Monroe City Manor Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and/or administer the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for three residents (Residents #1, #38 and #47), in a review of 17 sampled residents. The facility census was 54. Review of the CDC's Pneumococcal Vaccine Timing for Adults, updated October 2024, showed the following:-For adults 50 years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV15, PCV20, or PCV21; -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15. If the PPSV23 is not available, the PCV20 or PCV21 may be used;-If PCV20 or PCV21 is administered, regardless of which vaccine is used, their pneumococcal vaccinations are complete;-For adults 50 years or older who received the PPSV23 only at any age, administer the PCV15, PCV20 or the PCV 21 at least one year after the PPSV23 was administered;-For adults 50 years or older who received the PCV13 only at any age, administer the PCV20 or PCV21 at least one year after the PCV13 was administered;-For adults 50 years or older who received the PCV13 at any age and the PPSV23 when less than [AGE] years of age, administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose;-For adults 65 years or older who received the PCV13 at any age and the PPSV23 at 65 years or older, the individual and their vaccination provider may choose to administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose. (Refer to the CDC's Shared Clinical Decision-Making PCV20 or PVC21 Vaccination for Adults 65 Years or Older for additional information on clinical decision making.) 1. Review of the Resident #38's undated face sheet showed the following:-He/She admitted to the facility on [DATE];-He/She was over age [AGE];-He/She had a diagnosis of diabetes mellitus (medical condition characterized by abnormally high blood sugar levels) and asthma (chronic respiratory illness);-He/She had a representative responsible for making medical decisions. Review of the resident's preventative health documentation, located in his/her electronic health record (EHR), showed the following:-No documentation the resident received pneumococcal vaccinations;-No documentation the resident was offered or refused any pneumococcal vaccinations.(The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 05/24/25, showed the following:-His/Her cognition was severely impaired;-The resident's pneumococcal vaccinations were up to date. During an interview on 08/21/25 at 12:30 P.M., the resident's representative said he/she thought resident was up to date with pneumococcal vaccinations. He/She expected the resident to be up to date with all immunizations. 2. Review of the Resident 1's undated face sheet showed the following:-He/She was admitted to the facility on [DATE];-He/She was over the age of 65;-He/She had a diagnosis of diabetes mellitus;-He/She was his/her own person. Review of the resident's quarterly MDS, dated [DATE], showed the following:-His/Her cognition was intact;-The resident's pneumococcal vaccination was up to date. Review of the resident's preventative health documentation, located in his/her EHR, on 8/20/25 showed the following: -The resident received the pneumonia vaccination of unknown type on 12/31/19;-No documentation the resident was offered, received, or refused any additional pneumococcal vaccine.(The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) During an interview on 08/21/25 at 12:40 P.M., the resident said he/she was not sure if he/she was up to date with the pneumonia vaccination. No one from the facility had offered him/her the pneumonia vaccination. He/she would take the pneumonia vaccination if offered. 3. Review of Resident #47's undated face sheet showed the following:-He/She admitted to the facility on [DATE];-He/She was over the age of 65;-Diagnoses included pneumonitis (inflamed lung tissue) due to inhalation of food and vomit, chronic obstructive pulmonary disease (COPD; obstructed airflow causing breathing difficulty), altered mental status and dementia (loss of memory and judgement);-He/She had a listed durable power of attorney (DPOA). Review of the resident's significant change MDS, dated [DATE], showed the following:-Moderately impaired cognition;-Pneumonia vaccine up to date. Review of the resident's preventive health record, located in the EHR, on 08/18/25 showed the following:-The resident received the PPSV23 (Pneumococcal Polysaccharide Vaccine 23-valent) out of the facility on 11/30/20;-No documentation the resident was offered, received, or refused any additional pneumococcal vaccines.(The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) During an interview on 08/21/25 at 12:40 P.M., the resident's DPOA said he/she expected staff to offer any available vaccinations and wanted the resident to have them as needed. 4. During an interview on 08/20/25 at 11:30 A.M., the Director of Nursing said the facility did not track residents' pneumonia vaccination status. The current MDS Coordinator checked vaccination history for the new residents who are admitted . During an interview on 08/20/25 at 11:15 A.M., the MDS Coordinator said the following:-The nurse who had been tracking the residents' vaccinations quit a few months ago; -Upon a resident's admission, she assessed for vaccination history, including pneumococcal vaccinations, to see if vaccinations were up to date; -If resident and/or resident representative were unaware of the resident's vaccination history, the facility contacted the resident's primary care physician (PCP) for further instruction and orders. During an interview on 08/21/25 at 3:30 P.M., the Administrator said she expected all residents to be up to date with all immunizations, including the pneumococcal vaccination, per the CDC guidelines.

Based on interview and record review, the facility failed to implement policies and procedures to ensure residents' trust accounts were not allowed to go into a negative balance which affected one resident (Resident #40), in a review of seven sampled residents for which the facility maintained accounts. The facility census was 54. Review of the undated facility policy, Management of Residents' Personal Funds, showed the following:-The resident may have the facility hold, safeguard, and manage his or her personal funds;-Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident;-Inquiries concerning the facility's management of resident funds are referred to the administrator or to the business office. 1. Review of petty cash vouchers for the month of March, showed Resident #40 was allowed to obtain cash on the following dates:-On 03/07/25, the resident signed a facility petty cash voucher for $25.00 cash;-On 03/25/25, the resident signed a facility petty cash voucher for $30.00 cash;-On 03/28/25, the resident signed a facility petty cash voucher for $50.00 cash;-The sum of the resident's petty cash vouchers for the month of March was $105.00. Review of the facility-maintained Resident Trust Fund Statement, dated 04/01/25 through 04/30/25 showed the following: -On 04/01/25, the resident's beginning balance was $100.00;-On 04/06/25, check #2769 was taken out of the resident fund account and transferred to the facility account for $105.00 to replace the petty cash the resident had withdrawn for the month of March;-On 04/06/25, the resident's resident trust balance was -$5.00.