.
Interview with RN #2 on 7/18/23 at 11:10 AM, regarding Resident #2, she stated, I did not do her treatment yesterday.
Record review of Resident #2's admission Record revealed an admit date of 3/13/23. She admitted with diagnoses including Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 2 and Pressure Ulcer of Left Buttock, Stage 4.
Record review of the MDS with an ARD of 6/12/23 revealed a BIMS score of 15 which indicated Resident #2 was cognitively intact.
Resident #3
Record review of the care plan revealed, Focus: I have a Stage 3 pressure ulcer to my left lateral distal foot .Interventions .Administer treatments as ordered and monitor for effectiveness .WOUND CARE: Cleanse stage 3 to Left lateral distal foot with wound cleanser or NS (normal saline), pat dry with 4x4 gauze, apply calcium alg AG, and bordered dressing daily and prn soiled/dislodged dressing every day shift .
An interview on 7/18/23 at 3:15 PM with Resident #3 he stated that his treatment was not done yesterday.
Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of other site, Stage 3.
Record review of the MDS with an ARD of 6/22/23 revealed a BIMS score of 15 which indicated Resident #3 was cognitively intact.
Resident #4
Record review of Resident #4's care plan revealed, Focus: I was admitted with a stage 4 pressure ulcer to my right trochanter .Interventions: . administer treatments as ordered and monitor for effectiveness.
An interview with RN #2 on 7/18/23 at 11:10 AM, regarding Resident #4, she stated, I did not do the treatment to his right hip.
An interview with Resident #4 on 7/18/23 at 2:00 PM, revealed that his wound care was not performed on 7/17/23.
Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Pressure ulcer of right hip, Stage 4.
Record review of Resident #4's admission MDS with an ARD of 7/24/23, Section C revealed a BIMS score of 12, indicating moderately impaired cognition.

Based on interview, record review, observation and policy/procedure review, the facility failed to provide needed care and services in accordance with professional standards of practice for one (1) of ten (10) sampled residents, Resident #1, as evidenced by Resident #1 did not receive wound treatments on 7/8/23, 7/9/23, 7/10/23, and 7/17/23.
Findings include:
Record review of a statement on facility letterhead and signed by the Administrator revealed, We do not have a specific policy on Following Physician Orders. This was undated.
Record review of the facility's policy/procedure for Plans of Care, last revised 9/25/2017, revealed Procedure: Develop and implement an individualized person-centered comprehensive plan of care by the Interdisciplinary Team .
On 7/18/23 at 10:00 AM, in an interview with the Director of Nurses (DON) and Administrator, the DON revealed that Resident #1 went to the wound care center on 7/11/23 with a dressing on his wound dated 7/7/23. She stated that the wound care clinic contacted her letting her know the date on the dressing and that Resident #1 is being sent to the emergency room (ER) of the local hospital for evaluation. He stayed overnight and returned to the facility on 7/12/23. We were training a new treatment nurse, RN #2 on those days. She admitted during the investigation that she didn't do the wound care. The facility was about to suspend or terminate her employment due to the new allegation of wound care not being completed the day before. The Administrator went to visit Resident #1 this morning and Resident #1 stated his wound care was not done on 7/17/23. He then went to talk to Licensed Practical Nurse (LPN) #1 that was doing treatments on 7/18/23. She told him that when she did wound care on Resident #1 this AM that the dressing was not dated and he stated his wound care was not done on 7/17/23.
On 7/18/23 at 10:30 AM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that Resident #1's dressing was not dated and he said his wound care had not been done on 7/17/23.
On 7/18/23 at 11:10 AM, in an interview with RN #2 she stated On 7/10/23, I did not do treatments on him (Resident #1). I was the treatment nurse the day. Yes, I was the treatment nurse yesterday (7/17/23). His treatment didn't get done yesterday. I did not let anyone know. It was a lack of communication on my part.
On 7/18/23 at 10:45 AM, during an interview with Resident #1 he revealed that he did not have wound care performed on 7/17/23. He also confirmed that on the weekend before, his wound care was not done for four (4) days. He confirmed the dates were 7/8/23, 7/9/23, 7/10/23.
Record review of the admission Record revealed the facility admitted Resident #1 on 8/25/22 with diagnoses including Peripheral Vascular Disease, Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity and Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity.
