GOLDEN YEARS NURSING AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established national guidelines, were prepared in advance and were followed for 1-of -1 reviewed for menus. 1. The facility failed to ensure current, accurate menus were provided and visible to residents for one dining area 2. The facility failed to ensure residents were offered individual menus for meal which is not a homelike environment. These deficient practices could place at risk of not getting food that they want or like. Findings included: Observation on 8-05-2025 at 11:15 am, revealed There were no menus posted in the dining room. The menu was written on the chalkboard right before residents were served lunch. There was only one menu in the facility on one of the halls. The menu located on information board from a previous month and did not include the current lunch items. The menu on the board was beef stew and baked ham was served, The menu on the board was in small print.Interview on 8/7/2025 at 9:30 AM, Resident #56 stated during, she did not know what meal she was going to have until the meal was brought to her room. She said she did not have a menu in her room. She stated she did not know where the menu was located. Resident #56 stated she would like to know if there were other options on the menu besides what she got. Resident did not know that she could get a menu. She stated that in the past she has received a menu in the past, but that has been several months ago. Interview on 8/7/2025 at 9:40 AM, Resident #7 stated during Sometimes the food is okay, but I would like to know what I am eating ahead of time. Resident #7 stated she was bed-bound and could not get out of the room to see what was on the menu. She stated she would like to know what she was having before they brought the food in case, she wanted something else. She expressed frustration about not knowing what was on the menu. Interview on 8/7/2025 at 9:50 PM, Resident #7 stated she did not know where the menu was in the building. She said she did not have a menu in her room and was not told what was on the menu. She said she did not know what she was going to get for her meal. Resident #7 stated she ate in the dining room and was unsure where the menu was in the facility. The resident stated she did not know what the substitute item was on the menu. Interview on 8/7/2025 at 9:50 AM, the DM stated during residents only got a menu if they asked for it. He said residents at the facility did not usually ask for a substitute meal because they liked the food being served. He said the menu was on the board towards the front of the facility. He said that was the only menu posted. He said they wrote down the menu on the chalkboard in the kitchen in the morning, so residents knew what they were having for lunch after breakfast is served. DM manager said he put the menu out for residents to see and it is the one that he gets from [NAME]. DM manager said besides the one menu that is posted he writes the menu on the chalk board in the dining room. Interview on 8/7/2025 at 11:10 AM, the ADM stated Residents should be able to have access to the menus so that they know what their meal is going to be The menu should be posted in more than one place in the facility, and it should be big enough for the residents to see. The menu is written on the chalkboard in the kitchen before the meal is served in the dining room.Record review of Menus and Adequate Nutrition Policy, revised on 7/16/2025, reflected Policy.Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitution shall comprise of foods with comparable nutritive value.Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance.Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking. Review of the federal food code. Federal food safety regulations for nursing homes are primarily outlined in 42 CFR S 483.60, which addresses food and nutrition services. These regulations emphasize providing residents with a nourishing, palatable, and well-balanced diet that meets their individual nutritional needs and preferences. Key aspects include ensuring food safety, proper staffing, and adherence to dietary requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the medical record was complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records.<BR/>The facility failed to document nursing progress notes, assessments, or transfer documents when Resident #1 was transferred to the acute care hospital on [DATE].<BR/>This failure could place residents at risk for not receiving appropriate care due to incomplete information in the chart.<BR/>Findings included:<BR/>Review of Resident #1's admission MDS assessment, dated 10/04/24, Section A (Identification Information) reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including hypertension (high blood pressure), peripheral vascular disease, (disorder of the blood vessels outside of the heart, often decreased blood flow to the limbs) renal insufficiency (poor kidney function), diabetes mellitus (a condition that affects the way the body processes blood sugar), cerebrovascular accident (stroke), and subacute osteomyelitis right ankle and foot (a chronic infection of bone). Section C (Cognitive Patterns) reflected a BIMS score of 9 indicating moderately impaired cognition. Section M (Skin Conditions) reflected an infection of the foot and surgical wounds.<BR/>Review of Resident #1's electronic medical record reflected there were no assessments completed on 10/28/24.<BR/>Review of Resident #1's electronic medical record reflected there were no progress notes written 10/28/24 that reflected the resident's status, a change in status, or an emergent condition that warranted transfer to the acute hospital. There was no progress note that reflected the provider was notified nor an order to transfer to the acute hospital received.<BR/>Review of Resident #1's electronic medical record reflected there was no physician order to transfer the resident to the acute hospital.<BR/>Review of Resident #1's electronic medical record reflected a progress note dated 10/28/24 at 9:00 PM, written by LVN A, Ambulance transportation here to take resident to [name] ER. RP notified.<BR/>During an interview on 10/30/24 at 10:45 AM, the DON stated Resident #1 had wounds, and despite the interventions, the wounds had not improved. The plan had been to send the resident back to the hospital where the surgical team would request a consult from the vascular team. She stated the resident went to the ED then was admitted to the hospital. She stated the MDS nurse monitored completion of assessments but no one monitored the progress notes.<BR/>During a telephone interview on 10/30/24 at 4:03 PM, LVN A stated she was told EMS was scheduled to take the resident to the hospital so he could see the surgeon. She stated when EMS arrived, the resident was awake. I told him where he was going and told him I would call his family . She stated when a resident was sent out of the facility, the nurse was expected to write a note and complete an assessment. She stated, I didn't do it. She stated it was a busy time and she was going to go back later to complete the documentation but did not. She stated not documenting could lead to a lack of communication, not knowing the baseline or if changes occurred.