-On 04/18/25, receipt of $80.00 cash from family was deposited into the residents' trust fund account. Review of petty cash vouchers for the month of April, showed Resident #40 was allowed to obtain cash on the following dates:-On 04/22/25, the resident signed a facility petty cash voucher for $30.00 cash;-On 04/28/25, the resident signed a facility petty cash voucher for $50.00 cash;-The sum of the resident's petty cash vouchers for the month of April was $80.00. Review of the facility-maintained Resident Trust Fund Statement, dated 04/01/25 through 04/30/25 showed the following: -On 04/30/25 interest distribution of $0.01 was deposited into the residents' trust fund account;-On 04/30/25 the resident's ending balance was $75.01. Review of petty cash vouchers for the month of May showed Resident #40 was allowed to obtain cash on the following dates:-On 05/01/25, the resident signed a facility petty cash voucher for $40.00 cash;-On 05/05/25, the resident signed a facility petty cash voucher for $35.00 cash;-The sum of the resident's petty cash vouchers for the month of May was $75.00. Review of the facility-maintained Resident Trust Fund Statement, dated 05/01/2025 through 05/30/25 showed the following:-On 05/01/25, the resident's beginning balance was $75.01;-On 05/07/25, check #2882 was taken out of the resident fund trust account and transferred to the facility account for $80.00 to replace the petty cash the resident had withdrawn for the month of April;-On 05/07/25 the resident's resident trust balance was -$4.99. Review of the facility-maintained Resident Trust Fund Statement, dated 06/01/25 through 06/30/25 showed the following:-On 06/01/25, the resident's beginning balance was -$4.99;-On 06/09/25, check #2885 was taken out of the resident fund trust account and transferred to the facility account for $75.00 to replace the petty cash the resident had withdrawn for the month of May;-On 06/09/25, the resident's resident trust balance was -$79.99. Review of the facility-maintained Resident Trust Fund Statement, dated 07/01/25 through 07/31/25 showed the following:-On 07/01/25 the resident's beginning balance was -$79.99;-On 07/31/25 the resident's ending balance was -$79.99. During an interview on 08/21/25 at 8:45 A.M., Resident #40 said the following:-His/Her spouse provided money for his/her resident trust account;-He/She always gets his/her money from the receptionist;-He/She was told by the receptionist about six months ago, he/she did not have any money. During an interview on 08/20/25 at 12:07 P.M., the receptionist said the following:-If a resident asked for cash, she would have the resident sign a petty cash voucher and give them money from the facility's petty cash drawer;-She always checked a resident's account balance on the computer before giving a resident cash;-The computer system never showed Resident #40 was in debt;-She would not have given Resident #40 any money if he/she was in debt;-She balances the petty cash box monthly and gives the petty cash vouchers to the Business Office Manager (BOM) for reimbursement;-She did not check the slips in her petty cash drawer before giving Resident #40 money;-There was no accurate fund balance during the month until the slips are given to the BOM for reimbursement. During an interview on 08/20/25 at 10:07 A.M., 12:01 P.M. and 12:35 P.M., the BOM said the following:-If she was not available, the receptionist provided money for residents out of the facility petty cash drawer;-A resident would go to the receptionist and sign a petty cash voucher to obtain money;-The receptionist kept the petty cash vouchers in the facility's petty cash drawer for one month;-The receptionist turned the petty cash vouchers in to her for repayment one time per month;-There were two petty cash drawers at the facility - one is at the receptionist's desk and is the facility petty cash and the other is in the business office, and it is the resident trust petty cash drawer;-She was the only person who was authorized to get into the resident trust petty cash drawer; -The receptionist was the only person who had access to the facility's petty cash drawer;-She would only know the accurate balance after she reimbursed the cash vouchers the receptionist brought her one time a month; (this is when the computer would show the resident's actual balance);-The resident's spouse provided money for the resident's trust fund account;-The resident's spouse was in another state and had not sent money for the resident's trust fund account;-She had asked the resident to stay under $100.00 in debt;-The resident's spouse was told the resident was in debt and needed money for the resident's trust fund account, but the resident's spouse had not sent any money for the resident fund trust account;-She did not think the resident's debt in the resident fund trust account affected any of the other residents with funds in the resident trust fund account. During an interview on 08/21/25 at 10:40 A.M., the Administrator said the following:-When a resident wanted cash, they would go to the receptionist and ask for money and the receptionist will give them money;-She did not think the receptionist had access to check a resident's resident trust fund balance before giving the resident money;-The receptionist keeps the petty cash receipts in her drawer and gives them to the BOM one time a month for reimbursement;-The BOM would not have known how much money a resident was given out of the petty cash drawer; she was not updating the balances timely with every petty cash withdrawal because the receptionist was giving money, keeping a voucher in the petty cash drawer and only turning them in once a month; -Residents should not be able to withdraw money that was not available in their trust account;-Resident #40's spouse had not been able to send money for his/her trust account;-She was not aware Resident #40 went into debt in April 2025;-She did not consider Resident #40 was using other resident's money from the trust fund if he/she had a negative balance;-If all the residents wanted to withdraw their money today from the resident trust account there would not be enough money to cover all the accounts;-There should be a better system for cash disbursement to the residents.

Based on observation, interview and record review, the facility failed to follow physician orders for one resident (Resident #51), in a review of 17 sampled residents, when staff did not compare the pharmacy label of a medication card against the medication administration record and administered the wrong dose of medication to the resident. Staff also failed to follow manufacturer's recommendation and professional standards when administering eye drops for one resident (Resident #2), when pressure was not applied and held to the inside corner of the eye (inner canthus), after administration. The facility census was 54. Review of the facility's policy, Administering Medications, revised April 2019, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-Medications are administered in accordance with prescribed orders, including any required time frame;-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;-As required or indicated for a medication, the individual administering the medication records the dosage in the resident's medical record. Review of the undated facility policy, Procedure: Prepare, Administer, Report and Record Ophthalmic (Eye) Medications, showed the following:-The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes;-Hold lower eyelid away from the eye to form a pouch;- For eye drops instill drop into the pouch, never directly onto the center of the eyeball;- With a finger, apply pressure to the inside corner of the eye (inner canthus) for one minute;- Instruct resident to close eye gently and keep eyes closed for a few minutes;- Blot excess medication from cheek with tissue. 1. Review of Resident #51's Physician Order Report, dated 07/01/25 through 07/31/2025, showed the following:-Diagnosis of major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities);-Fluoxetine (medication for major depressive disorder), 20 milligram (mg) capsule, one capsule daily, by mouth, discontinued 07/24/2025;-Fluoxetine 20 mg capsule, one capsule daily, by mouth, start date 07/24/25 end date 07/25/25. Review of pharmacy records showed on 07/24/25, two fluoxetine 20 mg capsules and 15 fluoxetine 10 mg capsules were delivered to the facility. Review of the resident's MAR, dated 07/24/25 thru 07/25/25, showed the following:-07/24/25, staff documented fluoxetine 20 mg was administered;-07/25/25, staff documented fluoxetine 20 mg was administered. Review of the resident's Physician Order Report, dated 07/01/25 through 07/31/2025, showed an order for fluoxetine 10 mg capsule, one capsule daily, by mouth, start date 07/26/25. Review of the resident's MAR, dated 07/26/25 thru 07/31/25, showed staff documented fluoxetine 10 mg was administered. Review of the resident's Medication Administration Record (MAR), dated 08/01/25 through 08/19/25, showed an order for fluoxetine capsule, 10 mg, administer one capsule by mouth, once a day, start date 07/26/25. Review of pharmacy records showed on 08/11/25, 15 fluoxetine 20 mg capsules were delivered to the facility. Observation on 08/19/25 at 8:55 A.M., during medication administration, showed the following:-Registered Nurse (RN) C pulled a fluoxetine 20 mg medication card from the 100-hall medication cart, labeled for the