Record review of the Treatment Administration Record for July 2023 revealed wound care as Arterial ulcer to Lateral RLE cleanse with Dakins, pat dry with 4x4 gauze, cover with silvercel, Cover with ABD pad, wrap with kerlix and secure with tape daily and PRN . and Arterial Ulcer to Lateral LLE - Cleanse with Dakins, pat dry with 4x4 gauze, apply sivercel wound bed followed by Maxsorb AG, Cover with ABD pad, wrap with kerlix and secure with tape daily and PRN
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, record reviews and policy/procedure review, the facility failed to ensure that three (3) of 10 sampled residents received the necessary treatment and services, consistent with professional standards of practice for pressure ulcers, as evidence by Resident #2, Resident #3, Resident #4 did not receive their pressure sore treatments on 7/17/23.
Findings include:
Record review of the facility's policy/procedure for Skin and Wound, with a revision date of 1/24/2022 revealed Policy: To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure ulcers .
Licensed Practical Nurse (LPN) #1 reported during an interview on 7/18/23 at 10:30 AM, there were other residents that had dressings dated for 7/16/23 and not 7/17/23 as she anticipated she would see on the morning of 7/18/23. The SA obtained a list of residents that LPN #1 had performed the 7/18/23 wound care for and had on old dressings that were dated 7/16/23. The list indicated that Resident #2's wound dressings were not dated current. Resident # 2 told LPN #1 wound care was not done on 7/17/23. Resident #3 and Resident #4's wound care dressings were dated 7/16/23.
Resident #2
During an observation and interview with Resident #2 on 7/18/23 at 10:40 AM, revealed that the new treatment nurse came into her room yesterday, told Resident #2 she'd be back to do her wound care and never returned. Resident #2 confirmed that her wound care did not get done yesterday. She stated the new treatment nurse had performed her wound care before and has not had a problem with her until yesterday.
Observations of wound care with RN #1 on 7/19/23 at 10:45 AM, revealed multiple wounds. There are treatments for 4 wounds on her sacral, coccyx and bilateral buttocks but upon observation, there are 3 wounds noted. This was confirmed by RN #1. The wound on the coccyx is a Stage 4. It measures 5.0 cm L (centimeters/length) x (by) 6.0 cm W (width) x 7.4 cm D (depth). The wound bed is beefy in color. The right buttock inferior is a Stage 2 and measures 14.0 cm L x 8.7 cm W x 0.0 cm D. The left buttock wound is a Stage 2 and measures 4.2 cm L x 3.4 cm W x 0.0 cm D. She stated she is not going to do the treatment to the left heel due to that area is healed. She stated she is going to talk to the Medical Doctor (MD) or Nurse Practitioner (NP) to get the order discontinued due to it being healed at this time. She stated it was a Deep Tissue Injury that had a treatment begin on 7/4/23.
Interview with RN #2 on 7/18/23 at 11:10 AM, stated, I did not do her treatment yesterday. She gets Betadine on her foot, I believe. I was going to heal her wound today. I was going to get the CNA's to help me with positioning. I never did. I was going to wait to go with them on their incontinent rounds and I forgot.
Record review of the wound care orders were to Clean Stage 4 to coccyx with wound cleanser or NS (normal saline), pat dry with 4x4 gauze, pack wound with wet-dry dakins kerlix, cover with dry dressing daily and PRN (as needed). Cleanse Stage 4 to left buttock/sacrum with wound cleanser or NS (Normal Saline), pat dry with 4x4 gauze, apply CA+ alg AG (Calcium Alginate), cover with dry dressing daily and PRN (as needed). Cleanse Stage 2 to right buttock (inferior) with wound cleanser or NS, pat dry with 4x4 gauze, apply CA+ alg AG, cover with dry dressing daily and PRN.
Record review of Resident #2's admission Record revealed an admit date of 3/13/23. She admitted with diagnoses including Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 2 and Pressure Ulcer of Left Buttock, Stage 4.
Record review of the MDS with an ARD of 6/12/23 revealed a BIMS score of 15 which indicated Resident #2 was cognitively intact.
Resident #3
Observation and interview on 7/18/23 at 3:15 PM, with Resident #3 stated that his treatment was not done yesterday. Wound care observation revealed the wound is a Stage 3 on his left lateral foot. The measurements observed by the SA were 0.5 cm L x 0.3 cm W x 0.0 cm D.
Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Stage 3 pressure ulcer to left lateral distal foot.
Record review of the MDS with an ARD of 6/22/23 revealed a BIMS score of 15 which indicated Resident #3 was cognitively intact.