<BR/>During a telephone interview on 10/30/24 at 4:12 PM, LVN B stated she had contacted the surgeon about the wounds not improving and the surgeon said to send him to the ER. She stated EMS showed up but before they got to the resident, they received an emergent call so they left stating they should be back around 7 or 8:00 PM. She stated she left the facility around 7:30 PM and EMS had not yet returned. She stated she could not remember if she documented the conversation with the surgeon. She stated, I know I should have written a note, usually I do. She stated when a resident was sent out to the hospital, the nurse was expected to complete a transfer note. She stated the nurses were expected to document changes in the resident's condition.<BR/>During an interview on 10/30/24 at 4:30 PM, the DON stated it was her expectation that documentation was completed accurately and timely. She expected the documentation to depict a good view of the resident. She stated not documenting in the resident's medical record could lead to staff not knowing if the resident had a change, was declining, or improving. The lack of communication or documentation could lead to a delay in care.<BR/>During an interview on 10/30/24 at 4:37 PM, the ADM stated he expected accurate documentation and timely. He stated, When time is of the essence and trying to get someone transferred out, there is the human error aspect. He stated the nurses were aware of the documentation expectations. He stated delay of care would be the biggest negative outcome of not documenting in the resident's medical record.<BR/>Review of the facility policy revised July 2017 and titled, Charting and Documentation reflected in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations: d. Changes in the resident's condition: e. Events, incidents or accidents involving the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of 1 of 3 (Resident # 2) reviewed for misappropriation.<BR/>The facility failed to prevent a diversion (misappropriation) of Resident's #2's Ativan 0.5 mg, 60 tablets (an anti-anxiety medication) received from the pharmacy on 5/22/2024 at 12:17 am and reported missing 5/22/2024 during the day shift.<BR/>This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. <BR/>The non-compliance was identified as Past non-compliance, the facility had corrected the non-compliance before the survey began.<BR/>Findings included:<BR/>Review of Resident # 2's faced sheet printed `5/22/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Alzheimer's disease ( A progressive disease that destroys memory and other important mental functions) , Cognitive communication deficit ( a communication difficulty caused by a cognitive impairment, this impairment can affect any aspect of communication, including verbal and nonverbal language, ,speaking, listening, reading writing and social interaction) and palliative care(specialized medical care for people living with a serious illness)<BR/>Review of Resident's #2's of admission MDS dated [DATE] revealed a BIMS score of 3 which can indicate a serve cognitive impairment, Resident was receiving hospice care.<BR/>Review of Resident # 2's physician orders dated 6/3/2024 revealed order written on 5/5/2024 Ativan 0.5 mg Po PRN Q 4 hours for anxiety.<BR/>Review of the provider investigation report dated 5/31/2024 reflected, on 5/22/2024 at 12: 17 am the pharmacy delivered 60 (sixty) tablets of Ativan 0.5 mg for Resident # 2, packing slip from the pharmacy was signed by LVN A as received. Medication was noticed as missing, on the next shift. A search of the facility's medication rooms and medication carts and the medication was not located. The report reflected no injury or harm to the resident as medication was available in the emergency medication kit and the facility replaced the missing medication after the investigation was completed, the facility notified Hospice, the responsible party, the medical director, and the police. Statements were obtained and staff were drug tested. The investigation findings confirmed the drug diversion. <BR/>Review of the pharmacy packing slip dated 5/22/2024 reflected Ativan 0.5 mg 60 tablets was delivered to the facility and signed as received by LVN A<BR/>Review of the Business card left by the responding police officer reflected, Case No: 24-002740.<BR/>Review of Inservice dated 5/22/2024 reflected that all LVN and RN's were inserviced on Controlled Substance that included the process for accepting scheduled medications from the pharmacy. <BR/>Review of LVN A employee file reflected an counseling on 5/24/2024 for not following the controlled substance policy. <BR/>During a phone interview on 6/3/2024 am 12:55 PM with the local police department desk sergeant, the investigator on the case was working night shift this week, left message for return phone call. No return phone call received prior to exit. <BR/>During phone interview on 6/3/2024 at 1:00 PM LVN A stated that she does not remember getting the Ativan for Resident # 2 when the medication was delivered on 5/22/2024. She remembers receiving the other medication that she signed for as she had to lock it up in the refrigerator. She was not sure why she signed for the medication if she didn't see it, she stated it was her usual practice to verify each medication prior to signing the delivery receipt. She stated she was counseled on not following the Controlled substance policy after being inserviced on it. <BR/>During an interview with LVN B on 6/3/2024 at 1:30 PM she was inserviced on accepting controlled substances from the pharmacy and was able to verbalize the process for accepting scheduled medications from the pharmacy.<BR/>During an interview with DON on 6/3/2024 at 2:00 PM stated they did not identify a perpetrator or find the missing medications. He stated he was not sure the medication was even delivered, as the receiving nurse does not recall putting the medication in the lock box. After the medication was discovered missing, the facilities medication rooms and cart were searched, pharmacy was notified and stated since the medication was signed for, they would not be doing an investigation. There was no narcotic sign out sheet, which was delivered with the medication found. She stated that all staff were drug tested with negative results. He stated the medication and the sign out sheet were never located, and the medication was replaced by the facility. He stated that the medication was available in the emergency drug kit, so no doses were missed, there was no adverse reaction to the resident. <BR/>Review of the facility policy Controlled Substances revised November 2022 reflected 3. Controlled substances are counted upon deliver. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record <BR/>The facility course of action prior to surveyor entrance included:<BR/>1. <BR/>Review of in-service conducted on 5/23/204 revealed all licensed staff were in-serviced on controlled <BR/>substances that included the process for accepting controlled substance from the pharmacy.<BR/>2. <BR/>Interview with DON on 6/3/2024 at 2 PM. LVN A was consoled on 5/23/2024 for not following policy and <BR/>procedure.