resident; -He/She did not administer the medication. During an interview on 08/19/25 at 8:55 A.M. and 4:48 P.M., RN C said the following:-The fluoxetine 20 mg capsule card should not have been in the medication cart;-The medication was the incorrect dose;-The resident did not have a fluoxetine 10 mg medication card in the medication cart;-He/She did not administer fluoxetine 20 mg because it was the incorrect dose;-Several capsules had been taken out of the medication card labeled fluoxetine 20 mg;-The resident had been receiving the wrong dose of medication;-The staff member who put in the new fluoxetine 10 mg medication order would have been responsible for pulling the discontinued fluoxetine 20 mg medication card from the medication cart. During a phone interview on 08/27/25, Licensed Practical Nurse (LPN) D said the following:-On 07/24/25 he/she had transcribed the physician's order to decrease the resident's fluoxetine from 20 mg to 10 mg;-He/She had reported to the oncoming nurse the medication order had been sent;-He/She did not remove the fluoxetine 20 mg medication card from the medication cart because he/she thought it would take some extra time for the medication to be sent from the pharmacy;-Normally any medication which was discontinued would be pulled from the medication cart and any remaining medication in the card would be destroyed. Review of the resident's pharmacy profile, dated 07/01/2025 thru 08/28/25, showed the following:-Pharmacy profile provided via email from the dispensing pharmacy;-On 08/11/25, fifteen fluoxetine 20 mg were dispensed. Review of the resident's MAR, dated 08/01/25 thru 08/19/25, showed the following:-Staff documented the resident's fluoxetine 10 mg dose was administered on 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25 (a total of seven administrations);-Staff documented the resident's fluoxetine 10 mg dose was not administered on 08/19/25 because the medication was not available. During a phone interview on 08/27/25, LPN D said the following:-On 08/13/25 he/she administered one fluoxetine 20 mg (a green and white capsule) to the resident and documented he/she gave one fluoxetine 10 mg capsule on the resident's MAR; it was a mistake;-The best practice when administering medications to a resident is to compare the medication card to the MAR before administering the medication to the resident. During an interview on 08/19/25 at 8:55 A.M. and 4:48 P.M., RN C said the following:-He/She administered fluoxetine 20 mg, one capsule, on 08/14/25;-On 08/14/25 he/she had documented on the resident's MAR administration of fluoxetine 10 mg one capsule at 8:00 A.M.;-He/She had administered fluoxetine 20 mg capsule on 08/14/25 because he/she was in the habit of just checking the medication name and not checking the medication dosage to see if it matched the MAR;-It was best practice to check the medication order with the medication card and the dose of the medication before administering any medication. Review of the facility's Individual Resident's Disposition Record, dated 08/20/25, showed the following:-A label had been affixed under Resident column;-The label showed the prescription number, Resident #51's name, the medication, and the date the medication was dispensed;-The prescription number on the label showed 7362701;-The medication listed on the label showed fluoxetine 20 mg;-The dispensed date listed on the label showed 08/11/2025;-Seven doses of fluoxetine 20 mg had been administered from the medication card. During a telephone interview on 08/28/25 at 9:01 A.M., the pharmacist said the following:-On 08/11/25, the resident was dispensed fluoxetine 20 mg;-It was a mistake; -The pharmacy had been sent the correct order, but did not discontinue the fluoxetine 20 mg prescription and the 20 mg prescription was sent to the facility by mistake;-On 8/19/25 the charge nurse called the pharmacy and the pharmacy had to manually go into the residents record and discontinue the 20 mg prescription as it was still in their system;-The facility called on 08/19/25 to inform the pharmacy of the mistake. During an interview on 08/21/25 at 12:58 P.M. and 08/28/25 at 9:24 A.M., the Director of Nursing (DON) said the following:-Staff should follow physician orders;-Residents should receive the proper dose of medication;-Staff are supposed to transcribe new medication orders and send the order to the pharmacy; -Staff who transcribe the medication order should pull the discontinued medication from the medication cart;-Staff who transcribe a new medication order was responsible for following up to ensure the new medication was on the medication cart;-The discontinued medication card should be pulled from the cart and the medication destroyed;-Prescriptions are electronically sent to the pharmacy;-When medications are delivered from the pharmacy, the evening or night shift Certified Medication Technician (CMT) or the nurse checks the medications delivered with the list the pharmacy sends to ensure they match;-Staff then put the medication on the medication cart or in the medication storage room;-Staff administering medication should ensure a resident receives the correct dosage;-Staff should aways check the resident, the medication, the dose, and the route before any medication was administered;-Staff should not give a fluoxetine 20 mg capsule and document on the MAR fluoxetine 10 mg capsule was given. During an interview on 08/21/25 at 2:39 P.M. and 08/27/25 at 4:47 P.M., the Administrator said the following:-All discontinued medications are destroyed at the facility;-Staff should follow physician orders;-A resident should receive their ordered dose of medication;-Staff should not give 20 mg of a medication and chart 10 mg was given on the MAR. 2. Review of the Combigan (brimonidine tartrate and timolol maleate 0.2-0.5 percent (%) ophthalmic solution - medication used to decreases elevated intraocular (inside eye) pressure) website showed the following:- Instructions for applying eye drops:-Gently close your eyes and lightly press on the inside corners of your eyes;- Carefully blot away any excess liquid that may be on your skin. Review of Resident #2's face sheet showed diagnosis of ocular hypertension (a condition where the intraocular pressure (IOP) (pressure inside the eye) is higher than normal), bilateral (both eyes). Review of the resident's Physician Order Summary, dated August 2025, showed an order for Combigan 0.2-0.5 % drops, one drop in both eyes, administer two times a day. Observation on 08/19/25 at 8:59 A.M., during medication administration, showed the following:-RN C took brimonidine tartrate and timolol maleate 0.2-0.5% ophthalmic solution out of the medication cart;-RN C used hand sanitizer and applied gloves;-RN C gave the resident a Kleenex;-RN C pulled down the resident's lower right eye lid and instilled one drop of brimonidine tartrate and timolol maleate 0.2-0.5% ophthalmic solution into the eye lid pocket;-RN C did not apply pressure to the inside corner of the eye for one minute after instilling the eye drop;-RN C did not instruct the resident to close his/her eye or to keep his/her eyes closed for a few minutes;-RN C pulled down the resident's lower left eye lid and instilled one drop of brimonidine tartrate and timolol maleate 0.2-0.5% ophthalmic solution into the eye lid pocket;-RN C did not apply pressure to the inside corner of the eye for one minute after instilling the eye drop;-RN C did not instruct the resident to close his/her eye or to keep his/her eyes closed for a few minutes;-Liquid ran under the resident's right and left eye;-The resident used the Kleenex to wipe the liquid from under his/her eyes. During an interview on 08/19/25 at 9:55 A.M., RN C said the following:-When administering eye drops, pressure should be held on the corner of the eyelid by the nose for five minutes;-He/She started to tell the resident to hold pressure, but thought it was a missed opportunity because the resident was already wiping his/her eyes with a tissue;-He/She should have educated the resident on the proper administration of the eye drops. During an interview on 08/21/25 at 12:58 P.M., the DON said staff should hold pressure on the corner of the eyelid by the nose for one-two minutes after administering eye drops. During an interview on 08/21/25 at 2:39 P.M., the Administrator said staff should administer all medications properly.

