Friendship Village Of Tempe

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." NFPA 80 2010 edition, Chapter 5 Section 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. Chapter 19, Section 19.3.6.3 Corridor Doors Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Findings include:

Observations made while on tour on January 29, 2025, revealed the following:

1. Room 319 has play in the door resulting in gap at the top, handle side.
2. Room 317/318 has a gap at the top of the door, handle side.
3. Room 322 has play in the door resulting in a gap at the top, handle side.
4. Room 324 has play in the door resulting in a gap at the top, handle side.
5. Room 323 has play in the door resulting in a gap at the top, handle side.
6. Room 326/328 the door appears to be warped resulting in a gap at the top, handle side.
7. Room 327 the door appears to be warped resulting in a gap at the top, handle side.
8. Room 332 the door appears to be warped resulting in a gap at the top, handle side.
9. Room 329 has play in the door resulting in a gap at the top and handle side.
10. Room 331 the door appears to be warped resulting in a gap at the top, handle side.
11. Room 315/316 the door appears to be warped resulting in a gap at the top, handle side.
12. Room 314 the door appears to be warped resulting in a gap at the top.
13. Room 312/313 the door appears warped resulting in a gap at the top and handle side.
14. Room 301 gap along the side and top of the door, handle side.
15. Room 302 gap along the side and top of the door, handle side.
16. Room 303 gap along the side and top of the door, handle side.
17. Room 304 gap along the side and top of the door, handle side.
18. Room 306 gap along the top of the door, handle side.
19. Room 309 gap along the top of the door, handle side.
20. Room 311 gap along the top of the door, handle side.
21. Room 352/354 gap along the top of the door, handle side.
22. Room 358 has play in the door resulting in a gap at the top, handle side.
23. Room 355 has play in the door resulting in a gap at the top, handle side.
24. Room 357 has play in the door resulting in a gap at the top, handle side.
25. Room 360 has play in the door resulting in a gap at the top, handle side.
26. Room 362/363 has play in the door resulting in a gap at the top, handle side.
27. Room 364 gap along the top of the door, handle side.
28. Room 365/366 the door appears to be warped resulting in a gap at the top, handle side.
29. Room 367/368 the door appears to be warped resulting in a gap at the top, handle side.
30. Room 371/373 the door appears to be warped resulting in a gap at the top, handle side.
31. Room 372 gap along the top and side of the door, handle side.
32. Room 376/378 has play in the door resulting in a gap along the side and top, handle side.
33. Room 382 has play in the door resulting in a gap along the side and top, handle side.
34. Room 379 has play in the door resulting in a gap along the side and top, handle side.
35. Room 222 has play in the door resulting in a gap along the side and top, handle side.
36. Room 224 has play in the door resulting in a gap along the side and top, handle side.
37. Room 226/228 has play in the door resulting in a gap along the side and top, handle side.
38. Room 227 smoke seal needs to be replaced.
39. Room 230 has play in the door resulting in a gap along the side and top, handle side.
40. Room 232 has play in the door resulting in a gap along the side and top, handle side.
41. Room 229 the door has a gap along the handle side.
42. Room 220 has play in the door resulting in a gap along the side and top, handle side.
43. Room 214 has play in the door resulting in a gap along the side and top, handle side.
44. Room 212/213 has play in the door resulting in a gap along the side and top, handle side.
45. Room 201 has play in the door resulting in a gap along the side and top, handle side.
46. Room 200/202 has play in the door resulting in a gap along the side and top, handle side.
47. Room 203/205 has play in the door resulting in a gap along the side and top, handle side.
48. Room 204 has play in the door resulting in a gap along the side and top, handle side.
49. Room 206 has play in the door resulting in a gap along the side and top, handle side.
50. Room 207 has play in the door resulting in a gap along the side and top, handle side.
51. Room 208 has play in the door resulting in a gap along the side and top, handle side.
52. Room 209 has play in the door resulting in a gap along the side and top, handle side.
53. Room 211 has play in the door resulting in a gap along the side and top, handle side.
54. Room 250 has play in the door resulting in a gap along the side and top, handle side.
55. Room 255 has play in the door resulting in a gap along the side and top, handle side.
56. Room 256 has play in the door resulting in a gap along the side and top, handle side.
57. Room 257 has play in the door resulting in a gap along the side and top, handle side.
58. Room 258 has play in the door resulting in a gap along the side and top, handle side.
59. Room 259 has play in the door resulting in a gap along the side and top, handle side.
60. Room 260 has play in the door resulting in a gap along the side and top, handle side.
61. Room 264 has play in the door resulting in a gap along the side and top, handle side.
62. Room 265/266 has play in the door resulting in a gap along the side and top, handle side.
63. Room 267/268 has play in the door resulting in a gap along the side and top, handle side.
64. Room 269 has play in the door resulting in a gap along the side and top, handle side.
65. Room 270 has play in the door resulting in a gap along the side and top, handle side.
66. Room 271/273 has play in the door resulting in a gap along the side and top, handle side.
67. Room 274 has play in the door resulting in a gap along the side and top, handle side.
68. Room 275 has play in the door resulting in a gap along the side and top, handle side.
69. Room 276/278 has play in the door resulting in a gap along the side and top, handle side.
70. Room 277 has play in the door resulting in a gap along the side and top, handle side.
71. Room 279 has play in the door resulting in a gap along the side and top, handle side.
72. Room 281 has play in the door resulting in a gap along the side and top, handle side.

The management team confirmed the door deficiencies during the facility tour and exit conference on January 29, 2025.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure the clinical record was accurate for one resident (#24).

Findings include:

Resident #24 was admitted on December 30, 2024 with diagnoses of hypertension, encounter for surgical after care following surgery on the digestive system, and vitamin deficiency.

Review of nursing progress note dated December 30, 2024 revealed right lower abdomen with glue open to air, and left lower abdomen stitches with wound dressing in place.

The care plan dated December 30, 2024 revealed the resident had a hypertension problem, had skin integrity potential/skin breakdown related to recent surgery and had pain and potential alterations in level of comfort recent surgery and sciatica problem. The goal is resident will be free of complications related to hypertension, will maintain blood pressure and pulse within acceptable limits per physician's order and will receive relief from discomfort within 30-45 minutes after interventions. The intervention included to medicate per physician's order.

The admission Minimum Data Set (MDS) assessment dated January 5, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating cognitively intact, and resident receives scheduled and as needed pain medication.

The physician order dated December 31, 2024 included for lidocaine external patch 4% (local anesthetic) apply to abdomen topically in the morning related to pain and remove per schedule.