<BR/>3. <BR/>Interview with DON on 6/3/2024 at 2 PM medication was replaced by the facility on 5/30/204.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to prevent Resident #1 from eloping on 05/21/2024.<BR/>The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 5/21/2024 and ended on 5/22/2024 The facility had corrected the non-compliance before the survey began. <BR/>This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. <BR/>The findings were: <BR/>Record review of Resident # 1's face sheet, dated 6/3/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on 5/21/2024 with diagnosis that includes Schizophrenia ( a disorder that affects a person's ability to think, feel and behave clearly.), Type 2 Diabetes Mellitus ( A long term condition in which the body has trouble controlling blood sugar and using it for energy) and , Mild intellectual disabilities ( is a neurodevelopmental disorder that affects intellectual functions and daily living skills,)<BR/>Record review of Resident's # 1 admission MDS, dated [DATE] reflected a BIMS revealed resident was not appropriate for an evaluation as resident in rarely/ never understood. Section E revealed wandering occurred to 1 to 3 days, with no significant risk of getting to a potentially dangerous place. <BR/>Record review of Resident # 1's wandering/elopement risk assessment tool dated 5/2/204 had a score of 7 (moderate risk} , resident ambulates independently and a history of wandering behaviors, no history of elopement from home or previous facility.<BR/>Review of Resident #1's care plan dated 5/3/2024 reflected problems of wandering and risk for elopement with interventions that include a wander guard and redirection for the exit doors. <BR/>Review of Resident #1's orders dated 5/2/2024 reflected an order for signaling device is use, Signaling Device: Change electronic monitoring device according to manufacture's recommendations and PRN if noted non-functional, and Signaling Device: check electronic monitoring device via testing machine every day, every night shift for wandering/exit seeking. <BR/>Review of Resident #1's Treatment Record for the month of May 2024, reflected Signaling device check done daily on night shift. <BR/>Observation on 5/2/2024 at 12:45pm of the alarm response at the front door of the facility reflected the wander guard functional and sufficiently loud to alert the staff of a potential elopement. <BR/>During a phone interview on 6/3/2024 at 1:00 PM LVN A stated if a resident was not able to not be located a code pink was called a code Pink after searching the facility, they are to notify the Administrator, DON, and responsible party. A search of the ground was then completed and if not found the local police are notified. She stated there was a pink binder at both nurse's station with all resident's that are at risk of elopement with there picture and face sheet. She stated they had an elopement drill, and they were in-services on the elopement policy and protocol and abuse and neglect. <BR/>During an interview on 6/3/2024 at 1:15 PM with CNA B stated that if she could not find a resident, she would let the charge nurse know and help with the search, she is not sure when, but a some point the nurse will notify the administrator, DON and family members. If there is a missing resident, they will call a CODE PINK then we start making sure all of my resident are accounted for and then help the others to look for theirs. We had a drill a couple of weeks ago, along with an in-service on elopement and abuse and neglect. The Abuse coordinator lithe administrator,and if he is not here, she would let the charge nurse and the DON know.<BR/>During an interview on 6/3/2024 at 2:00 PM with the DON he stated saw Resident #1 in the dining room at 5:45 PM looking for some more to eat. The DON stated he received a phone call at 6 PM that a off duty employee had seen the resident in the parking lot of a local grocery store, about a block away and brought him back to the facility. The wander guard did go off when the resident returned to the building. He stated they were unable to determine how the resident left the building, placed him on one to one and moved him to a sister facility with a secure unit. The front door is now locked at all times with a code for entrance and exit, delay exit is still active. at the time of the incident, it was unlocked till 8 PM for visiting hours and there was no one at the desk after PM. <BR/>During an interview on 6/3/2024 at 2:30pm with Maintenance director reported they have done an code Pink elopement drill on both shifts since the incident, the Fire safety company has come out and tested the doors with sensors on them and verified they are working and increased the sensitivity and the volume of the alarm. <BR/>Record review of policy Wandering/ Elopement revised March 2019 reflected 3. If a resident is missing, initiate the elopement/missing resident emergency procedure:<BR/> a. Determine if the resident is out on an authorized leave or pass.<BR/> b. If the resident was not authorized to leave, initiate a search of the building, and premises and<BR/> c If the resident is not located notify the administrator, and the director of nurses, the resident's legal representative, the attending physician, law enforcement officials and (as necessary) volunteer agencies. <BR/>The DON was notified on 6/3/2024 at 5:45 PM that a past non-compliance Immediate Jeopardy had been identified due to the above failures. <BR/>The facility course of action prior to surveyor entrance included:<BR/>Record review of Resident # 1 Progress notes, he was initial placed on 1:1 supervision and moved to a sister facility with a <BR/>secure unit, on 5/21/2024 <BR/>The facility contacted the alarm company, who increased the volume and sensitivity for the alarm system on 5/22/2024 confirmed with invoice of work dated 6/3/2024.<BR/>Record review of Provider instigation revealed all residents with wander guards were checked for functioning, <BR/>Interview with DON on 6/3/2024 at 4:00pm the facility has standing MD orders on all residents with a wander guard has the device checked daily on the nightshift, that include placement, function with a testing device and skin assessment under the device. <BR/>Interview with Maintenance director stated that immediately after the elopement incident, the front doors to the facility were locked with entry and exit code required 24 hours a day, previously they were unlocked till 8 PM with no one at the desk after PM. <BR/>Review of In-services reflected the facility had an elopement drill on 5/22/2024 for all staff members on both shifts.<BR/>Record review of an In-service training dated 5/22/2024, related to elopement and abuse and neglect revealed 50 out of 50 staff member's signatures. <BR/>Interview were conducted with 17 employees on 6/3/2024 between 10 am and 4 PM, which consisted of LVN's ( 2) Medication Aides(1), CNA's (4), Physical therapist, Physical therapy assistance (3) Occupational therapist, Certified Occupational therapy assistance (2), Speech Therapist and Housekeepers (2) on 6/3/2024 from 10:00 am to 2:00 PM revealed they had received in-services on Elopement Response, All were able to state the key elements of the elopement policy which included<BR/>If a resident is missing, initiate the elopement/missing resident emergency procedure: <BR/>a. Determine if the resident is out on an authorized leave or pass.