Based on observation, interview, and record review, the facility failed to ensure the range hood was free of an accumulation of grease and debris, failed to ensure the floors in the kitchen were free of a buildup of grease and debris, and failed to properly store food items. The facility census was 54.1. Review of the facility policy, Cleaning Instructions: Hoods and Filters, dated 2020, showed hoods and filters will be cleaned regularly, at least once a month. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the hoods and filters were not clean and dust was noted. Review of the Dietary Sanitation Evaluation, dated 7/11/25 and completed by the facility's consultant dietitian, showed the hoods and filters were not clean and had dust. Observation on 8/18/25 at 10:35 A.M., of the kitchen range hood showed the following:-A moderate buildup of yellow grease and dark-colored debris on the baffle filters under the range hood;-The range hood protected a six-burner stove, flat-top griddle and a double fryer. During an interview on 8/18/25 at 10:35 A.M., the Dietary Manager said staff were supposed to clean the hood and filters weekly. She was unsure if staff cleaned the range hood last week. 2. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the floor was not clean. Review of the Dietary Sanitation Evaluation, dated 7/11/25 and completed by the facility's consultant dietitian, showed the floor was sticky. Observation on 8/18/25 at 10:38 A.M. and on 8/19/25 at 8:53 A.M. showed an extremely heavy buildup of yellow and brown pooled grease and food debris on the floor underneath the six-burner stove, griddle, double fryer, and metal preparation counter. Yellow grease visibly ran down the front of the stove and dripped into the existing puddle of grease on the floor. During an interview on 8/19/25 at 8:53 A.M., the Dietary Manager said staff was supposed to clean the grease off the floor weekly. Staff was behind in the scheduled duties and it was overwhelming to try to get caught up. The grease trap didn't always catch the grease, and the grease leaked out inside the stove. 3. Review of the Dietary Sanitation Evaluation, dated 6/6/25 and completed by the facility's consultant dietitian, showed the floor of the walk-in freezer was not clean. Observation on 8/18/25 at 9:33 A.M. of the walk-in freezer showed a heavy accumulation of paper trash, potato wedges. and other food debris/crumbs on the floor of the unit. During an interview on 8/19/25 at 8:53 A.M., the Dietary Manager said staff were to clean spills and messes as they occurred. 4.Observation on 8/18/25 at 9:34 A.M. of the walk-in cooler showed a black crate sat on the cooler floor that held a plastic bag of liquid ice cream mix that directly touched the floor. Observation on 8/18/25 at 10:27 A.M. of the kitchenette refrigerator showed an open 1-pound stick of butter. The paper wrapper loosely covered the butter and left the butter open to air. During an interview on 8/19/25 at 8:53 A.M., the Dietary Manager said the ice cream mix should not be stored on the floor.

Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents. Staff failed to prepare and serve food according to the diet spreadsheet menu. The facility census was 54.
Review of the facility's Diet Orders Policy, 2011 Edition, showed the following:
-Guideline: Each resident will have a diet order prescribed by the physician and documented in the health record. All physicians will prescribe diets using the terminology of the house diets and/or terminology in the diet manual. Diet orders received from an admission source that do not conform to the standard language of the facility will be converted to an available diet order offered at the facility;
-Procedure: Diet orders are clearly communicated, using the designated diet order communication form, to dining services; All diet order communication forms received by dining services are confirmed for accuracy by the dining services manager or designee and noted as received in the resident health record; Consult with the Registered Dietitian for further guidance.
1. Review of the Diet Orders, obtained 11/13/23 and 11/14/23, showed ten residents with a physician-ordered consistent carbohydrate (CCHO) diet.
Review of the Diet Spreadsheet, for 11/13/23 (Day 2, Monday) lunch, showed the following:
-Staff were to serve one #6 dip (5.33 ounce) serving of apple crisp to residents with a regular diet;
-Staff were to serve one #12 dip (2.66 ounce) serving of apple crisp to residents with a CCHO diet.
Observation on 11/13/23 at 10:15 A.M., in the walk-in cooler showed a cart containing individual bowls of apple crisp desserts, each of the same portion size serving.
Observation on 11/13/23 at 11:00 A.M., showed a cart containing individual bowls of apple crisp desserts, each of the same portion size serving, outside the kitchen entrance door in the dining room.
Observations on 11/13/23 from 11:13 A.M. to 12:14 P.M., in the main dining room during the lunch meal service, showed Dietary Aide C served bowls of apple crisp to the residents. All of the bowls contained the same amount of apple crisp.
During an interview on 11/13/23 at 4:39 P.M., Dietary Aide C said all residents receive the same serving size of dessert from the dessert cart.
Observation of the Special Care Unit on 11/13/23 at 11:40 A.M. showed the following:
-Dietary staff delivered a cart with the lunch meal to the special care unit;
-Special care unit staff removed items from the cart, including two trays of individually prepared bowls of apple crisp. All of the bowls appeared to contain the same amount of apple crisp. The bowls were not labeled for specific residents.
Observation of the lunch meal service on 11/13/23 at 12:25 P.M., in the Special Care Unit, showed staff served residents, including Resident #51 (who was on a physician-ordered CCHO diet), the bowls of apple crisp from the trays.
During an interview on 11/13/23 at 12:30 P.M., Licensed Practical Nurse (LPN) A said the following:
-Resident #51 was the only diabetic currently on the unit;
-All of the desserts were the same; he/she did not know if diabetics were to get something different.
During an interview on 11/14/23 at 8:34 A.M., the Dietary Manager said the following:
-She did not realize dietary staff served the same portion size of apple crisp to all residents for lunch on 11/13/23;
-She expected dietary staff to follow the diet spreadsheet menus when preparing/serving meals to the residents;
-The residents on a CCHO diet should have received a #12 serving of apple crisp, not a #6 serving;
-She was responsible for making sure staff followed the diet spreadsheet menus.
During an interview on 11/17/23 at 12:02 P.M., the Registered Dietitian said dietary staff should be familiar with and follow the diet spreadsheet menu when preparing/serving food items to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct regular inspections of bed frames, mattresses and bed rails to identify areas of possible entrapment and to ensure the bed rails, mattresses and bed frames were compatible for five residents (Residents # 2, #3, #4, #36, #48) with bed rails, in a review of 14 sampled residents. The facility census was 54.
Review of the facility's bed assist device policy, updated on 2/20/23, showed maintenance staff will install all bed assist devices using the manufacturer's instructions and regularly check the mattress and assist device for areas of possible entrapment and other safety concerns.
Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following:
-Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet;
-Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail;
-Reduce the gaps between the mattress and side rails;
-A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety;
1. Observation on 11/15/23, at 1:30 P.M., showed 17 beds in the facility (currently in use) had some type of bed rail/side rail device attached to the bed.
2. Review of Resident #3's Continuity of Care Document showed his/her diagnoses included dementia, history of falls, altered mental status, need for assistance with personal cares, muscle weakness and abnormalities of mobility.
Review of the resident's annual side rails assessment and consent, dated 4/24/23, showed the following:
-Reason for side rail use: bed mobility;
-Type of rail used: one side;
-Used daily
Review of the resident's October 2023 physician order sheet (POS) showed an order documenting the resident may use bed rail assist rails for safety (original order date of 12/22/18).
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/23, showed the following:
-Functional limitations in range of motion (ROM) in upper and lower extremities on both sides of his/her body;
-Required substantial to maximal assistance with mobility when rolling left and right, when sitting to lying, and when lying to sitting.
Review of the resident's care plan, last revised 10/24/23, showed the following:
-Required assistance with turning and repositioning while in bed;
-Safe and appropriate with use of bilateral bed assist rails.
Observations on 11/13/23 at 11:31 A.M. and 12:15 P.M., showed the resident lay in his/her bed. The resident had 1/8 bed rails (assist rail that does not raise or lower) on both sides of the bed.
Observation on 11/15/23, at 5:05 A.M., showed the resident lay in his/her bed. The resident had 1/8 bed rails on both sides of the bed.
Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment.