This order was transcribed onto the MAR (medication administration record) for January 2025 and revealed a schedule to put on the patch at 8:00 a.m. and to remove the patch on 8:00 p.m. It also included that the MAR documented that the lidocaine patch was applied to the abdomen on January 15, 2025 at 8:00 a.m. and was removed on January 15, 2025 at 8:00 p.m.

However, during a medication administration observation was conducted on January 16, 2025 at 8:12 a.m. with registered nurse (RN/Staff #222). During the observation, the RN removed a white patch from the resident's left lower back side. The RN also stated that staff did not take the patch off last night and then threw the patch in the bedside trash can. The RN proceeded to clean the resident's left lower buttocks skin area and applied a new patch. The RN said that the patch was not applied on the resident's abdomen as ordered because to the resident's surgery.

The physician order for the lidocaine patch was changed on January 17, 2025 to include the application of the patch to the back topically in the morning and remove per schedule.

An interview was conducted on January 16, 2025 at 12:19 p.m. with the RN (staff #222) who stated that the lidocaine patch for resident #24 had an order to be on for twelve hours on during the day and off for twelve hours at night time; and that, the nurse comes around to take it off. Regarding resident #24, the RN stated that this morning the resident still had the lidocaine patch on; and that, the order was to apply the patch to the resident's abdomen. However, the RN said that it does not make sense because the resident had a dressing on, had a binder on, and had a wound on the abdomen. She stated that this was the reason the lidocaine patch was applied to the resident's lower back side and not the abdomen. Further, she stated that there was no way to place lidocaine patch on the resident's abdomen due to having three incision and an open wound. The RN said that she would call the doctor to discontinue the order and get a new order for a new site (back) for the patch. Further, the RN stated that the lidocaine patch being left on and she was not sure what would happen if it was longer than ordered.

An interview was conducted on January 17, 2025 at 2:00 p.m. with the DON (staff #241) who stated that her staff administered the medication (patch) as ordered, the night nurse documented that it was removed but the day nurse was one who actually removed and disposed of the patch. Further, the DON stated that the expectation was for staff to follow the physician order.

The facility policy on Medication Administration, revised on June 2014 revealed a purpose to ensure the safe, appropriate, and accurate administration and handling of medications. The procedure included rotating transdermal patch sites, read label and compare with EMR (electronic medical record) during preparation. If discrepancies exist, to verify with physician's orders. The policy also included to implement the "Five Rights" of medication administration: A. Right patient; B. Right medication; C. Right dose; D. Right route; and, E. Right time and frequency.

Based on interview, record review, and facility policy review, the facility failed to implement their policy by failing to ensure that a written notification of transfer and the reason/s of the transfer was provided to the resident representative for one resident (#33); and failed to ensure a copy of that notice of transfer for one resident (#33) was sent to the long term care Ombudsman.

Findings include:

Resident #33 was admitted on December 15, 2024 with diagnoses that included type 2 diabetes, epilepsy, dysphagia, and dementia.

The discharge care plan dated December 17, 2024 revealed the resident expressed a wish to be discharged to home. Interventions included to determine discharge date, location, and needs with the health care team and physician.

A Minimum Data Set (MDS) assessment dated December 22, 2024 revealed the resident had severely impaired daily decision making skills.

A nursing progress note dated January 13, 2025 revealed that the resident was presenting with elevated blood pressure, increased respirations, tachycardia, was afebrile, clammy to touch, face flushed and oxygen saturation of 82% which decreased to 70%. Per the documentation, the provider and family were notified and an order was received to send the resident out to the hospital; and that, 911 was called and resident was taken out to the hospital.

A physician order dated January 13, 2025 included to send the resident out to the hospital for respiratory distress.

The SNF (skilled nursing facility)/NF (nursing facility) hospital transfer form dated January 13, 2025 revealed that the resident was sent to the hospital because of respiratory distress.

A review of the email correspondence from the facility's admissions manager addressed to the resident's family/representative sent on January 13, 2025 at 10:34 a.m. revealed that the facility offered a bed hold when a resident goes on leave of absence or was hospitalized; and that, if a response from the representative was not provided to the facility within 24 hours of the written notice, it will be presumed that the Bed Hold Policy was declined. Per the documentation, at the time of the resident's transfer, the resident and/or resident representative will be provided a written notice that specified their bed hold policy. The documentation did not include the reason for the resident's transfer.

There was no evidence found in the clinical record that a written notification of the resident's transfer and the reasons for the transfer was sent to the Ombudsman and the resident representative.

An interview was conducted on January 17, 2025 at 11:56 a.m. with a Registered Nurse (RN/staff #180) who stated that the resident was given pain medication because the resident asked for it and was then was taken back to her room because the resident was crying. The RN said that when the vitals were taken and checked, the resident's vitals were declining, 911 was called and the resident was taken to the hospital for respiratory distress.

In an interview with the social services (staff #122) conducted on January 17, 2025 at 1:18 p.m., staff #122 stated that social services do not notify the ombudsman when residents go to the hospital; and that, the administrator was responsible for notifying the ombudsman.

During an interview with the administrator (staff #115) conducted on January 17, 2025 at 1:50 p.m., the administrator stated that a notification regarding residents discharged and/or transferred will be sent to the Ombudsman on the first week of each month. Regarding resident #33, the administrator said that the resident representative was notified over the phone of the transfer to the hospital; and that, the resident representative sent the facility an email notifying that the resident was not able to return to the facility.

An interview was conducted on January 17, 2025 at 3:15 p.m. with Director of Nursing (DON/staff #214) with the administrator (staff #115) present. The DON stated that for 911 calls, the facility would not notify the Ombudsman of transfer.

The facility policy on Discharge and Transfer Notification revealed that in an emergency, which means that the family or responsible party are given written notice within 24 hours of transfer or a copy is sent with other papers accompanying the resident to the hospital.

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure that policies and procedures were implemented to cover provision of services by failing to ensure that a medication was provided as ordered and failed to ensure that the physician was notified for a missed dose of antibiotic therapy for one resident (#104).

Findings include:

Resident #104 was admitted on October 13, 2022 with diagnoses of encephalopathy, pneumonia, and urinary tract infection.

An Admission Minimum Data Set (MDS) assessment dated May 11, 2024 revealed a brief interview for mental status (BIMS) score of 13 indicating the resident had intact cognition. It also included that active diagnosis of urinary tract infection (UTI) in the last 30 days.