Record review of the Order Summary Report with active orders as of 7/20/23 revealed Wound Care: Cleanse stage 3 to left lateral distal foot with wound cleanser or NS, Pat dry with 4x4 gauze, apply calcium alg AG, and bordered dressing daily and PRN every day shift.
Resident #4
RN #2 stated in an interview on 7/18/23 at 11:10 AM, regarding Resident #4, I did the wound care on his toe on the left foot. The wound under his arm is healed and I don't think there is a treatment ordered. I did not do the treatment to his right hip because he said the last dressing fell off. There was a dressing on it. He said there was an extra dressing in his room, and they put it on his wound. He didn't say who 'they' were. So, I didn't redo the treatment.
Observations and interview on 7/18/23 at 2:00 PM, of Resident #4's wound care performed by RN#1 being assisted by RN #3 revealed Resident #4 has multiple wounds. The right hip Stage 4 pressure ulcer measured 5.0 cm L x 5.7 cm W with tunneling between 2:00-3:00 o'clock measured 1.4 cm D. The wound on his left medial foot is below his great toe measured 3.8 cm L x 2.4 cm W x 0.0 cm D. Hyper granulation is noted. Resident #4 revealed that his wound care was not performed on 7/17/23. He said he asked staff several times on 7/17/23 if the treatment nurse was in the facility and staff would tell him yes but he never saw her or spoke to her. I waited up until 10:00 PM last night on RN #2 but I went on to bed and figured she'd wake me up to do the treatment. I never spoke to RN #2 yesterday. I never even saw her.
Record review of the Order Summary Report with active orders as of 07/20/23 revealed Wound Care: Clean Stage IV (4) abrasion to Right Trochanter with wound cleanser or normal saline and gauze daily: dry the peri-wound skin and place skin proctetant .Place santyl on slough of wound base;Dampen non-stretch gauze with 1/4 strength Dakin's solution and fan to cover wound bed ONLY;fill the volume of the wound with FLUFFED (not stuffed) with the least amount of gauge. Cover with ABD pad and secure. Wound Care: Cleanse abrasion to left medial foot below great toe with wound cleanser or normal saline daily and PRN;cover with meplix dressing every day shift .
Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Pressure ulcer of right hip, Stage 4.
Record review of the MDS with an ARD of 7/24/23 revealed a BIMS score of 12 which indicated Resident #4 had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy/procedure review the facility failed to ensure staff provided competent care as ordered by the physician for four (4) of ten (10) residents. Resident #1 did not receive wound treatments on 7/8/23, 7/9/23, 7/10/23 and on 7/17/23 and Resident #2, Resident #3, and Resident #4 did not receive their pressure sore treatments on 7/17/23.
Findings include:
Record review of the facility's policy/procedure for Skin and Wound, last revised 1/24/2022 revealed .To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .
During an interview on 7/18/23 at 10:00 AM, with the Director of Nurses (DON) and Administrator, the DON stated that Resident #1 went to the wound care center on 7/11/23 and had a dressing on his wound dated 7/7/23. She stated that the wound care clinic contacted her letting her know the date on the dressing and that Resident #1 was being sent to the emergency room (ER) at (Name of local hospital) for evaluation. He stayed overnight and returned to the facility on 7/12/23. When the State Agency (SA) questioned the DON about RN #2, she said she did that wound care. She finally admitted during the investigation that she didn't do the wound care. During this interview, the DON stated that the facility was about to suspend or terminate her employment due to the new allegation of wound care not being completed the day before. The Administrator stated he went to visit Resident #1 this morning and Resident #1 stated his wound care was not done on 7/17/23. He then went to talk to Licensed Practical Nurse (LPN) #1 that was doing treatments on 7/18/23. She told him that when she did wound care on Resident #1 this morning that the dressing was not dated and Resident #1 stated his wound care was not done on 7/17/23.
During an interview on 7/18/23 at 10:30 AM, LPN #1 reported there were other residents that had dressings dated for 7/16/23 and not 7/17/23 as she anticipated she would see on the morning of 7/18/23. The SA obtained a list of residents that LPN #1 had performed the 7/18/23 wound care for and had on old dressings that were dated 7/16/23. The list indicated that Resident #1 and Resident #2's wound dressings were not dated current.