2. Review of Resident #4's Continuity of Care Document showed his/her diagnoses included multiple sclerosis.
Review of the resident's annual side rail assessment and consent, dated 4/24/23, showed the following:
-Reason for side rail usage: bed mobility (assist with turning side-to-side);
-Types of rails used: two sides;
-Frequency of use: daily.
Review of the resident's October 2023 POS showed the resident may use two assist devices to bed (original order date of 9/24/20).
Review of the resident's quarterly MDS, dated [DATE], showed the resident required substantial to maximal assistance for mobility when rolling left to right.
Review of the resident's care plan, last revised 9/5/23, showed the resident had two assistive devices to aid with bed mobility.
Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment.
Observations on 11/14/23 at 10:40 A.M., 11/15/23 at 5:05 A.M. and 9:25 A.M. showed the resident lay in bed with 1/8 bed rails on both sides of the bed.
Observation on 11/15/23 at 12:05 P.M. showed the resident sat in bed eating lunch with 1/8 bed rails on both sides of the bed.
3. Review of Resident #36's Continuity of Care Document showed his/her diagnoses included history of repeated falls, mild cognitive impairment, bilateral primary optic atrophy (condition that affects the optic nerve, which carries impulses from the eye to the brain, characteristics include deficits in central vision, difficulties distinguishing contrast, and loss of visual acuity), and generalized muscle weakness.
Review of the resident's annual side rails assessment and consent, dated 4/24/23, showed the following:
-Reason for side rail use: bed mobility;
-Type of rail used: two sides;
-Used daily.
Review of the resident's October 2023 POS showed the resident may use an assistive device on bed for mobility (original order date of 03/30/22).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Functional limitations in range of motion (ROM) in upper and lower extremities on one side of his/her body;
-Required supervision or touching assistance when rolling left and right, when sitting to lying and when lying to sitting.
Review of the resident's care plan, last revised 11/06/23, showed the following:
-He/She had two assistance devices to aide with bed mobility;
-He/She was able to turn and reposition himself/herself in bed.
Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment.
Observations on 11/15/23, at 5:37 A.M., 5:49 A.M., and 5:57 A.M. showed the resident in his/her bed. The resident had 1/8 bed rails on both sides of the bed.
4. Review of Resident #2's side rails assessment and consent, dated 4/24/23, showed the following:
-Medical symptom requiring use of side rails was decreased mobility;
-Reason for side rail usage was bed mobility (assist with turning side-to-side);
-Rails used on two sides;
-Frequency of use was daily.
Review of the resident's annual MDS, dated [DATE], showed the resident required moderate assist to roll left and right in bed.
Review of the resident's care plan, updated 10/3/23, showed the following:
-He/She had assistive device bilaterally to aide with bed mobility;
-He/She had impaired mobility related to recent right above knee amputation, history of left below knee amputation, and severe morbid obesity.
Observation on 11/14/23 at 9:15 AM, showed the resident lay in bed with bilateral half side rails up.
Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment.
5. Review of Resident #48's side rails assessment and consent, dated 9/1/23, showed the following:
-Medical symptom requiring use of side rails was decreased bed mobility;
-Reason for side rail usage was bed mobility (assist with turning side-to-side);
-Rails used on two sides;
-Frequency of use was daily.
Review of the resident's admit MDS, dated [DATE], showed the following:
-The resident was cognitively intact;
-Required moderate assistance with roll left and right in bed and lying to sitting.
Review of the resident' care plan, updated 10/18/23, showed the following:
-The resident had impaired functional mobility related to unsteady gait and deconditioning;
-The resident had two assistive devices to aide with bed mobility.
Observation on 11/14/23 at 11:55 AM, showed the resident lay in bed with 1/8 bed rails on both sides of the bed.
Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and bed rails to identify areas of possible entrapment.
6. During interviews on 11/15/23 at 10:00 A.M., 11:54 A.M. and 1:48 P.M., and on 11/16/23 at 8:29 A.M., the maintenance supervisor said the following:
-He does not do any type of assessments on bedrails; he has only checked them when staff tell him they are loose and they need tightened;
-He installed bed rails when nursing staff asked him to do so per residents' physician orders;
-He did not conduct bed rail entrapment risk assessments, bed rail inspections, or check compatibility of the bed rails with the bed frames or mattresses;
-He was unaware of the manufacturer or model of the bed rails or what the manufacturer's recommendations were for conducting risk assessments or bed frame/mattress compatibility;
-He had only worked at the facility four months and could not find any prior bed rail entrapment risk or inspection documentation;
-Housekeeping staff conducted monthly inspections of bed rails, frames and mattresses;
-The housekeeping supervisor gave him the monthly inspection sheets; he only had September and November 2023 because that's all that he could find.
Record review of the September 2023 and November 2023 inspection forms, completed by housekeeping staff, showed the following:
-Beds and mattresses: inspect bed rails, bed frames, and bed mattresses;
-Beds listed for each room had a pass or fail option;
-No measurements or detailed inspection information was listed on the forms;
-Staff inspector names for the East Hall inspections conducted on 9/15/23 and 9/16/23 were blank.
During an interview on 11/16/23 at 8:29 A.M., the housekeeping supervisor said the following:
-Housekeeping staff conducted monthly inspections of resident beds and mattresses to ensure the items were in good working order;
-Housekeeping staff did not inspect the bed rails but made sure there were no big gaps between the rail and mattress;
-Housekeeping staff did not follow manufacturer's recommendations for assessing if a bed rail was compatible with the bed frame or mattress or for checking for gaps between the bed rail and mattress.
During an interview on 11/16/23 at 9:58 A.M., the nurse manager said she could not locate a bed rail maintenance program, policy, or past inspection documentation. She assumed the bed rails were compatible with the bed frames since many were installed years ago.
During an interview on 11/15/23 at 9:38 A.M., and 11/16/23 at 9:13 A.M., the director of nursing said she expected maintenance staff to ensure compatibility with bed frames and mattresses, and follow manufacturer's recommendations for installation and maintenance of bed rails.

Based on observation, interview, and record review, the facility failed to post the total hours nursing staff (registered nurse (RN), certified nurse assistant (CNA), certified medication technician (CMT), and licensed practical nurse (LPN)) worked for each shift. The facility census was 54.
Review of the facility's undated policy, Posting Direct Care Daily Staffing Numbers, dated 2001 and last revised 2006, showed the following:
-Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents;
-Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and Licensed Vocational Nurse (LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format;
-Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of condition;
-Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information ·recorded on the form shall include:
a. The name of the facility;
b. The date for which the information is posted;
c. The resident census at the beginning of the shift for which the information is posted;
d. Twenty-four (24)-hour shift schedule operated by the facility;
e. The shift for which the information is posted;
f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing
staff working during that shift;
g. The actual time worked during that shift for each category and type of nursing staff;
h. Total number of licensed and non-licensed nursing staff working for the posted shift;
-When computing hours of direct care staff working split shifts, count only the total number of hours the individual is actually scheduled to work for the shift information being posted. (Example: You are posting data for the Day Shift. A CNA reports to work and is scheduled to work four (4) hours on the Day Shift and four (4) hours on the Evening Shift. In computing the number of hours worked for that shift, count only the four (4) hours scheduled for the Day Shift. The remaining four (4) hours would then be counted toward the totals on the Evening Shift);
-Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator;
-The form may by typed or handwritten. If completed by typewriter or word processor, the recorded information shall be a minimum font size of 12 points. Should the information be handwritten, it must be legibly printed in black ink and must be written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in our facility's daily staffing information.