The care area assessment (CAA) worksheet signed and dated May 12, 2024 included that the resident had a diagnosis of dementia and had difficulty with making her needs known. Medications included gentamycin (antibiotic) and tobramycin (antibiotic).

A care plan dated May 15, 2024 revealed that the resident had UTI and Fosfomycin (antibiotic). Intervention included to administer antibiotic therapy per physician's orders.

A nursing progress note dated May 15, 2024 included that a urinalysis results were received and was positive for UTI. Per the documentation, new orders for Fosfomycin was received from the nurse practitioner (NP).

A physician order dated May 15, 2024 included for Fosfomycin Tromethamine oral packet 3 grams, give 1 packet by mouth in the morning every 2 days related to UTI for 3 administrations and to give 1 packet every 2 days for 3 doses. This order had a start date of May 16, 2024.

The medication administration record for May 2024 revealed that Fosfomycin was not marked as administered on May 16; and, was marked as administered on May 19 and May 20. The documentation in the MAR included that the resident only received 2 of 3 administrations/doses ordered by the physician.

An eMAR administration note dated May 16, 2024 included that the facility was waiting for pharmacy to bring in Fosfomycin".

The encounter note dated May 20, 2024 revealed that the resident was on Fosfomycin 1 packet every 2 days for 3 doses for UTI. The plan for the 3 doses of Fosfomycin was active from May 16 through May 22, 2024.

However, the clinical record revealed no evidence that the resident received the 3rd dose of Fosfomycin; and that, the physician had been informed of the missed dose of antibiotic.

An interview was conducted on January 17, 2025 at 1:12 p.m. with a registered nurse (RN/staff 76) who stated that if a resident was on a scheduled antibiotic therapy and it has not been delivered from pharmacy yet, the RN would get it from their emergency kit if they have it. The RN also said that any time a resident was going to miss or missed a dose of antibiotic she would notify the physician; and that, she would document that notification and any attempts to obtain the medication in the medication administration progress note, or in a standard progress note.

In an interview with the RN Nurse Manager (staff #223) conducted on January 17, 2025 at 1:21 p.m., the RN nurse manager stated that if an antibiotic was ordered for a resident and was not available for administration, staff would check the facility's emergency kit. The RN nurse manager said that if the medication such as an antibiotic was not available from the emergency kit, she would notify the provider then let the pharmacy know to deliver the medications STAT. Regarding resident #104, the RN nurse manager stated that Fosfomycin was not available in their emergency kit; and that, Fosfomycin was not given on May 16 when it was ordered to start but, it was given on the next dose.

An interview was conducted on January 17, 2025 at 3:37 p.m. with the Director of Nursing (DON/staff #241) who stated that if a resident missed a dose of an antibiotic, staff should absolutely notify the physician; and, follow the physician's order.

During an interview with the administrator conducted on January 17, 2025 at 2:00 p.m., the administrator said that the facility did not have a policy on notification of the physician.

The facility policy on Medication/Treatment Administration Schedule included a purpose to ensure medications and treatments are provided timely.

Review of the facility policy on Medication Administration included that it is their policy to ensure that medications are administered to residents by qualified personnel in compliance with Federal and State laws and standards of professional practice.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure scheduled medications were obtained and administered accurately for one resident (#24) of four sampled residents. The deficient practice could result in medications not being available for residents and medications not administered according to physician's orders.

Findings include:

Resident #24 was admitted on December 30, 2024 with diagnoses of hypertension, encounter for surgical after care following surgery on the digestive system, and vitamin deficiency.

Review of nursing progress note dated December 30, 2024 revealed right lower abdomen with glue open to air, and left lower abdomen stitches with wound dressing in place.

The care plan dated December 30, 2024 revealed the resident had a hypertension problem, had skin integrity potential/skin breakdown related to recent surgery and had pain and potential alterations in level of comfort recent surgery and sciatica problem. The goal is resident will be free of complications related to hypertension, will maintain blood pressure and pulse within acceptable limits per physician's order and will receive relief from discomfort within 30-45 minutes after interventions. The intervention included to medicate per physician's order.

The care plan initiated on December 31, 2024 revealed resident had dehiscence abdominal incision related to obstruction surgical wound. Interventions included to assess for pain with wound care and provide pain medication as ordered.

The admission Minimum Data Set (MDS) assessment dated January 5, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating cognitively intact, and resident receives scheduled and as needed pain medication.

The care plan was revised on January 8, 2025 to include an intervention to use an abdominal binder to be in place for wound care.

The skin & wound evaluation dated January 14, 2025 revealed that the resident had a surgical wound with staples in the left lower side of the abdomen with surrounding tissue intact, no swelling or edema and wound dressing appearance is intact; and that, this wound was present on admission.

-Regarding the lidocaine patch:

The physician order dated December 31, 2024 included for lidocaine external patch 4% (local anesthetic) apply to abdomen topically in the morning related to pain and remove per schedule.

This order was transcribed onto the MAR (medication administration record) for January 2025 and revealed a schedule to put on the patch at 8:00 a.m. and to remove the patch on 8:00 p.m. It also included that the MAR documented that the lidocaine patch was applied to the abdomen on January 15, 2025 at 8:00 a.m. and was removed on January 15, 2025 at 8:00 p.m.

However, during a medication administration observation was conducted on January 16, 2025 at 8:12 a.m. with registered nurse (RN/Staff #222). During the observation, the RN removed a white patch from the resident's left lower back side. The RN also stated that staff did not take the patch off last night and then threw the patch in the bedside trash can. The RN proceeded to clean the resident's left lower buttocks skin area and applied a new patch. The RN said that the patch was not applied on the resident's abdomen as ordered because to the resident's surgery.

The physician order for the lidocaine patch was changed on January 17, 2025 to include the application of the patch to the back topically in the morning and remove per schedule.

-Regarding medications not administered during medication administration observation:

Review of the physician order summary report from December 30, 2024 through January 31, 2025 revealed the resident was also prescribed with the following medications:
-Amlodipine Besylate (anti-hypertensive) oral tablet 5 mg, give two tablets by mouth in the morning related to essential (primary) hypertension. Hold for systolic blood pressure less than 110;
-Bifidobacterium (probiotic) oral capsule give one capsule by mouth in the morning related to acquired absence of other specified parts of the digestive tract;
-Multivitamin-Minerals (supplement) oral tablet give one tablet by mouth in the morning related to vitamin deficiency; and
-Caltrate 600+D3 (supplement) oral tablet give one tablet by mouth in the morning related to vitamin deficiency.

These medications were transcribed onto the MAR (medication administration record); and, review of the MAR revealed that these medications were not marked as administered from January 15 through 17, 2025.