<BR/> b. If the resident was not authorized to leave, initiate a search of the building, and premises and <BR/>c If the resident is not located notify the administrator, and the director of nurses, the resident's legal representative, the attending physician, law enforcement officials and (as necessary) volunteer agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care based on the comprehensive assessment of a resident and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 16 Residents reviewed for quality of care<BR/>The facility failed to perform Resident #33's left fifth toe wound treatment as ordered on 07/01/24.<BR/>This failure placed residents at risk of worsening infection, sepsis, and amputation.<BR/>Findings included:<BR/>Review of the undated face sheet for Resident #33 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), type two diabetes mellitus, morbid obesity, need for assistance with personal care, difficulty in walking, long-term use of anticoagulants, and venous insufficiency (malfunction of venous walls and/or valves in systemic circulation, especially in the legs, that result in peripheral pooling of blood known as stasis).<BR/>Review of the quarterly MDS assessment for Resident #33 dated 05/22/24 reflected a BIMS score of 15, indicating an intact cognitive response. It reflected that she did not have an infection or other wound of the foot during the lookback period (seven days of data from which the assessment results are drawn). <BR/>Review of laboratory culture results for Resident #33 dated 06/25/24 reflected MRSA was detected in a sample taken from the fluid filled blister on her left fifth toe on 06/24/25.<BR/>Review of the care plan for Resident #33 dated 07/01/24 reflected the following:<BR/>Altered skin integrity non pressure related to: Right 5th toe fluid filled blister. Affected area will heal without complications through next review date. <BR/>o Antibiotic ointment per MD order<BR/>o Evaluate need for pain reliever prior to cleansing or dressing changes<BR/>o Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings<BR/>o Notify practitioner if symptoms worsen or do not resolve<BR/>o Treatments as ordered<BR/>o Weekly Wound evaluation<BR/>Review of physician orders for Resident #33 reflected an order for Mupirocin External Ointment 2 % (Mupirocin) Apply to Left small toe topically every day shift for Staph infection for 10 Days with a start date of 06/25/24 and an end date of 07/05/24.<BR/>Review of the June 2024 and July 2024 TAR for Resident #33 reflected the following treatment was documented on 06/30/24 and 07/01/24 by LVN A: Mupirocin External Ointment 2 % (Mupirocin) Apply to Left small toe topically every day shift for Staph infection for 10 Days.<BR/>Observation and interview on 07/02/24 at 09:16 AM revealed Resident #33 seated in her easy chair with her feet elevated. She had a sign on her door indicating contact precautions were in place, and her left foot was wrapped in gauze. The date 06/30/24 was written on a piece of white tape on the gauze. Resident #33 stated she had a blister on her foot and was receiving wound treatment for it. She stated she thought she had gotten wound treatment the day before but was not completely sure. She stated it had not been done that day. She stated the wound did not hurt. <BR/>During observation and an interview on 07/02/24 at 11:05 AM, the DON was preparing to administer medications to Resident #33. She stated she had not yet been in Resident #33's room and had not seen the bandage on her foot. The DON went into Resident #33's room and returned within a few moments. She stated the bandage on Resident #33's left foot was dated 06/30/24. She stated she needed to check the orders to determine why the bandage was documented as changed on 07/01/24 but still dated 06/30/24.<BR/>During an interview on 07/02/24 at 02:00 PM, the DON stated she had determined the wound treatment for Resident #33's fifth left toe had not been completed by LVN A. She stated LVN A had made a mistake and thought she completed the treatment so had signed the TAR to indicate as such, but she could not find the notes that the treatment had been done. The DON stated it was only her second day at the facility, and she had not developed a system for monitoring to ensure wound care was completed, but she had already started in-servicing the staff on the failure. She stated the potential impact of not receiving antibiotic ointment on a skin infection was worsening infection. <BR/>Observation on 07/02/24 at 03:00 PM revealed LVN B provided the wound treatment to Resident #33's blister to the left fifth toe. Observation of the wound revealed a large fluid-filled blister the size of the entire fifth (pinky) toe. The blister membrane was intact, and the fluid inside it was slightly serous (clear with a slight yellow). The fifth toe was almost completely obscured by the blister.<BR/>During an interview on 07/02/24 at 04:18 pm, LVN A stated yesterday, 07/01/24, was her first day back at the facility after a leave of absence. She stated she was not familiar with all the wounds in the building but normally, she kept track of her treatments by looking at the TARs for all of her residents and handwriting the orders down on a piece of paper. She stated she then documented her notes about the wound on the paper and entered all of it into the system when she was done. She stated she did not pull a report of treatments; she just went through and looked at all of her residents. LVN A stated she had Resident #33 on her list and had no excuses for not performing the treatment. She stated there were four or five new residents after coming back, and she was getting to know them, and she was not in the groove of things. LVN A stated she had a new admission after 03:00 PM on 07/01/24 and she got distracted and marked Resident #33's treatment as done when it was not. LVN A stated the orders for Resident #33's blister were to cleanse with normal saline and apply mupirocin. LVN A stated she was trained to complete all her treatments as ordered and to only document in the EMR if she completed the treatment. She stated the potential impact of the treatment not being done as ordered was the infection could become worse, Resident #33 could get sick and possibly even die. <BR/>During an interview on 07/03/24 at 02:00 PM, the ADM provided policy on Medication and Treatment Orders, but these were not relevant to the failure. There was no other policy that was specifically relevant to the failure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for one (Resident #2) of 15 residents reviewed for care plans.