1. Observation on 11/13/23 at 12:30 P.M., of the facility staffing sheet posted across from the nurses' station showed the following:
-The facility census was 54;
-Day shift included three LPNs and seven CNA/CMTs for a total of ten staff;
-There was no area to document total staff hours.
Observation on 11/13/23 at 3:30 P.M., of the facility staffing sheet posted across from the nurses' station showed the following:
-The facility census was 54;
-Day shift included three LPNs and six CNA/CMTs for a total of nine staff;
-There was no area to document total staff hours.
Observation on 11/14/23 at 8:21 A.M., of the facility staffing sheet posted across from the nurses' station showed the following:
-The facility census was 54;
-Day shift included one RN, three LPNs and eight CNA/CMTs for a total of 12 staff;
-There was no area to document total staff hours.
Observation on 11/14/23 at 2:20 P.M. and 4:16 P.M, of the facility staffing sheet posted across from the nurses' station showed the following:
-The facility census was 54;
-Evening shift for all disciplines was blank;
-There was no area to document total staff hours.
Observation on 11/15/23 at 5:02 A.M., of the facility staffing sheet posted across from the nurses' station showed the staffing sheet from 11/14/23 and there was no evening and night shift staff numbers documented.
Observation on 11/15/23 at 12:30 P.M., of the facility staffing sheet posted across from the nurses' station showed the following:
-The facility census was 54;
-Day shift included three LPNs and seven CNA/CMTs for a total of ten staff;
-There was no area to document total staff hours.
Observation on 11/16/23 at 8:35 A.M., of the facility staffing sheet posted across from the nurses' station showed the following:
-The facility census was 51;
-Day shift included one RN, two LPNs and six CNA/CMTs for a total of nine staff;
-There was no area to document total staff hours.
During interview on 11/16/23 at 8:45 A.M., LPN D said the following:
-There is no specific person assigned to fill out staffing sheet. It is just whoever remembers first;
-The numbers listed per RN/LPN/CNA is the number of staff not the number of hours.
During interview on 11/16/23 at 9:38 A.M., the Director of Nurses (DON) said the nurses usually fill out the staffing sheet but there is no one specific assigned. If they forget then she will do fill it out. The numbers listed on the staffing sheet are the number of staff for each discipline, not the number of hours. It had been a while since she had read the regulation but the hours should be listed.

Based on observation, interview, and record review, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust and debris, failed to remove damaged food containers from the dry storage room, failed to seal/date opened packages, and failed to ensure an ice machine drain contained a drainage air gap. The facility census was 54.
Review of the facility's Cleaning Rotation Policy, 2011 Edition, showed the following:
-Guideline - Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions;
-Items cleaned after each use included can opener, small food preparation equipment, work tables and counters;
-Items cleaned daily included stove top, grill, kitchen and dining room floors, toaster, and exterior of large appliances;
-Items cleaned weekly included hoods, filters, shelves, ovens, and cupboards);
-Items cleaned monthly included refrigerators and walls).
Review of the facility's Ice Handling and Cleaning Policy, 2011 Edition, showed ice will be handled, transported, and stored in such a manner as to be protected against contamination. Ice storage bins shall be drained through an air gap.
1. Observations on 11/13/23 from 9:55 A.M. to 4:39 P.M., in the kitchen, showed the following:
-A moderate buildup of oil and debris on the counter-mounted can opener;
-A moderate buildup of dust and debris on the two bulb emergency light fixture;
-A moderate buildup of grease, dust, and debris on top of the wall-mounted knife holder;
-A moderate buildup of grease and debris on the counter top toaster;
-A buildup of grease and debris on surfaces of the Ansul System Unit, metal conduits out of the unit, and to the kitchen hood and Ansul pull station;
-A moderate buildup of dust and debris on the eight support pipes above the kitchen hood;
-A buildup of dust and debris on the shelving above the three-compartment sink, the back splash, and on the flooring underneath and between the sink and the up-right refrigerator;
-The contact paper on the bottom shelving of the three preparation tables was worn and peeling away from the metal surfaces (not easily cleanable);
-A moderate buildup of grease, dust, and debris on the metal wall shelving, located above the food preparation counter;
-A moderate buildup of grease, debris, and dark stains on the metal back splash, above and to the right side of the griddle top oven;
-A buildup of grease, debris, and dark stains on the right side of the griddle top oven;
-A moderate buildup of grease and debris on the left side of the stove top oven;
-A buildup of grease and debris under stove top burner grates;
-A moderate buildup of dust and debris on the left wall in the walk-in cooler.
2. Observation on 11/13/23 at 9:55 A.M., in the dry storage room, showed the following:
-Three 6 pound, 10 ounce cans of pineapple tidbits, located on the the shelving with products for use, were dented/damaged;
-A 1 pound, 8 ounce package of gelatin dessert, labeled as opened on 10/29/23, was not sealed;
-An opened 5 pound package of fudge brownie mix was not sealed.
3. Observation on 11/13/23 at 2:51 P.M., showed the ice machine, located in the 200 hall clean utility storage room, had no drainage air gap under the machine or entering into the main sink drain.
During an interview on 11/13/23 at 10:33 A.M., the Maintenance Supervisor said unaware an ice machine was required to have an air gap.
4. During an interview on 11/14/23 at 8:34 A.M., the Dietary Manager said the following:
-She expected staff to clean and sanitize the kitchen and dietary equipment daily and as needed;
-Dietary staff should remove dented and damaged cans from the dry food storage room and return the cans to the vendor;
-Dietary staff should seal and date open packages of food in the dry food storage room.
During interviews on 11/17/23 at 12:02 P.M. and 11/21/23 at 11:00 A.M., the Registered Dietitian said the following:
-She expected the dietary or maintenance staff to clean and sanitize the kitchen and dietary equipment daily, weekly and as needed;
-She expected dented/damaged cans to be removed and returned to the vendor;
-She expected open packages to be sealed and dated.
During an interview on 11/14/23 at 2:45 P.M., the Administrator said the following:
-She expected the dietary and maintenance staff to clean and sanitize the kitchen and dietary equipment daily, weekly, or as needed;
-She expected the ice machine in the 200 hall clean utility room to have air gaps at the machine's drain locations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy for cardiopulmonary resuscitation (CPR, process of providing rescue ventilation and chest compressions to maintain circulation of blood) and failed to initiate CPR for one resident (Resident #1) of four sampled residents who was identified as having full code status (CPR required in the event of cardiac or respiratory arrest), when staff found the resident unresponsive and without a pulse or respirations. The resident expired at the facility. The facility census was 54.
On [DATE], the administrator was notified of a Past Noncompliance Immediate Jeopardy (IJ) which occurred on [DATE]. On [DATE], the facility inserviced staff on the CPR policy and procedure, identified other full code residents in the facility and ensured their code status was accurate and easily identifiable. The facility added lists of full code residents to each medication cart and the nurse's station. Licensed Practical Nurse (LPN) B was educated and would work with another licensed staff member for at least three shifts (more if deemed necessary) before working without supervision again. The IJ was corrected on [DATE].