The eMAR (electronic MAR) administration notes dated January 15, 2025 revealed that Caltrate 600+D3 and Bifidobacterium were on order from pharmacy.

During the medication observation conducted with registered nurse (RN/Staff #222) on January 16, 2025 at 8:12 a.m. revealed that the RN did not administer the amlodipine, multivitamin-minerals and Caltrate 600+D3 to resident #24.

The eMAR administration notes dated January 16, 2025 revealed that amlodipine, multivitamin-minerals and Caltrate 600+D3 were on order from pharmacy.

The eMAR administration notes dated January 17, 2025 included that the amlodipine, multivitamin-minerals and Caltrate 600+D3 were not available; and that, the prescription was refilled.

An interview was conducted on January 16, 2025 at 12:19 p.m. with the RN (staff #222) who stated that the lidocaine patch for resident #24 had an order to be on for twelve hours on during the day and off for twelve hours at night time; and that, the nurse comes around to take it off. Regarding resident #24, the RN stated that this morning the resident still had the lidocaine patch on; and that, the order was to apply the patch to the resident's abdomen. However, the RN said that it does not make sense because the resident had a dressing on, had a binder on, and had a wound on the abdomen. She stated that this was the reason the lidocaine patch was applied to the resident's lower back side and not the abdomen. Further, she stated that there was no way to place lidocaine patch on the resident's abdomen due to having three incision and an open wound. The RN said that she would call the doctor to discontinue the order and get a new order for a new site (back) for the patch. Further, the RN stated that the lidocaine patch being left on and she was not sure what would happen if it was longer than ordered.

An interview was conducted on January 17, 2025 at 9:57 a.m. with another RN (staff #180) who stated that the process on obtaining medication for residents included calling the pharmacy directly or ordering the resident's medications from the computer, or faxing the ordered medications to the pharmacy. The RN said that if medication was ordered today, the pharmacy has a run time and can deliver the same day. Regarding disposing of medications, the RN said that she disposes the medications in a trash can by her medication cart; and that, she does not dispose medications such as patches in the resident's room for safety. She said that the resident's trash can was open and had no lid on.

An interview was conducted on January 17, 2025 at 2:00 p.m. with the DON (staff #241) who stated that her staff enters orders in the resident's electronic medical record and then the medications are delivered from the pharmacy. Regarding the process of reordering medications, the DON said that there was an area in the electronic record where her staff can click to reorder the resident's medication; and that, staff reorder the residents' medications few days before running out, and are delivered by the pharmacy on the same day. The DON also stated that the staff can call the medication order in and order it as soon as possible; and, when the nurse receives the delivery from the pharmacy, the nurse sig

Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to implement and maintain their infection control policy on placement of the indwelling catheter bag for one resident (#12) and, oxygen tubing for one resident (#155).

Findings include:

Resident #12 was re-admitted to the facility on December 12, 2024 with diagnoses that included urinary tract infection, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease and urinary incontinence.

Review of the Admission Minimum Data Set (MDS) assessment dated December 11, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had an intact cognition. The assessment also included that the resident had an indwelling catheter and urinary incontinence.

The Foley catheter care plan initiated on January 9, 2025 included interventions to maintain closed drainage system with drainage bag lower than bladder at all times and to keep drainage bag off floor and covered for dignity.

The skin evaluation dated January 9, 2025 revealed the resident had a catheter due to a diagnosis of neurogenic bladder.

An observation was conducted on January 14, 2025 at 9:52 a.m. Resident #12 was sitting on a recliner with his uncovered indwelling catheter bag placed on a towel on the floor and clipped on the side of the trash bin beside the resident's chair. There was trash found inside the trash bin where the uncovered indwelling catheter bag was clipped on.

During a second observation conducted on January 14, 2025 at 2:40 p.m., resident #12 was sitting on a recliner and watching TV with her uncovered indwelling catheter bag placed inside the trash bin beside the resident's chair. There was trash found inside the trash bin.

In another observation conducted with a registered nurse (staff #237) on January 15, 2025 at 1:28 p.m. Resident #12 was sitting on a recliner with her uncovered indwelling catheter bag on the floor and attached on the side of trash bin with the help of white clip. Trash was also found inside the trash bin. The RN (staff #237) stated that the resident's catheter bag was touching the floor and was also attached to trash bin, which was not an appropriate place to put catheter bag. She then stated that risk would be the resident getting in urine infection from floor and trash because it may not be clean or disinfected.

An interview was conducted with Certified Nursing Assistant (CNA/staff #135) dated January 15, 2025 at 2:20 p.m. The CNA said that indwelling catheter bag may be hanging on the side of mattress or on the wheelchair; and that, it should be off the floor so that it does not get dirty. The CNA further stated that it was not appropriate to hang the indwelling catheter bag with or inside the trash bin because the trash and the floor have all kinds of germs.

An interview was conducted with the two infection preventionists (staff #114 and staff #232) on January 16, 2025 at 12:02 p.m. Both infection preventionists stated that the indwelling catheter bag touching the floor was not an expectation and the risk included residents getting an infection.

In an interview conducted with the Director of Nursing (DON/staff # 241) on January 16, 2025 at 2:17 p.m., the DON stated that indwelling catheter bag should stay lower than bladder and should not touch the floor. She also stated that the indwelling catheter bag on floor or inside the trash bin was also not acceptable; and that, the risk would be resident getting an infection. Regarding the catheter bag of resident #12, the DON stated that maybe resident #12 had placed the catheter bag in the trash bin or the floor while the resident was getting up; and that, she does not believe that staff did it.

During an interview with resident #12 conducted on January 17, 2025 at 8:55 a.m., resident #12 stated that she never touches her indwelling catheter bag; and that, the CNA generally empties her catheter bag.

A review of the facility policy on Indwelling Foley Catheter revised on September 2023 included a purpose to ensure the safe, sterile placement, maintenance and removal of the Foley catheter. It also provides guidelines for catheter care and drainage collection system. The policy also included a procedure to position the bag hanger on the bed rail near the foot of the bed using the clip to secure the drainage tube to the sheet and do not let the bag rest on the floor.

-Resident #155 was admitted on January 13, 2025 with diagnoses of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease.

The clinical admission note dated January 13, 2025 included that the resident had oxygen via nasal cannula.

A physician order dated January 13, 2025 included to administer oxygen to keep saturation >90% via nasal cannula or mask

Review of a care plan initiated on January 13, 2025 revealed the resident was on oxygen therapy.