<BR/>The facility failed to identify Resident #2's preference for wearing a hospital gown daily instead of her personal clothing. <BR/>This failure put residents at risk for their preferences not to be honored and decreased quality of life. <BR/>Findings included:<BR/>Review Resident #2 Face sheet dated 04/27/2023 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnosis Cataract (a clouding of the lens of the eye or of its surrounding transparent membrane that obstructs the passage of light), Chorioretinal scars (a pigmentary change in the back of the eye that may result from an infection, injury, or inflammation), and Vitreous degeneration (a change or deterioration of the vitreous humor, the gel-like substance that fills the inside of the eye and helps with vision and eye shape). <BR/>Review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 12 to indicate mild cognitive impairment. Resident #2 required extensive assistance by one staff member for dressing and personal hygiene. <BR/>Review of Resident #2's care plan dated 03/10/2023 revealed Resident #2 required staff to assist me to choose simple comfortable clothing that enhances the resident's ability to dress self. Review of care plan did not include Resident #2's preference to wear a hospital gown instead of her personal clothing.<BR/>In an observation and interview on 04/25/2023 at 9:57 AM, Resident #2 was in her wheelchair wearing a hospital gown. Resident #2 stated she just had a shower and said she asked to wear the hospital gown. Resident #2 pointed at her clothes in the cabinet in her room and said she had clothes but liked to wear the hospital gown because it was more comfortable. <BR/>In a follow-up observation on 04/26/2023 at 9:10 AM, Resident #2 wore a hospital gown while watching TV in her room.<BR/>In an interview on 04/26/2023 at 10:00 AM, the DON stated she was new to the facility and unsure of whether it was Resident #2's preference to wear a hospital gown or not. She stated she would check with staff and her documentation. She stated Resident #2 did have her own clothing to wear. <BR/>In an interview on 04/27/2023 at 10:13 AM, CNA J stated Resident #2 preferred to wear a hospital gown because it was more comfortable for her. She stated Resident #2 said it made her feel cooler and Resident #2 felt like her clothes were too restrictive. She stated she was not sure if Resident #2's preference for a hospital gown was included on her care plan. <BR/>In a follow-up interview on 04/27/2023 at 11:30 AM, the DON stated it was Resident #2's preference to wear a hospital gown instead of her clothing. She stated Resident #2's preference to wear a hospital gown was not on her care plan. She stated Resident #2's preference for wearing a hospital gown instead of her personal clothing should be on the care plan so anyone caring for Resident #2 knew that it was Resident #2's preference. She stated adding Resident #2's preference to wear the hospital gown to her care plan ensured the facility was not violating any dignity issues for Resident #2.<BR/>In an interview on 04/27/2023 at 11:55 AM, the MDS NURSE stated Resident #2's preference for wearing a hospital gown over Resident #2's personal clothing should have been added to Resident #2's care plan. She stated she was not made aware of Resident #2's preference until recently and had not had a chance to add the information to Resident #2's care plan. She stated anytime there was change for a reference that affected their including resident preferences she tried to update their care plan immediately or within a day or two to ensure continuity of care among caregivers . She said not updating a residents care plan could result in confusion for a resident's preferences and needs not being met.<BR/>Review of Care Plans, Comprehensive Person-Centered Policy dated Quarter 3 2018 revealed a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further revealed the care planning process will . <BR/>Incorporate the resident's personal and cultural preferences in developing the goals of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one resident reviewed for catheter care (Resident #11).<BR/>The facility failed to ensure Resident #11's catheter was secured to his body with a catheter secure device.<BR/>This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.<BR/>Findings Included:<BR/>Review of Resident #11's Face sheet dated 04/27/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), Diabetes Mellitus Type II (a chronic disease where the body has high blood sugar, insulin resistance, and relative lack of insulin), Pressure ulcer of Sacral Region. <BR/>Review of Resident #11's Significant change in status MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 9 indicating he had mild cognitive impairment. Resident #11 was further assessed to require extensive assist with all ADLs. Resident #11 was assessed to have an indwelling catheter.<BR/>Review of Resident #11's Care Plan reflected a focus area initiated on 01/27/2023 and revised on 04/21/2023 Alteration in elimination of bowel and bladder related to incontinent of bowel and indwelling foley catheter, has history of UTI and the potential for recurrence. Interventions included .Anchor catheter, avoid excessive tugging on the catheter during transfer and delivery of care .<BR/>Review of Resident #11's History and Physical dated 03/17/2023 reflected Resident #11 had history of chronic foley catheter and history of penis damage from foley.<BR/>Observation on 04/26/2023 at 2:00 PM revealed Resident #11 in room in bed. Resident #11 had a Foley Catheter in place without a device to secure the catheter to his leg.<BR/>Observation and interview on 04/27/2023 at 9:29 AM revealed Resident #11 in room in bed. Observation with the DON revealed resident with no catheter secure device was in place. Further observation revealed Resident #11's meatus and glans (penis) were split from the tip of the glans to base. The DON stated the resident should have a catheter secure device in place in prevent further injury to his glans. The DON stated it was the nurse on duty responsibility to ensure catheter care is done and to ensure the catheter secure device is in place . <BR/>In an interview on 04/27/2023 at 9:49 AM LVN A stated she was responsible for catheter care and to ensure catheter secure devices are in place. LVN A stated she did not notice that Resident #11 did not have a catheter secure device in place. LVN A stated there should have been one but usually they have an order for it, and she did not see one .<BR/>In an interview 04/27/2023 at 9:51 AM the DON stated the nursing staff should ensure the catheter secure devices are in place for residents with indwelling urinary catheters and the devices should be checked regularly. The DON further stated that the lack of the catheter secure device could cause further penis damage and or infections.<BR/>Review of the facility's policy Catheter Care, Urinary dated 3rd Quarter 2018 reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater for when the facility had a medication error rate of 20% based on 7 of 35 opportunities, which involved 3 of 5 residents (Resident #2, Resident #11, and Resident #22) and 1 of 3 LVN's (LVN A) observed during medication administration. <BR/>A) Resident #2 had a physician order for Preser Vision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. LVN A failed to administer the medications. <BR/>B) Resident #11 had a physician order for Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. LVN A failed to administer the medications.