In an interview with RN #2 on 7/18/23 at 11:10 AM, revealed she began employment at this facility on 7/7/23. She was to shadow the treatment nurse over the weekend of 7/8/23, 7/9/23, and 7/10/23. She stated she was hired as the RN treatment nurse. She would do measurements and assessments of wounds weekly. She was responsible for giving the weekly measurements to the DON for the weekly wound log. She stated she was assisting the weekend treatment nurse doing treatments. On 7/9/23 I did treatments for ½ the day. On 7/10/23, Sunday, I came in around 5:00 PM that day. The treatment nurse here that day had to leave early. She stated, On 7/10/23, I did not do treatments on him (Resident #1). I was the treatment nurse that day. My initials are not on the Treatment Administration Record (TAR). I didn't chart any treatments for Monday due to a computer problem. It was a couple of treatments I didn't do that Monday. I was the treatment nurse yesterday (7/17/23). His treatment didn't get done yesterday. I did not let anyone know. It was a lack of communication on my part. I did look at his legs and both dressings were on. I didn't check the dates on the dressings but they were not soiled through.
Resident #1
During an interview with Resident #1 on 7/18/23 at 10:45 AM, revealed that he did not have wound care performed on 7/17/23. He also confirmed that on the weekend before his wound care was not done. He confirmed the dates his wound care was not completed were 7/8/23, 7/9/23 and 7/10/23.
Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses the included Peripheral Vascular Disease and Unspecified atherosclerosis of native arteries of extremities, bilateral legs.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact.
Resident #2
On 7/18/23 at 10:40 AM, during an interview with Resident #2 revealed that the new treatment nurse came into her room yesterday and told Resident #2 she'd be back to do her wound care and never returned. Resident #2 confirmed that her wound care did not get done yesterday. She stated the new treatment nurse had performed her wound care before and has not had a problem with her until yesterday.
In an interview with RN #2 on 7/18/23 at 11:10 AM, RN #2 revealed I did not do her treatment yesterday. She gets Betadine on her foot, I believe. I was going to heal her wound today. I was going to get the CNA's to help me with positioning. I never did. I was going to wait to go with them on their incontinent rounds and I forgot. She then confirmed, I can't remember anyone else's treatment I didn't do. I didn't tell anyone I had not done the treatments. I did not ask for help from another nurse.
Record review of Resident #2's admission Record revealed an admit date of 3/13/23. She admitted with diagnoses including Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 2 and Pressure Ulcer of Left Buttock, Stage 4.
Record review of the MDS with an ARD of 6/12/23 revealed a BIMS score of 15 which indicated Resident #2 was cognitively intact.
Resident #3
Interview on 7/18/23 at 3:15 PM, with Resident #3 revealed that his treatment was not done yesterday.
Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Stage 3 pressure ulcer to left lateral distal foot.
Record review of the MDS with an ARD of 6/22/23 revealed a BIMS score of 15 which indicated Resident #3 was cognitively intact.
Resident #4
During an interview with RN #2 on 7/18/23 at 11:10 AM, regarding Resident #4, she stated, I did not do the treatment to his right hip because he said the last dressing fell off. There was a dressing on it. He said there was an extra dressing in his room, and they put it on his wound, He didn't say who 'they' were. So I didn't redo the treatment.
During an interview with Resident #4 on 7/18/23 at 2:00 PM, revealed that his wound care was not performed on 7/17/23. He said he asked staff several times on 7/17/23 if the treatment nurse was in the facility and staff would tell him yes but he never saw her or spoke to her. I waited up until 10:00 PM last night on RN #2 but I went on to bed and figured she'd wake me up to do the treatment. I never spoke to RN #2 yesterday. I never even saw her.
Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Pressure ulcer of right hip, Stage 4.
Record review of the MDS with an ARD of 7/24/23 revealed a BIMS score of 12 which indicated Resident #4 had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy/procedure review, the facility failed to protect four (4) of ten (10) residents, Resident #1, Resident #2, Resident #3 and Resident #4, from neglect as evidenced by Resident #1 did not receive wound treatments on 7/8/23, 7/9/23, 7/10/23 and on 7/17/23 and Resident #2, Resident #3, Resident #4 did not receive their pressure sore treatments on 7/17/23.