The nursing progress note dated January 14, 2025 included that the resident had shortness of breath when lying flat and continued on oxygen while up.

Another nursing progress note dated January 14, 2025 revealed the resident on oxygen at 1 liter per nasal cannula.

An observation was conducted on January 14, 2025 at 12:56 p.m. Resident #155 was sitting on a chair next to her bed wearing a hospital gown and her nasal cannula was on the floor next to the trash bin.

A second observation with the registered nurse (RN/staff #237) was conducted on January 15, 2025 at 1:00 p.m. Resident #155 was lying on the bed with one end of oxygen tubing was connected to the concentrator and other end of the oxygen tube was on resident's nose. The mid part of oxygen tube was placed on top of the trash bin near the resident's bed. The trash bin was found to have few blue pieces of trash inside it. The RN stated that the resident's oxygen tubing should not be hanging on the top of trash bin because resident was breathing it and the resident can get infection.

An interview was conducted with certified nursing assistant (CNA/staff #138) dated January 17, 2025 at 8:24 a.m. and she stated that it was not appropriate to drape the oxygen tubing over top of trash can because it may cause infection.

An interview was conducted with two infection preventionists (staff #114 and #232) on January 16, 2025 at 12:02 p.m. Both infection preventionists stated that the oxygen cannula position over the trash bin was not appropriate and acceptable; and that, this can cause infection.

An interview with director of nursing (DON/staff #241) conducted on January 16, 2025 at 2:17 p.m. The DON stated that she was not sure whether oxygen tubing touching the trash bin was a problem or not, as this was a close system.

The facility policy on Infection Prevention and Control Surveillance with revision date of June 2023 included that the quality care specialist (QCS)/Infection Preventionists analyzes data, prepares and presents reports to the Quarterly Quality Assessment and Assurance Committee (QAA). Reports include but may not be limited to observations of employees including the identification of ineffective practices (e.g. hand hygiene, appropriate use of PPE (personal protective equipment when indicated and compliance with infection prevention and control surveillance policies and procedures.

Based on clinical record review, resident and staff interviews review of facility documentation and policy, the facility failed to ensure an alleged violation for one resident (#31) was reported was reported to the State Agency (SA), Adult Protective Services (APS) and law enforcement.

Findings include:

Resident #31 was admitted on December 13, 2024 with a diagnoses of multiple fractures of the pelvis without disruption of pelvic ring, age related osteoporosis with current pathological fracture, anxiety disorder and cognitive communication disorder.

Review of the Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident had intact cognition.

The care plan on functional abilities dated December 12, 2024 revealed the resident required maximum assistance of 2 for transfers to and from bed, toilet, chair with assistive device of walker & wheelchair.

Review of a progress note dated January 1, 2025 included that the certified nurse assistant (CNA) reported that the resident had a tear in the right leg while transferring she was transferring the resident. Per the documentation, the resident reported that the CNA bumped her leg against the door.

The care plan on the use of anti-anxiety medication dated January 9, 2025 revealed the client had a target behavior of restlessness. Intervention included to provide a quiet atmosphere with one-on-one support during periods of increased anxiety and allow the resident to talk about event and causes, if known.

An interview with Resident #31 was conduced on January 15, 2025 at 8:56 a.m. The resident stated that a few weeks prior a CNA (staff #151) grabbed her to put her in the chair; and the CNA told her to "get in the chair" and pushed her down that my leg started to bleed. The resident further stated that she told the main nurse and that CNA was no longer assigned to her. Further, the resident stated that the incident made her "angry and scared".

There was no evidence found in the clinical record and facility documentation that this incident was reported to the State Agency (SA), Adult Protective Services (APS) and law enforcement.

A phone interview with the CNA (staff #151) who was involved in this allegation was attempted on January 16, 2025 at 12:28 p.m. but was unsuccessful.

An interview with the Administrator (staff #115) and the Director of Nursing, (DON/staff #241) was conducted on January 16, 2025 at 1:22 p.m. The administrator stated that she was aware of the incident and she spoke with the resident and her family about it. She stated the resident had been at the facility for 27 years and was "very much loved" at the facility. The administrator also said that when she was informed of the incident, she went and spoke with the resident; and she was told by the resident that a staff member was rough and aggressive with the resident during care. However, the administrator said that the resident could not tell her which staff member it was; and that, the resident told her that the resident did not want to get anyone in trouble. Further, the administrator said that the resident also reported that her leg was bleeding; however, the resident had a scab on the leg and it had fallen off. The administrator said that Resident #31 had a history of being fearful at night; and that, the administrator think it was just because the resident was alone at night; and that, during the day the resident always had her friends or family at the facility. The administrator also said that there had been other instances when the resident reported that no one came to check on her, but when the administrator reviewed the camera footage of that night, staff had been in the resident's room a total of 8 times in a four hour window. Regarding the incident, the administrator stated that initially, they thought that the incident was a miscommunication, because the staff from that night had a heavy accent. Further, both the the administrator and the DON (staff #241) said that the resident made it sound like it was more of a customer service issues.

In a later interview with the administrator (staff #115) conducted on January 16, 2025 at 2:20 p.m., the administrator stated that she did not consider the terms "aggressive" or "rough" an allegation of abuse because the resident was fearful at night, was a poor historian and did not insinuate that the incident was abuse. The administrator said that the resident did say the staff it was "rough" and "aggressive". Further, the administrator said that she did not ask the resident if it was abuse because it seemed more like a customer service issue. The administrator also said that rough handling or an injury of unknown origin should be reported to the State Agency only if it was unknown. She said that the staff reported that the resident's leg was bleeding due to the leg being bumped into a wheelchair; but, she does know the actual reason for the injury to the resident's leg. The administrator said that the CNA was removed from resident #31's care because the resident did not like what happened to her.

The facility's policy on Abuse Prevention revised on January 2023 included a purpose to protect residents from willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, verbal abuse or emotional distress. This presumes that instances of abuse of all residents irrespective of any mental or physical condstion, cause physical harm, pain, mental anguish, verbal abuse, or emotional distress. Any allegations of abuse will be reported to the administrator immediately and to the State Agency and the resident's representative as soon as possible within 24 hours. If a reasonable suspicion of a crime has occurred, the resident's representative and the State Agency and local law enforcement shall be informed according to the following timeframes: Serious Bodily Injury - immediately but not later than 2 hours after forming the suspicion. All Others - not later than 24 hours after forming the suspicion. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation.

Based on clinical record review, resident and staff interviews review of facility documentation and policy, the facility failed to ensure an alleged violation for one resident (#31) was throughly investigated.