<BR/>C) Resident #22 had a physician order for Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. LVN A failed to administer the medications.<BR/>These deficient practices could place residents at risk of not receiving therapeutic dosage of medications.<BR/>Findings Include: <BR/>A) Review Resident #2 Face sheet dated 04/27/2023 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnosis Cataract (a clouding of the lens of the eye or of its surrounding transparent membrane that obstructs the passage of light), Chorioretinal scars (a pigmentary change in the back of the eye that may result from an infection, injury, or inflammation), and Vitreous degeneration (a change or deterioration of the vitreous humor, the gel-like substance that fills the inside of the eye and helps with vision and eye shape). <BR/>Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 12 indicating mild cognitive impairment. Resident #2 was assessed to require extensive to dependent assist with all ADLs. <BR/>Review of Resident #2's Comprehensive Care Plan reflected a focus area dated 04/14/2021 Resident has impaired visual function related diagnosis of glaucoma and history of cataracts <BR/>Review of Resident #22 Consolidated Physician dated 04/27/2023 reflected an order for PreserVision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools.<BR/>Observation on 04/26/2023 at 8:33 AM revealed LVN A preparing Resident #2's 9:00 AM medication for administration. The medications included the following: <BR/>-Myrbetrig 50 mg ER on e tab<BR/>-Docusate Sodium 100 mg one capsule<BR/>-Fexofenadine Hydrochloride 180 mg one tablet<BR/>-Vitamin D3 25mcg (1000 IU) two tabs<BR/>-Multi vitamin with minerals one tab<BR/>-Tussin DM Liquid 10-200mg/ML 10 MLS<BR/>LVN A did not administer Resident #2's PreserVision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools.<BR/>B) Review of Resident #11's Face sheet dated 04/27/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), Diabetes Mellitus Type II (a chronic disease where the body has high blood sugar, insulin resistance, and relative lack of insulin), Pressure ulcer of Sacral Region.<BR/>Review of Resident #11's Significant change in status MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 9 indicating he had mild cognitive impairment. Resident #11 was further assessed to require extensive assist with all ADLs.<BR/>Review of Resident # 11's Consolidated Physician dated 04/27/2023 reflected an order for Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily.<BR/>Observation on 04/26/2023 at 8:40 AM revealed LVN A preparing Resident #11's 9:00 AM medication for administration. The medications included the following:<BR/>-Pro-state liquid 30 ML<BR/>-Ciprofloxacin 500 mg one tablet<BR/>-Hydrocodone/ Apap 5-325mg one tablet<BR/>-Gabapentin 300 mg one tablet<BR/>-Famotidine 20 mg tablet<BR/>-Amlodipine 5mg one tablet<BR/>-Labetalol 100 mg one tablet<BR/>- Decubi-Vit oral capsule one tablet<BR/>LVN A did not administer Resident #11's Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily.<BR/>C) Review of Resident #22's Face sheet reflected a [AGE] year-old female admitted on [DATE] with the following diagnosis of Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall. Symptoms vary depending on the clogged artery.), and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache). <BR/>Review of Resident #22 Quarterly MDS dated [DATE] reflected Resident #22 was assessed to have a BIMS score of 4 indicating serve cognitive impairment. Resident #22 was further assessed to require extensive assist with all ADLs. Resident #22 was assessed to have coronary artery disease and Hypertension. <BR/>Review of Resident #22's Comprehensive Care Plan reflected a focus area dated 09/05/2018, Resident has coronary artery disease interventions included Give all cardiac meds as ordered by the physician .Give meds for hypertension . <BR/>Review of Resident #22 Consolidated Physician dated 04/27/2023 reflected an order for Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily.<BR/>Observation on 04/26/2023 at 9:14 AM revealed LVN A preparing Resident #22's 9:00 AM medication for administration. The medications included the following:<BR/>-Decubi-Vit one tablet<BR/>-Buspirone 10mg one tablet<BR/>-Eliquis 5mg one tablet<BR/>-Hydroxyzine HCL 25 mg one tablet<BR/>-Fluoxetine 10 mg one tablet<BR/>-Memantine HCL 10 mg tablet <BR/>LVN A did not administer Resident #22's Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily.<BR/>In an interview on 10:38 AM LVN A stated after reviewing the medications given to Resident #2 that she did not administer her physician ordered PreserVision AREDS 2 or Probiotic capsule. LVN further stated after reviewing the medications given to Resident #11's that she did not administer his physician ordered Potassium Chloride or Probiotic capsule. LVN A further stated after reviewing the medications given to Resident #22 that she did not administer her physician ordered Lisinopril, Aspirin, or Probiotic. LVN A stated she thought she was checking off all the medications as she went but she must have missed some of the medications because she was nervous. <BR/>In an interview on 04/26/2023 at 10:41 AM the DON stated she reviewed all the missed medications with LVN A. The DON stated LVN A stated she missed the medications and was not sure how. The DON stated she expected nurses who pass medication to follow the 10 rights of medication administration and to administer all the medications the resident's physician ordered .<BR/>Review of LVN A's Licensed Nurse orientation/ Annual Skills/ Competency Checklist dated 05/18/2022 reflected she was checked off to have successfully completed Medication Administration. <BR/>In an interview on 04/26/2023 at 1:46 PM the RNC stated he could not see how LVN A missed all those medications for Resident #2, #11 and #22 during her med pass when she could see them in PCC . The RNC stated he started an action plan and would re-train LVN A. <BR/>Review of the facility's policy Administering Medications dated quarter 3 2021 reflected Medications shall be administered in safe and timely manner and as prescribed .medications must be administered in accordance with the orders, including any required time frame .The individual administering the medications must check the label carefully to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a therapeutic diet as prescribed by the attending physician for one (Resident #15) of eight residents reviewed for therapeutic diet.<BR/>The facility failed to provide Resident #15 with the therapeutic diet as prescribed by her attending physician when she was provided a meal with extra carbohydrate portions when she was prescribed a consistent carbohydrate diet order.<BR/>This failure put residents at risk for health complications related to in adherence to diet order, increased blood sugar and decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #15's Face Sheet dated 04/27/2023 revealed Resident #15 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnoses of pulmonary disease (disease of the lungs that causes trouble breathing), type 2 diabetes, high blood pressure, bipolar disorder (mood disorder in which mood alternates from manic to depression) and arthritis.