Review of the facility CPR policy, dated [DATE], showed the following:
-Residents at the facility will be designated as full code or do not resuscitate (DNR) as per their request and physician order;
-Residents will be identified as a full code by a code status paper in their red folder, full code on their header in the electronic health record and a blue dot on their name tag outside of their room;
-When a resident is unresponsive, the CPR certified staff member will check the resident for a pulse. If the resident does not have a pulse the CPR certified staff member will initiate CPR. If the unresponsive resident is found by a non CPR certified staff member they will immediately find help of a certified staff member;
-When it is determined CPR should be initiated, the staff member should turn on the call light and yell for help. Once help arrives the charge nurse should take over directing CPR and delegating tasks appropriately;
-CPR certified staff will either call 911 or delegate this task to another staff member;
-CPR will be continued until emergency services personnel arrive and take over the care of the resident.
1. Review of Resident #1's undated face sheet showed the following:
-The resident was admitted to the facility on [DATE];
-The resident had diagnoses that included type 2 diabetes, cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), high blood pressure, and paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own).
Review of the resident's physician order sheet showed an order dated [DATE], for the resident to be full code status.
Review of the resident's care plan, last reviewed on [DATE], showed no evidence of the resident's preferred code status.
Review of the facility's list of CPR certified staff, updated on [DATE], showed the following staff was certified:
-LPN B;
-Certified Nurse Aide (CNA) G;
-Registered Nurse (RN) C.
Review of the resident's progress notes, dated [DATE] at 6:23 A.M., showed LPN B charted the following:
-At 5:20 A.M. the resident's oxygen concentrator was beeping and LPN B went to the resident's room and adjusted the settings, spoke with the resident, and tested his/her blood sugar. The resident rested with his/her eyes closed when LPN B left the room;
-At 5:45 A.M. CNA G alerted LPN B the resident had expired;
-LPN B immediately went to the resident's room and found the resident in the same position as when he/she left the resident at 5:20 A.M.;
-The resident was unresponsive and cold to touch with very deep blue ears and lips and pallor (paleness);
-LPN B removed the roommate from the room;
-LPN B called the supervisor and the resident's family;
-LPN B called the funeral home as directed by the resident's family.
There was no documentation in the resident's record that showed LPN B or CNA G initiated CPR or called 911.
During an interview on [DATE] at 10:38 A.M., LPN B said the following:
-He/She received training upon hire, but not specifically on the CPR policy;
-He/She was not aware which residents were a full code. There was no list of full code residents on the medication carts until after the resident expired;
-He/She did not know a resident's code status was listed on the electronic health record;
-He/She did not know about red folders with the code status of each resident;
-He/She was in the resident's room on [DATE] at 5:20 A.M. to adjust the resident's oxygen level and test the resident's blood sugar. The resident was pleasant and compliant;
-At 5:45 A.M. CNA G ran up the hall and told LPN B the resident had expired;
-LPN B ran to the resident's room and checked for a pulse at the resident's wrist, foot and neck, and there was no pulse. LPN B also used a stethoscope to check for a heartbeat and there was no heartbeat. The resident's ears were the bluest LPN B had ever seen and the resident's face was completely white;
-The resident was in such bad shape LPN B never thought the resident would be a full code;
-There was no one at the facility to ask questions and LPN B waited for the day nurse to arrive;
-It did not occur to LPN B to look in the resident's chart for his/her code status.
During an interview on [DATE] at 6:53 P.M., CNA G said the following:
-He/She was CPR certified;
-On [DATE] he/she went to check on Resident #1 and the resident was unresponsive;
-He/She did a sternal rub and still no response and the resident was foaming from his/her mouth. CNA G checked for a pulse and there was no pulse present;
-He/She ran to the nurse's station to get LPN B;
-On the way to the nurse's station, CNA G realized the resident was a full code;
-He/She started screaming the resident isn't responding, he/she is a full code;
-When CNA G got to the nurse's station, LPN B asked are you sure the resident is a full code? CNA G told LPN B he/she was absolutely sure the resident was a full code, but the nurse did not start CPR;
-He/She felt LPN B should have started CPR;
-CNA G did not start CPR, because he/she did not want to step on the nurse's toes by doing something he/she wouldn't do since he/she was the CNA.
During an interview on [DATE] at 11:33, RN C said the following:
-He/She arrived to the facility at about 5:50 A.M.;
-LPN B said Resident #1 had died;
-LPN B said the resident was okay at 5:20 A.M. when he/she was in the resident's room;
-CNA G said during 15 minute checks he/she found the resident unresponsive and ran out of the room shouting He/She is dead. He/She is a full code!;
-RN C asked LPN B if he/she coded the resident. LPN B said No, he/she was blue and cold to the touch;
-He/She called the administrator and said to have LPN B chart everything and contact the family;
-LPN B asked RN C where to find the code status in a resident's electronic health records.
During an interview on [DATE] at 12:36 P.M. and [DATE] at 12:13 P.M., the administrator said the following:
-She did not think LPN B got information regarding who the full code residents were or how to identify them;
-She felt that was an area where the facility had failed;
-She would have expected LPN B to have started CPR on the resident until emergency services arrived;
-When RN C arrived for day shift, the administrator would have expected RN C to have started CPR on the resident until emergency services arrived;
-She would expect any CPR certified staff to start CPR on a resident that was found unresponsive without a pulse that was a full code.
MO220884

Based on observation, interview, and record review, the facility failed to ensure the walk-in freezer temperature was maintained at 0 degrees Fahrenheit (F) or below, failed to ensure food items were labeled and dated, failed to ensure a food item was not prepared on the steam table, failed to ensure two ice machines were free of an accumulation of debris, failed to ensure fresh produce was washed prior to preparation, and failed to ensure cookware was free of a buildup of black debris and were easily cleanable. The facility census was 48.
Record review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, and showed the following:
-Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety;
-Frozen storage guidelines to be followed: Keep freezer at a temperature that ensures products will remain frozen (0 degrees F);
-Check freezer temperature regularly;
-All food items will be labeled. The label must include the name of the food and the day by which it should be sold, consumed or discarded;
-Discard food that has passed the expiration date and discard food that has been prepared in the facility after seven days of storing under proper refrigeration;
-Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers.
Review of the facility policy, Ice Handling and Cleaning, dated 2011 showed the following guideline and procedure:
-Ice will be stored and served to residents in a sanitary manner;
-Ice will be handled, transported and stored in such a manner as to be protected against contamination;
-Ice machine will be emptied quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build-up in the ice discharge area and floor of the machine.