Findings include:
Record review of the facility's policy/procedure for Abuse, Neglect, Exploitation & Misappropriation, last revised 11/16/2022, revealed Neglect is the failure of the center, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
Interview at 10:00 AM on 7/18/23, with the Director of Nurses (DON) and Administrator, the DON stated that Resident #1 is the resident that went to the wound care center on 7/11/23 and had a dressing on his wound dated 7/7/23. She stated that the wound care clinic contacted her letting her know the date on the dressing and that Resident #1 is being sent to the emergency room (ER) at the local hospital for evaluation. He stayed overnight and returned to the facility on 7/12/23. The DON stated the wound care clinic said something about Resident #1's antibiotic therapy. They had called us with culture results and our Nurse Practitioner (NP) ordered Bactrim DS times 10 days. We were training a new treatment nurse, Registered Nurse (RN) #2 on those days. The DON stated RN#2 finally admitted during the investigation that she didn't do the wound care. During this interview, the DON stated that RN#2 was in the facility. The facility was about to suspend or terminate her employment due to the new allegation of wound care not being completed the day before. The Administrator revealed he went to visit Resident #1 this morning and Resident #1 stated his wound care was not done on 7/17/23. He stated he went and let the DON know what Resident #1 had said. He then went to talk to Licensed Practical Nurse (LPN) #1 who was doing treatments on 7/18/23. She told him that when she did wound care on Resident #1 this AM that the dressing was not dated and Resident #1 stated his wound care was not done on 7/17/23.
Interview with LPN #1 on 7/18/23 at 10:30 AM, revealed there were other residents that had dressings dated for 7/16/23 and not 7/17/23 as she anticipated she would see on the morning of 7/18/23. The SA obtained a list of residents that LPN #1 had performed the 7/18/23 wound care for and had on old dressings that were dated 7/16/23. That list revealed that Resident #1 and Resident #2's dressings were not dated. These residents have a Brief Interview for Mental status (BIMS) score above 10 and are interviewable. They told LPN #1 their wound care was not done on 7/17/23. Resident #3 and Resident #4's wound dressings were dated 7/16/23.
Interview with RN #2 on 7/18/23 at 11:10 AM, revealed she began employment at this facility on 7/7/23. She was to shadow the treatment nurse over the weekend of 7/8/23, 7/9/23, and 7/10/23. She stated she was hired as the RN treatment nurse. She would do measurements and assessments of wounds weekly. She was responsible for giving the weekly measurements to the DON for the weekly wound log. She stated she has done treatments in other facilities. She stated she was becoming familiar with the supplies used by this facility, getting familiar with their computer system and that she was assisting the weekend treatment nurse doing treatments. On 7/9/23, I did treatments for ½ the day. On 7/10/23, Sunday, I came in around 5:00 PM that day. The treatment nurse here that day had to leave early. The DON was in the facility and did treatments until I could get here. She stated, On 7/10/23, I did not do treatments on him (Resident #1). I was the treatment nurse the day. My initials are not on the Treatment Administration Record (TAR). I didn't chart any treatments for Monday due to a computer problem. She then stated, It was a couple (of treatments) I didn't do that Monday. Yes, I was the treatment nurse yesterday (7/17/23). I came in at 10:15 AM on 7/17/23. I went in as lunch was being served. Resident #1 said to wait for him to eat. I missed the time when the Certified Nurse Aides (CNA) were doing rounds for incontinent care. They help with positioning for him and other residents. His treatment didn't get done yesterday. I did not let anyone know. It was a lack of communication on my part. Regarding Resident #4, she stated, I did not do the treatment to his right hip because he said the last dressing fell off. There was a dressing on it. He said there was an extra dressing in his room, and they put it on his wound. He didn't say who they were so I didn't redo the treatment. Regarding Resident #2, she stated, I did not do her treatment yesterday. I was going to get the CNA's to help me with positioning. I never did. I was going to wait to go with them on their incontinent rounds and I forgot. She then confirmed, I didn't tell anyone I had not done the treatments. I did not ask for help from another nurse.
Resident #1
Interview with Resident #1 on 7/18/23 at 10:45 AM, revealed that he did not have wound care performed on 7/17/23. He also confirmed that on the weekend before, his wound care was not done for four (4) days. He confirmed the dates were 7/8/23, 7/9/23, and 7/10/23. He stated he went to the wound care clinic on 7/11/23, got his wound care done while at the clinic then was sent to the ER and admitted to the hospital overnight.
Record review of the admission Record revealed the facility admitted Resident #1 on 8/25/22 with diagnoses including Peripheral Vascular Disease, Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity and Non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact.