<BR/>Review of Resident #15's quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of two to indicate severely impaired cognition. Resident #15 was noted to required a therapeutic diet.<BR/>Review of Resident #15's Care Plan dated 06/23/2022 revealed Resident #15 had diabetes mellitus with the goal of no complication related to diabetes through review date. Resident #15 had interventions including dietary consult for nutritional regimen and ongoing observation, discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan and compliance with nutritional regimen.<BR/>Review of Resident #15's Physician Orders dated 03/15/2023 revealed Resident #15 was ordered a Consistent Carbohydrate diet, regular texture and regular consistency. <BR/>In an observation on 04/25/2023 at 12:25 PM, Resident #15 was in the dining room eating a dinner roll. Additionally on Resident #15's tray there were two pieces of fried fish, white rice and pasta salad. <BR/>Review of Resident #15's tray card dated 04/25/2023 revealed Resident #15 received CCHO (Consistent Carbohydrate) diet, Finger Foods and thin liquids. <BR/>In an interview on 04/27/2023 at 11:18 AM, the DM stated Resident #15 received the pasta salad as a finger food selection as it would be easier for Resident #15 to feed herself than the zucchini or rice offered with the regular meal. When asked if the rice, pasta salad and dinner roll included with the meal was consistent with a CCHO diet order, she said no the pasta salad should have been substituted for the rice and an alternative offered with the meal besides a starch. She stated Resident #15 received more carbohydrates with her meal that residents with a regular diet order. <BR/>In an interview on 04/27/2023 at 11:30 AM, the DON stated the therapeutic diet for Resident #15 should have been followed in that Resident #15 was ordered a consistent carbohydrate diet and should be served less carbohydrates than residents on a regular diet. She stated the addition of pasta salad with rice, fried fish and a dinner roll was consistent with professional guidelines for a consistent carbohydrate diet order. She stated failure to serve the physician ordered therapeutic diet could result in Resident #15 experiencing high blood sugar and poor control of Resident #15's diabetes mellitus. <BR/>In an interview on 04/27/2023 at 11:41 AM, the RD stated she could not determine whether Resident #15 was served the physician ordered consistent carbohydrate diet when she was served pasta salad, rice, fried fish and a dinner roll . She said she did not know if the food served was consistent with professional guidelines for a consistent carbohydrate diet. She stated she did not know if serving more starch food choices to a resident on a consistent carbohydrate diet than residents on a regular diet was within professional guidelines. She stated she did not know what the outcome might be if a diabetic resident was served more starch foods than a resident on a regular diet that is not diabetic. <BR/>Review of Resident #15's quarterly Nutrition assessment dated [DATE] revealed Resident #15 was ordered a consistent carbohydrate diet (CCD) with no significant weight gain or loss recently. <BR/>Review of Diet Abbreviations and textures (undated) revealed CCHO-Consistent Carbohydrate-Diabetic-No sugar.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure that expired foods were discarded. 2. The facility failed to ensure the food processor was sanitized between each food item. 3. The facility failed to ensure food items were labeled and dated. 4. The facility failed to ensure that serving utensils and dishes were not stored dirty.These failures could place residents at risk for foodborne illness, causing the residents to get sick in 1 of 1 kitchen. Findings included: Observation on 8/05/2025 at 7:30 AM of the walk-in refrigerator reflected the following:- Tomatoes in a sealed bag were dated 7-22 with no discard date. - Strawberries in a container had no date and were moldy. - A cardboard box, dated 7-02-2025, contained green grapes were brown. - Sliced cheese in a Ziplock bag, dated 8-01-25, had no discard date. - Celery in a sealed bag, dated 8-02-25 had no discard date. - Asparagus in a Ziplock bag, dated 8-01-25, had no discard date.Observation on 8/05/2025 at 7:40 AM of the kitchen reflected the following:- Blue coffee cups on a dishwasher rack with other clean items had white debris on the cups. - Utensils in a dishwasher rack were mixed with clean and dirty utensils. - Serving utensils stored in a clear container had food debris in with the serving utensils. Observation on 8/05/2025 at 11:04 AM of the kitchen reflected the following:CK A Pureed the green beans, then rinsed the food processor in hot water without sanitizing the food processor. There were still pureed green beans inside the food processor when CK A pureed baked beans. CK A then rinsed the blender in hot water, but it was not sanitized before pureeing the bread. CK A then Pureed the cabbage without sanitizing the food processor. CK A rinsed the blender in hot water and did not sanitize the food processor before pureeing the ham.Observation on 8/06/2025 at 11:15 AM of the kitchen reflected the following:CK A pureed the chicken, then rinsed the food processor in hot water without sanitizing it for the next food item. CK A pureed the green beans, then rinsed the food processor in hot water without sanitizing it for the next food item. CK A pureed the potatoes. An interview on 8/07/2025 at 10:20 AM with CK B CK B stated when he put a food item in a container, he added the date on the container. CK B stated he checked daily for expired food items. If he saw an expired food item, he then threw it away. CK B stated any prepared food items past 3 days were thrown away. CK2 said there was no list they went by that told him how many days an item could be stored before it was thrown away. CK B stated prepared food was stored for three days before being discarded. CK B stated the kitchen was cleaned daily. CK B said there was a cleaning checklist they used. CK B said he was supposed to clean and sanitize the food processor in between food items. CK B said he forgot to do it this time. CK B said he was supposed to change his gloves when he did something else and came back to pureeing food. CK B said it had been a while since there was any training. CK B stated a resident could get sick if the equipment was not thoroughly cleaned and he did not change his gloves.An interview on 8/07/2025 at 10:29 AM with the DA revealed when the truck arrived, all staff are responsible to make sure that food items are dated. When a prepared item was placed in a Ziplock bag, it should have the date it was stored and an expiration date. If she noticed food going bad, she informed the DM and disposed of it. The DA mentioned everyone checked the walk-in cooler for expired items. The DA said staff did not put the expiration date on the packages. The DA stated prepared items should be discarded after three days because then the item is not good. The DA said the kitchen was cleaned daily at the end of each shift, including sweeping and mopping. DA said that