Findings include:

Resident #31 was admitted on December 13, 2024 with diagnoses of multiple fractures of the pelvis without disruption of pelvic ring, age related osteoporosis with current pathological fracture, anxiety disorder and cognitive communication disorder.

Review of the Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating the resident had intact cognition.

The care plan on functional abilities dated December 12, 2024 revealed the resident required maximum assistance of 2 for transfers to and from bed, toilet, chair with assistive device of walker & wheelchair.

Review of a progress note dated January 1, 2025 included that the certified nurse assistant (CNA) reported that the resident had a tear in the right leg while transferring she was transferring the resident. Per the documentation, the resident reported that the CNA bumped her leg against the door.

The care plan on the use of anti-anxiety medication dated January 9, 2025 revealed the client had a target behavior of restlessness. Intervention included to provide a quiet atmosphere with one-on-one support during periods of increased anxiety and allow the resident to talk about event and causes, if known.

An interview with Resident #31 was conducted on January 15, 2025 at 8:56 a.m. The resident stated that a few weeks prior a CNA (staff #151) grabbed her to put her in the chair; and the CNA told her to "get in the chair" and pushed her down that my leg started to bleed. The resident further stated that she told the main nurse and that CNA was no longer assigned to her. Further, the resident stated that the incident made her "angry and scared".

There was no evidence found in the clinical record and facility documentation that this incident was thoroughly investigated.

A phone interview with the CNA (staff #151) who was involved in this allegation was attempted on January 16, 2025 at 12:28 p.m. but was unsuccessful.

An interview with the Administrator (staff #115) and the Director of Nursing, (DON/staff #241) was conducted on January 16, 2025 at 1:22 p.m. The administrator stated that she was aware of the incident and she spoke with the resident and her family about it. She stated the resident had been at the facility for 27 years and was "very much loved" at the facility. The administrator also said that when she was informed of the incident, she went and spoke with the resident; and she was told by the resident that a staff member was rough and aggressive with the resident during care. However, the administrator said that the resident could not tell her which staff member it was; and that, the resident told her that the resident did not want to get anyone in trouble. Further, the administrator said that the resident also reported that her leg was bleeding; however, the resident had a scab on the leg and it had fallen off. The administrator said that Resident #31 had a history of being fearful at night; and that, the administrator think it was just because the resident was alone at night; and that, during the day the resident always had her friends or family at the facility. The administrator also said that there had been other instances when the resident reported that no one came to check on her, but when the administrator reviewed the camera footage of that night, staff had been in the resident's room a total of 8 times in a four hour window. Regarding the incident, the administrator stated that initially, they thought that the incident was a miscommunication, because the staff from that night had a heavy accent. Further, both the administrator and the DON (staff #241) said that the resident made it sound like it was more of a customer service issue.

In a later interview with the administrator (staff #115) conducted on January 16, 2025 at 2:20 p.m., the administrator stated that she did not consider the terms "aggressive" or "rough" an allegation of abuse because the resident was fearful at night, was a poor historian and did not insinuate that the incident was abuse. The administrator said that the resident did say the staff it was "rough" and "aggressive". Further, the administrator said that she did not ask the resident if it was abuse because it seemed more like a customer service issue. The administrator also said that rough handling or an injury of unknown origin should be reported to the State Agency only if it was unknown. She said that the staff reported that the resident's leg was bleeding due to the leg being bumped into a wheelchair; but, she does know the actual reason for the injury to the resident's leg. The administrator said that the CNA was removed from resident #31's care because the resident did not like what happened to her. Further, the administrator stated that she really felt like it was a situation of customer service and not an allegation of abuse; and, she should have done a thorough investigation and asked the resident if the resident felt safe after the incident.

The facility's policy on Abuse Prevention revised on January 2023 included all incidents will be documented, whether or not abuse occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, or misappropriation will result in abuse investigation. The appointed investigator will follow the abuse investigation procedures identified in this policy. The investigator will report the conclusions of the investigation in writing to the administrator or designee within 5 working days of the reported incident. The final investigation report shall contain the following:
-The original allegation (note day, time, location, the specific allegation, by whom, witnesses to the occurrence, circumstances surrounding the occurrence, and any noted injuries;
-Facts determined during the process of the investigation, review of medical record, and interview of witnesses;
-Conclusion of the investigation base on known facts;
-A summary of all interviews conducted.
The administrator or designee is then responsible for forwarding the final written report of the results of the investigation and of any corrective action taken to the State Agency within 5 working days of the reported incident.

Based on observation, clinical record review and facility policy, the facility failed respect and value the resident's private space by knocking and requesting permission before entering the room for one resident (#17).

Findings include:

Resident #17 was admitted on December 9, 2024 with diagnoses of encephalopathy, acute respiratory failure with hypoxia, and type 2 diabetes mellitus.

A care plan dated December 16, 2024 included daily preferences with interventions that it was important to the resident to be able to use the phone in private.

An observation was conducted on January 14, 2024 at 10:32 a.m. The resident's call light was not turned on. While conducting an interview with resident #17, a Certified Nursing Assistant (CNA/staff #145) entered the resident's room and stated that the call light was on. The CNA did not knock or announce her presence prior to entering the resident's room. The CNA then spoke to resident #17 and exited the room after. A few minutes later, the CNA (staff #145) reentered the resident's room again with another CNA (staff #15) without knocking or announcing their presence before they entered the resident's room. In both times, resident #17 was not asked whether the CNAs were okay to enter the room.

An interview was conducted on January 14, 2024 at 10:36 a.m. with the CNA (staff #145) who said that when a call light is on, she would go into room, ask what the resident needed and take the resident's vitals. She stated that she would normally knock on the resident's door because she needed to. However, she said that if the call light was on that she would just enter the resident's room without knocking at the door prior to entry.

An interview with another CNA (staff #35) was conducted on January 17, 2025 at 8:53 a.m. The CNA (staff #35) stated that prior to entering the resident's room, the CNA was to knock on door, and greet resident by name. The CNA (staff #35) also said that staff do not want to scare the residents and it is respectful for staff to introduce themselves and address the residents.

In an interview with a Registered Nurse (RN/staff #180) conducted on January 17, 2024 at 9:22 a.m., the RN said her practice was to knock before she goes in the resident's room, introduce herself and tell the resident why she was in their room.