Resident #2
Interview with Resident #2 on 7/18/23 at 10:40 AM, she revealed that the new treatment nurse came into her room yesterday, told Resident #2 she'd be back to do her wound care and never returned. Resident #2 confirmed that her wound care did not get done yesterday. She stated the new treatment nurse had performed her wound care before and has not had a problem with her until yesterday.
Record review of Resident #2's admission Record revealed an admit date of 3/13/23. She admitted with diagnoses including Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Buttock, Stage 2 and Pressure Ulcer of Left Buttock, Stage 4.
Record review of the MDS with an ARD of 6/12/23 revealed a BIMS score of 15 which indicated Resident #2 was cognitively intact.
Resident #4
Interview with Resident #4 on 7/18/23 at 2:00 PM, revealed that his wound care was not performed on 7/17/23. He stated that his wound care has been performed daily until yesterday. He said he asked staff several times on 7/17/23 if the treatment nurse was in the facility and staff would tell him yes but he never saw her or spoke to her. I waited up until 10:00 PM last night on RN #2 but I went on to bed and figured she'd wake me up to do the treatment. I never spoke to RN #2 yesterday. I never even saw her.
Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Pressure ulcer of right hip, Stage 4.
Record review of Resident #4's admission MDS with an ARD of 7/24/23, Section C revealed a BIMS score of 12, indicating moderately impaired cognition.
Resident #3
Interview on 7/18/23 at 3:15 PM, with Resident #3, he stated that his treatment was not done yesterday.
Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of other site, Stage 3.
Record review of the MDS with an ARD of 6/22/23 revealed a BIMS score of 15 which indicated Resident #3 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policy and procedure review, the facility failed to protect a resident from misappropriation of property as evidenced by a Certified Nurse Aide (CNA) withdrew money from a resident's account and deposited the money into her account for one (1) of four (4) residents reviewed for misappropriation. Resident #1
Findings include:
Record review of the facility's policy titled Abuse, Neglect, Exploitation & Misappropriation policy and procedure with a revision date of 11/16/2022 revealed page 4 of 9 last revised on 11/16/2022, revealed .Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. Employee' Misappropriation includes but is not limited to . Theft of money from bank accounts, unauthorized or coerced purchases on a resident's credit card .
Record review of the Verification of Investigation with a date/time of occurrence of 04/14/2023 at 4:00 PM revealed, Resident presented banking information to nurse supervisor on 4/17/23 at approximately 6:40 PM showing an unauthorized transaction to employed CNA, (Proper Name of CNA), for $25.00 on 4/14/2023. DON (Director of Nurses)/Administrator/Human Resources Director notified. Employee immediately suspended. Investigation initiated .Resident Interview Summary: I gave her my card. I do not even know her name. I asked her to get me two drinks .
Record review of the Employee Corrective Action Form dated 4/17/23 revealed .Employee Comments: I went to the vending machine and got (Formal Name of Resident #1) two (2) sprites and afterwards I sat the sprites on his tables because he wasn't in the room. I hacked his card to my cash app and sent myself 205 (25.00) .
Interview on 6/13/23 at 10:30 AM, with the DON revealed that when the CNA #1 was interviewed during the investigation, she did not deny or admit to taking the money out of the resident's account.
Interview with the Administrator on 6/13/23 at 3:00 PM, revealed that on 4/20/23 he was shown the picture of Resident #1's account and the evidence that CNA #1 had taken the $25.00 and deposited the money into her own account.
Interview on 6/14/23 at 3:05 PM, with the facility's Human Resources staff, she revealed CNA #1 was in the facility when Resident #1 told her that he had given CNA #1 his account information to go to the facility soda machine and get him two (2) soft drinks. She revealed that she immediately went to CNA #1 and began the investigation. She stated that CNA #1 denied taking the money but when she saw the picture of the $25.00 taken from the resident's account and was deposited into her own account, she then admitted to doing it.
An interview with CNA #2 on 6/14/23 at 4:23 PM, revealed that Resident #1 came to her on 4/17/23 and gave her his phone to see what was wrong with his account and what was the name of the person who received $25.00 from his account. CNA #2 revealed that when she saw the name of CNA #1, she was shocked, and asked if she could take a picture of the account statement that was on his phone. She then went to the facility Human Resource staff, showed her the picture and told her what Resident #1 said.
An interview with the Attorney General investigator on 6/15/23 at 1:30 PM, revealed that he did an interview with CNA #1 and she admitted on a video that she did take the $25.00 from Resident #1's account and deposited it into her own account.