residents could get sick if hand hygiene was not followed.An interview on 8/07/2025 at 10:20 AM with the DM revealed they went by newest item in the back and the oldest in the front. The DM said items were checked daily to see if there were any expired food. If there was expired food in the cooler it should be thrown away. The DM said food should be labeled with the name of the item, the date it was added, as well as the expiration date. The DM stated there was a list that had the shelf life of different foods. The kitchen was cleaned and sanitized daily. There were policies for sanitation, hand hygiene and food storage. The DM stated if equipment and utensils were not sanitized or cleaned, then it could be an infection control issue. An interview on 8/07/2025 at 10:20 AM with the ADM revealed when a food item was prepared and stored in a Ziplock bag, it should have the date it was put in the bag and the expiration date. The DM said when there was an out-of-date item, it should be thrown out. Looking for items should be checked weekly by staff. The kitchen should be cleaned and sanitized daily. There were polices in place for out-of-date food and the food should be discarded, and Kitchen equipment should be sanitized. The expectations are for staff to check for out-of-date food items and sanitized equipment. The ADM stated if out-of-date food was served to the residents, they could get sick. The ADM stated if equipment and utensils were not sanitized or cleaned, and said that CK A and CK B said they forgot to sanitize the equipment. then it could be an infection control issue.Record review of the facility's Sanitation policy, updated October 2008, reflected Policy Interpretation and Implementation: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.4. Sanitizing of environmental surfaces must be performed with one of the following solutions:a. 50-100 ppm chlorine solution.b. 150-200 ppm quaternary ammonium compound (QAC); orc. 12.5 ppm iodine solution.5. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways:a. Contact for at least 30 seconds with an iodine solution (at approved concentration);b. Contact with QAC (at approved concentration) per manufacturer's instructions.c. Contact for at least l 0 seconds with a chlorine (at approved concentration); ord. Immersion for thirty (30) seconds in hot (at least 171 F) water.Record Review of the facility's, undated, Food Storage Policy reflected: All foods shall be dated with the month and year received and shall be rotated on the first in/first out basis upon receipt. The oldest items are to be moved to the front to be used first. Food shall be purchased in quantities which can be stored properly. Frozen products purchased in larger quantities than needed are divided into appropriate quantities, wrapped, and labeled with the description of the product, the date it was wrapped and placed in the freezer.

Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates for 1of 2 medication rooms and 2 of 4 medication carts reviewed for medication storage.<BR/>-The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards. <BR/>-The facility failed to ensure expired medications were removed from the medication carts and medication rooms.<BR/>-The facility failed to ensure medications were stored in a clean, safe, and sanitary manner. <BR/>These failures place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication.<BR/>Findings Included:<BR/>Observation on 04/25/2023 at 2:57 PM revealed the facility North Medication room with a bottle Of Vitamin E 1000 IU with an expiration date of 07/2022.<BR/>Observation on 04/25/2023 at 3:00 PM revealed the North Medication cart with a bottle of Aspirin 325mg with an expiration date of 09/2022. Observation further revealed Resident #22's Latanoprost eye drops open without an open date and Resident #30's bottle of artificial tears eye drops open with no open date. <BR/>Observation on 04/25/2023 at 3:10 PM revealed the South Medication cart with an open bottle of Lactulose with a sticky liquid on both sides of the bottle. When the bottle of lactulose was pulled out the cart a box of Mucinex, Imodium and AZO Cranberry tablets were stuck to the side of the bottle with the sticky liquid in and on the boxes of medication that were stuck to the Lactulose bottle. <BR/>In an interview on 04/25/2023 at 3:15 PM the DON stated that eye drops should be labeled with an open date when they are opened. The DON further stated that all medications on the carts should have readable labels with medications stored in a manner that keeps them clean and dry. The DON and carts should be checked by the Nurses during the medication pass to ensure no expired medications are on the carts to ensure residents are not receiving expired medications to might have altered therapeutic effects. <BR/>Review of the facility's Policy Storage of Medications dated April 2021 reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure the resident's right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for 1 of 1 full recertification survey (Survey A) reviewed for survey results. <BR/>The facility failed to post the results of Survey A dated 04/27/23 in a public area for all residents and visitors to view on 07/01/24. <BR/>This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility. <BR/>Findings included:<BR/>During a confidential interview with 11 anonymous residents, all 11 agreed they had not ever seen the results of any of the previous State Agency inspections or noticed them posted or advertised in any public area around the facility. Seven of the 11 residents interviewed stated they would have wanted to view the survey results and wanted to know how they could do so. <BR/>Observation on 07/01/24 at 03:11 PM revealed no survey results posted in any public area anywhere in the facility. <BR/>During an interview on 07/01/24 at 04:02 PM, the ADM stated he had just begun working at the facility a few weeks prior, and he thought the survey results book had been posted in a bracketed wire file folder hung outside his office door, but he had confirmed it was not hung there. He stated he was responsible for ensuring the survey results were available for residents, staff, and visitors to read. He stated the potential negative impact of not having survey results available was people would not know what was going on in their home. <BR/>Review of facility policy dated April 2017 and titled Examination of Survey Results reflected the following: Survey reports and plans of correction are readily accessible to the resident, family members, resident representatives and to the public. Policy Interpretation and Implementation<BR/>1. Residents may examine the results of the most recent survey of the facility conducted by federal or state surveyors, as well as any plans of correction in effect.<BR/>2. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' day room.<BR/>3. Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request.<BR/>4. Information concerning the rights to examine, the location of and how to request preceding years' survey reports and plans of correction (and related materials as noted above) are posted on the resident bulletin board and at each nurses' station.