An interview was conducted on January 17, 2025 at 2:43 P.M. with a Registered Nurse Unit Manager (RN/ staff# 223) who said that expectation is that the staff knock and announce themselves to make sure they are going into the right room

An interview was conducted on January 17, 2025 at 3:37 P.M. with the Director of Nursing (DON/#241) who said that her expectations would be that the staff announce themselves in some way and ask to come in. This DON said that if the call light was pushed it would be reasonable for the staff to come right in.

An interview was conducted on January 17, 2025 at 2:00 P.M. with the Administrator (staff#115) who said that they do not have a policy or procedure for staff knocking or announcing themselves before entering a residents' room.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that unnecessary pain medication was not administered for one resident (#154).

Findings include:

Resident #154 was admitted on January 2, 2025, with diagnoses of lymphedema, pain, osteonecrosis due to drugs, pelvis and muscle weakness.

The clinical admission note dated January 2, 2025 revealed that the resident was alert and oriented x 3, had vocal complaints of generalized chronic pain; and that, the resident reported that her pain was always above a 10.

A pain care plan dated January 2, 2025, revealed a goal that the resident will receive relief from discomfort within 20-45 minutes after interventions. The interventions included to medicate per physician's order, evaluate for pain using pain scale of 1-10, evaluate/document level of pain relief attained on pain flow sheet, offer non-pharmacological interventions and report signs/symptoms of distress or pain unrelieved by ordered treatment/medications to the physician.

A physician's order dated January 3, 2025 revealed an order for acetaminophen (analgesic) tablet 325 milligrams (mg), give 2 tablets by mouth every 4 hours as needed for pain scale between 1-10. The order also directed not to exceed 3 grams (gm)/24 hour.

An admission Minimum Data Set (MDS) assessment dated January 9, 2025, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident had no cognitive impairment. The assessment also revealed that the resident had frequent pain or hurting at any time almost constantly, pain scale of 10 in the last 5 days of the assessment.

The MAR (medication administration record) for January 2025 revealed that acetaminophen was administered to the resident outside the pain parameters established by the physician for the following days:
-January 4 - had 6 doses equivalent to approximately 3.9 gm (0.9 gm above the 3 gram/24 hour limit);
-January 5 - had 5 doses equivalent to approximately 3.2 gm (0.2 gm above the 3 gram/24 hour limit);
-January 6 - had 5 doses equivalent to approximately 3.2 gm (0.2 gm above the 3 gram/24 hour limit); and,
-January 11- had 5 doses equivalent to approximately 3.2 gm (0.2 gm above the 3 gram/24 hour limit).

An interview was conducted on January 14, 2025 at 9:01 a.m. with resident #154 who stated that she had four active fractures and that both legs were swollen due to lymphedema. She also said that she was supposed to get pain medication around 6:30 a.m.; but that, the medication administration was delayed by an hour and half almost every day. The resident further stated that staff informed her that it was her fault because she was sleeping.

During an interview with a Registered Nurse (RN/staff #10) conducted on January 17, 2025, at 2:03 p.m., the RN stated that pain medications were given to residents after a pain assessment was done; and that, during the pain assessment a resident identifies how much pain they were having using a pain scale to determine if they were eligible to take the specific pain medication. The RN also said that she would also look at the medication order which would specify what dose of pain medication to give to the resident. A review of the clinical record was conducted with the RN who stated that the MAR for January 2025 revealed that acetaminophen was not administered within the physician ordered parameters. The RN said that if the pain medication such as acetaminophen was not administered following the ordered parameters, it can affect the resident's liver because the dose exceeded the limit for acetaminophen.

An interview with the Director of Nursing (DON/staff #241) was conducted on January 17, 2025, at 2:46 p.m. The DON stated that her expectation was for staff to follow the physician ordered parameters when administering pain medications; and that; administering acetaminophen outside of the parameters may cause adverse effects to the resident.

A review of the facility policy on Administering Medications, with revision date of June 2014 revealed that medications are to be administered according to orders.

Based on clinical record review, interviews and facility documentation and policy review, the facility failed to assist in maintaining the highest practicable well-being by failing to ensure that Activity of Daily Living (ADL) care was provided for 1 resident (#2).

Findings include:

Resident #2 was admitted on November 21, 2022 with diagnoses of fracture of the sacrum and other disorders of bone density and structure.

A care plan dated June 13, 2024 included that resident had a current functional performance of extensive assistance with one-person assist with most activities of daily living (ADLs) such as personal hygiene and transfers. The care plan also included that the resident's vision and hearing were impaired. Interventions included announce self when entering room, explain procedures and anticipate and meet needs promptly.

The care plan on daily preferences with revision date of June 16, 2024 included that it was important to the resident to choose between a tub bath, shower, bed bad, or sponge bath.

A quarterly Minimum Data Set (MDS) assessment dated December 12, 2024 included that this resident was severely cognitively impaired and required partial to moderate assistance with showering/bathing himself.

The 2 west bathing schedule updated January 16, 2025 included that the resident's room had a shower schedule of twice a week on night shift.

The task documentation for November 2024 through January 2025 revealed the resident received showers on the following dates:
-November 5, 11, 12, 29;
-December 3, 10, 17, 24 and 31; and,
-January 7 and 17.
Continued review of the documentation revealed that the resident was not receiving showers twice weekly as scheduled.

Further review of the clinical record from November 1, 2024 through January 17, 2025 revealed no documentation that the resident refused showers.

An interview was conducted on January 17, 2025 at 2:43 p.m. with a certified nursing assistant (CNA/staff #35) who said that showers provided to residents would be recorded on a shower sheet. The CNA further stated that he has not heard of resident #17 refusing bath/showers.

An interview was conducted on January 17, 2025 at 2:43 p.m. with a Registered Nurse Unit Manager (RN/staff #223) who reviewed the clinical record of resident #17 and said that she found that the showers were not charted appropriately because the software was put to trigger charting for day shift. She stated that the room of resident #17 was assigned for night shift to provide the showers as written on the shower assignment paper sheet. The RN also stated that bathing/showers should be offered at least on scheduled days; and, the residents should be offered a bath, shower, or bed bath. Further, she stated that if a resident refuse showers, it should be documented in the clinical record.

In an interview was with the Director of Nursing (DON/staff# 241) conducted on January 17, 2025 at 3:37 p.m., the DON stated that it was her expectation that residents were setup on a shower schedule of twice a week; and that, if the resident prefers more showers then staff should provide them.

The facility policy on Activities of Daily Living Documentation included that the ADLs, which include but are not limited to eating bathing, toileting, transferring, bed mobility, walking, locomotion, and hygiene will be documented by nursing and activity staff performing the task Each ADL must be documented on at least once every shift.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that food was stored under sanitary conditions.