1. Review of the walk-in freezer temperature log sheet, dated October 2020, showed the following:
-On 10/1/20, the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F;
-On 10/2/20, the day shift temperature was 8 degrees F, and the night shift temperature was 8 degrees F;
-On 10/3/20, the day shift temperature was 7 degrees F, and the night shift temperature was 8 degrees F;
-On 10/4/20, the day shift temperature was 8 degrees F, and the night shift temperature was 9 degrees F;
-On 10/5/20, the day shift temperature was 10 degrees F, and the night shift temperature was 8 degrees F;
-On 10/6/20, the day shift temperature was 9 degrees F, and the night shift temperature was 7 degrees F;
-On 10/7/20, the day shift temperature was 7 degrees F, and the night shift temperature was 9 degrees F;
-On 10/8/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F;
-On 10/9/20, the day shift temperature was 7 degrees F, and the night shift temperature was 8 degrees F;
-On 10/10/20, the day shift temperature was 8 degrees F, and the night shift temperature was 8 degrees F;
-On 10/11/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F;
-On 10/12/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F;
-On 10/13/20, the day shift temperature was 7 degrees F, and the night shift temperature was 6 degrees F;
-On 10/14/20, the day shift temperature was 10 degrees F, and the night shift temperature was left blank;
-On 10/15/20, the night shift temperature was left blank;
-On 10/16/20, ,the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F;
-On 10/17/20, the day shift temperature was 7 degrees F, and the night shift temperature was 8 degrees F;
-On 10/18/20, the day shift temperature was 8 degrees F, and the night shift temperature was 9 degrees F;
-On 10/19/20, the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F;
-On 10/20/20, the day shift temperature was 9 degrees F, and the night shift temperature was 9 degrees F;
-On 10/21/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F;
-On 10/22/20, the day shift temperature was 8 degrees F, and the night shift temperature was left blank;
-On 10/23/20, the day shift temperature was 10 degrees F, and the night shift temperature was 8 degrees F;
-On 10/24/20, the night shift temperature was 8 degrees F;
-On 10/25/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F;
-On 10/26/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F;
-On 10/27/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F;
-On 10/28/20, the day shift temperature was 7 degrees F, and the night shift temperature was 7 degrees F;
-On 10/29/20, the day shift temperature was 9 degrees F, and the night shift temperature was 8 degrees F;
-On 10/30/20, the day shift temperature was left blank, and the night shift temperature was 7 degrees F;
-On 10/31/20, the day shift temperature was 7 degrees F, and the night shift temperature was 9 degrees F.
Review of the walk-in freezer temperature log sheet, dated November 2020, showed the following:
-On 11/1/20, day shift temperature was 7 degrees F, and night shift temperature was 8 degrees F;
-On 11/2/20, day shift temperature was 8 degrees F, and night shift temperature was 8 degrees F;
-On 11/3/20, day shift temperature was 9 degrees F, and night shift temperature was 9 degrees F;
-On 11/4/20, day shift temperature was 8 degrees F, and night shift temperature was 7 degrees F;
-On 11/5/20, day shift temperature was 7 degrees F, and night shift temperature was 9 degrees F;
-On 11/6/20, day shift temperature was 9 degrees F, and night shift temperature was 10 degrees F;
-On 11/7/20, the number documented for day shift was not legible, and night shift temperature was 10 degrees F;
-On 11/8/20, day shift temperature was 9 degrees F, and night shift temperature was 10 degrees F;
-On 11/9/20, day shift temperature was 7 degrees F.
Observation on 11/9/20 at 9:45 A.M. showed the temperature of the walk-in freezer was 10 degrees F.
Review of the walk-in freezer temperature log sheet, dated November 2020, showed the following:
-On 11/9/20, the night shift temperature was 8 degrees F;
-On 11/10/20, the day shift temperature was 7 degrees F.
Observation on 11/10/20 at 9:14 A.M. showed the thermometer inside the walk-in freezer measured a temperature of 10 degrees F.
Observation on 11/10/20 at 10:38 A.M. of the walk-in freezer showed the thermometer inside the unit measured an internal temperature of 11 degrees F. The digital display outside the freezer showed an internal temperature of 11 degrees F.
During an interview on 11/10/20 at 9:14 A.M., the dietary manager said she was not aware the walk-in freezer temperature was measuring above 0 degrees F.
During an interview on 11/10/20 at 2:43 P.M., the dietary manager said freezer temperatures should be 0 degrees F or colder. If she found out the freezer temperatures was not measuring 0 degrees F or colder, she would contact maintenance staff. Maintenance staff was then responsible for contacting a repairman if needed. She was not aware the temperature had not been cold enough, as she had been on vacation recently.
2. Observation on 11/9/20 at 9:45 A.M. during the initial tour of the kitchen, showed the following:
-In the dry food storage room, a package of tortilla shells was open and not dated;
-In the reach-in refrigerator, a container of pimento cheese was open and not dated;
-In the reach-in refrigerator, a zippered plastic bag of waffles was not dated;
-In the reach-in refrigerator, a zippered plastic bag of donuts were not dated;
-In the walk-in freezer, a plastic storage tub held three zippered plastic bags. One bag contained a food item that could not be identified and was not labeled or dated. Two additional bags contained what appeared to be breadsticks and were not labeled or dated.
During an interview on 11/10/20 at 2:43 P.M., the dietary manager said staff should label and date food items. Leftovers were good for seven days and then staff should discard them.
3. Observation on 11/10/20 at 10:28 A.M. showed Dietary Staff A poured a 26-ounce package of instant mashed potatoes into a large steam table pan that sat inside the steam table. The pan contained water. He/She stirred the instant potatoes into the water. He/She added approximately half of a second bag of instant mashed potatoes to the pan and stirred the potatoes and water together until they began to thicken and combine. He/She then placed the lid on the steam table pan.
During an interview on 11/10/20 at 2:43 P.M., the dietary manager said staff usually prepared mashed potatoes on the steam table. Staff obtained hot water from the coffee maker and added to the steam table pan, added instant potatoes and stirred the mixture together. He/She was not aware food items were not supposed to be prepared on the steam table.
4. Observation on 11/10/20 at 9:00 A.M. showed the ice machine located in the kitchen had a buildup of crusty white-colored debris under the edge of the lid as well as in the area around the hinge located above the accumulated ice cubes below.
Observation on 11/11/20 at 10:36 A.M. showed the ice machine located inside a clean utility room on the 200 Hall had an accumulation of crusty white-colored debris around the hinges over the ice and had black-colored debris on the white plastic separator piece above the ice discharge area.
During an interview on 11/10/20 at 2:43 P.M., the dietary manager said dietary staff cleaned the ice machine in the kitchen every three months. Staff emptied the unit, melted and drained, then rinsed and refilled. Maintenance staff was responsible for cleaning the ice machine in the utility room.
During an interview on 11/11/20 at 10:36 A.M., the maintenance supervisor said maintenance staff was responsible for cleaning the ice machine in the utility room and dietary staff cleaned the ice machine in the kitchen. Maintenance staff cleaned the ice machine in the utility room every three months.
5. Observation on 11/10/20 at 10:36 A.M. showed Dietary Staff B wore gloves, reached into a plastic grocery bag and removed a tomato from the piece of the remaining vine. He/She did not wash the tomato and began slicing the tomato with a knife. He/She placed the slices into a plastic storage container.
Observation on 11/10/20 between 11:03 A.M. and 12:29 P.M. during the lunch meal service, showed Dietary Staff A placed slices of tomato from the plastic container onto a resident's tray per the resident's request.
During an interview on 11/10/20 at 2:43 P.M., the dietary manager said staff should wash fresh produce prior to food preparation.
6. Observation on 11/10/20 at 10:13 A.M. showed a red skillet hung on a hook from the suspended ceiling storage rack. The skillet had an extremely heavy buildup of black crusty carbon debris that covered approximately 50-75% of the cooking surface on the inside of the skillet.
Observation on 11/10/20 at 12:09 P.M. showed a metal wire fryer basket stored below the metal preparation counter. The upper one-third of the basket had a buildup of black carbon-like debris all the way around the basket. The black debris covered the wire basket holes in several areas.
During an interview on 11/10/20 at 2:43 P.M., the dietary manager said the red skillet and the wire basket couldn't be cleaned very well and probably needed to be thrown away.