Record review of the admission Record revealed Resident # 1 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Heart failure.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was cognitively intact.

Based on observation, staff interview, facility policy review, and record review, the facility failed to prevent the likelihood of foodborne illness as evidence by out of date and unlabeled food items in the refrigerator and failed to clean the ice machine as evidence by black substance on the ice and the interior walls of the kitchen ice machine for two (2) of two (2) kitchen tours.
Findings include:
Record review of the facility policy titled Receiving revised 9/2017 revealed # 5, All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.
Record review of the facility policy titled Food Storage: Cold Foods revised 4/2018 revealed # 5, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
Record review of the facility policy titled Food: Preparation revised 9/2017 revealed #17, All TCS foods that are to be held for more than 24 hours at a temperature of 41 degrees F or less, will be labeled and dated with a prepared date (Day 1) and a used by date (Day 7).
Record review of the facility in-service titled Labeling and Dating Inservice Quiz was completed on 10 dietary department members on 6-4-2021.
Record review of the facility policy titled Equipment had no issue date or revision date and revealed in the policy statement, All foodservice equipment will be clean, sanitary, and in proper working order.
Record review of the facility policy titled Ice Machines and Ice Storage Chests revised 01/2012 revealed with the policy statement, Ice machines and ice storage/distribution containers will be used and maintained to assure a save and sanitary supply of ice.
On 10-04-21 at 10:05 AM an observation during a tour of the kitchen revealed in the double door cooler to the right of the kitchen, a 48-ounce box of cream cheese that was 3/4 full and with an expiration date of 8-10-2021, a block of yellow sliced cheese in an opened zip lock bag with no date or label, a zip lock bag of lettuce with an expiration date of 10-2-2021 and a bag of shredded cabbage and carrots with no date or label.
On 10-4-21 at 10:20 AM an interview with Dietary Stafff (DS) #1, #2 and # 3 confirmed that the date on the 48-ounce box of cream cheese that was 3/4 full was expired as of 8-10-2021, a zip lock bag of lettuce had an expiration date of 10-2-2021, the opened zip lock bag of yellow sliced cheese had no date or label, and the bag of shredded cabbage and carrots had no date or label. Dietary staff # 1, #2 and # 3 confirmed that all food in the cooler should be dated, labeled and if expired or not dated and labeled should be disposed of.
On 10-4-21 at 10:35 AM, an observation of the inside of the ice maker revealed a small black substance stuck to one piece of ice. DS # 1 confirmed there was a small black substance stuck to one piece of ice.
On 10-4-21 at 10:36 AM an interview with DS #1 revealed that the black substance attached to the piece of ice was sediment from when they clean the ice machine. Dietary staff #1 confirmed the ice machine cleaning schedule taped to the front of the ice maker revealed the last documented cleaning was dated 7/13/21.
On 10-5-21 at 4:15 PM an observation and interview with DS # 4 confirmed the ice maker had 13 black spots, approximately the size of a pencil eraser, scattered on the ice and the back interior wall of the ice maker. The cleaning log on the front of the ice maker had the last cleaning date as 7/13/21.
On 10-6-21 at 8:52 AM an interview with DS # 4 revealed that if residents would have ingested the black substance that was on the interior walls of the ice machine it could have made them sick and could have been served to all of the residents. Dietary department # 4 stated, I think it was mold. Dietary department # 4 revealed that residents could have become sick with a food borne illness if they had ingested the expired foods and confirmed that the cheese could have been served to all residents.
On 10-6-21 at 9:00 AM an interview with the facility Administrator (ADM) revealed the maintenance man is responsible for cleaning the ice machine. The facility ADM revealed she observed the black substance in the ice maker and it was bad.
On 10-6-21 at 9:12 AM an interview with Maintance Staff (MS) # 1 revealed the ice maker should be cleaned monthly and the filter should be changed every three months. MS # 1 revealed, I would not want to drink it.
On 10-7-21 at 8:35 AM an interview with DS # 4 revealed that the ice from the ice machine in the kitchen is used for both tea glasses and water glasses for all residents.
Record review of the facilities Ice Machine Cleaning Schedule 2020-2021 revealed the last documented ice removal was dated 7-13-2021, last documented cleaning of the ice maker was 07/13/2021, and last documented sanitized was 7-13-2021.
Record review of the facility ice machine cleaning instructions revealed a cleaning instruction titled Basic Ice Machine Cleaning and Sanitizing Procedures.