Findings include:

On January 14, 2025 at 8:22 a.m., an initial tour of kitchen was conducted with kitchen manager (staff #80). There was a "ladder/speed" rack that had 4 uncovered trays of uncooked breaded cod fish with opened date of January 13, 2025 in the walk-in refrigerator. There was a label/sticker for a discard date of January 15, 2025 placed on the side of the "ladder/speed" rack. There was also one tray of uncovered cooked beef pot pie on flat metal trays on the rack above the rack where that uncooked breaded cod fish was. The individual food items (fish and beef pot pie) on the rack were not covered; and, was the entire "ladder/speed" rack containing these trays were also not covered.

An interview was conducted on January 14, 2025 at 8:22 a.m. with kitchen manager (staff #80) who stated that the uncooked breaded cod fish on the trays were not covered; and that, the cooked beef pot pie was for tonight's dinner. The kitchen manager stated that the kitchen staff did not want to cover the cooked beef pot pie till it has completely cooled down.

In another observation conducted on January 14, 2025 at 8:48 a.m., an uncovered and unlabeled plastic food storage container that contained a brown powdery substance at the bottom of the food prep table. The kitchen manager (staff #80) placed his hands inside the container and mixed it around repeatedly without using a scoop or without donning gloves. The kitchen manager then placed the plastic food storage container back on the table next to the washing stink.

An interview was conducted with the kitchen manger (staff #80) on January 14, 2025 at approximately 8:48 a.m. The kitchen manager stated that the brown powdery substance contained in the uncovered and unlabeled plastic food storage container was a barbecue spice seasoning.

In a later interview with the kitchen manager (staff #80) conducted on January 14, 2025 at 1:51 p.m., the kitchen manager said that if there was a bag that covers the entire ladder/speed rack, there was no need for individual covers for the trays on the rack. The kitchen manager also said that if there was no bag covering the entire ladder/speed rack, then the individual food tray will be covered individually.

In another interview with the kitchen manager (staff #80) conducted on January 16,2025 at 1:28 p.m., the kitchen manager said that it was not ok for staff to use their bare hands digging into the dry seasoning because staff does not know when the dry seasoning will go into ready to cook meals. The kitchen manager also said that when staff put their hands in the seasoning container without gloves on, that item should be thrown out; and, this practice would not follow the facility expectations. Further, the kitchen manager stated that ladder/speed rack in the walk-in refrigerator had to be covered and dated; and that, food that were not covered would not be served to residents.

During an interview with Register Dietitian (RD/staff #7) conducted on January 16, 2025 at 1:57 p.m., the RD stated that staff cannot dig into dry seasoning without gloves on; and that, staff digging into the dry seasoning with their bare hands was a risk because other kitchen staff would not be aware of it. The RD also stated that the reason for food covering was to prevent cross contamination and things dropping onto the meal. Further, the RD stated that not having food cover would lead to microorganism growing at full speed, food borne illness, or chemicals to get on to the meat.

An interview was conducted on January 17, 2025 at 9:58 a.m. with dietary staff who stated that it was never okay to leave food uncovered regardless of where it is located; and that, uncovered food was unsanitary. Further, the dietary staff stated that it was never allowed to not wear gloves when digging into the dry seasoning; and that, if that happens, then the seasoning should be thrown away.

The facility policy on Food and Supply Storage Procedure included that foods stored on the " Ladder/Speed" rack must be fully covered to prevent contamination and tray to be covered individually or a bag that covers the entire cart.

The facility on Food Handling Guidelines included that when the food is placed in the cooling equipment (walk-in, blast chiller, etc.) loosely cover or uncovered if protected from over contamination.

Review of the facility policy on Food and Supply Storage included that all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

A Policy Review for Food Handling Guidelines (HACCP) (Cont.) states that if food is contaminated it will not be served.

A Policy Review for Food and Supply storage should be covered, dated, and labeled for unused portions and open packages.

Based on documentation, staff interviews, and facility procedures, the facility failed to ensure that the information posted on the daily staff posting was complete and correct.

Findings include:

Review of the daily staff posting dated July 4, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m.

Review of the daily staff posting dated August 6, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. The total number of hours worked for one certified nursing assistant (CNA) documented was 24 hours for the night shift, 6:00 p.m. to 6:30 a.m.

Review of the daily staff posting dated September 16, 2023 did not reveal the number of registered nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m.

During an interview conducted on October 5, 2023 at 8:36 a.m. with Staff Development Coordinator (staff #102), she reviewed the daily staff postings dated July 4, 2023, August 6, 2023, and September 16, 2023 along with the time cards for all the staff scheduled to work. She stated that the daily staff posting dated August 6, 2023 showed one CNA worked a total of 24 hours was incorrect and should have been 12 hours. She stated that the daily staff posting is supposed be updated and corrections made as changes occur.

An interview was conducted on October 5, 2023 at 11:04 a.m. with the Staff Development Coordinator (staff #102), Administrative Assistant (staff #62) and the Administrator (staff #90). Staff #90 stated that the night shift supervisor completes the daily staff posting and everything that is required on the posting is on it. Staff #90 and staff #102 agreed that the total number of each category of staff should be documented on the posting. Staff #102 also stated that the total number of hours worked by each staff should be documented on the posting and staff #90 stated that it is her expectation that any changes regarding the information on the posting are penned in by the supervisor as changes occur. Staff #90 stated there is a regulation that the staffing information is posted and the facility doesn't have a policy regarding the posting.

Based on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for Resident #32 by failing to administer medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm.

Resident #32 was admitted into the facility on August 8, 2023 with diagnoses that included fracture of upper end of left humerus, pain, Alzheimer's, dementia, anxiety, and constipation.

Review of the physician orders revealed the following: Morphine Sulfate Oral Solution 20 milligram (mg) / 5 milliliters (ml) (Morphine Sulfate) to give 0.125 milliliters sublingually every 4 hours as needed for pain 4-10 with start date of August 21, 2023.

Review of Medication Administration Records (MAR) revealed that this medication was administered outside of physician ordered parameters (pain 4-10) on:

Thursday August 24, 2023 pain level of 3.
Monday September 18, 2023 pain level of 2.
Tuesday September 19, 2023 pain level of 3.
Friday September 29, 2023 pain level of 0.

An interview was conducted on October 10, 2023 at 12:03 PM with LPN (Licensed Practical Nurse) Staff #244. Staff #244 was asked about the process of administering medication and explained that medication is given to residents as per written orders. Staff #244 confirmed that written pain levels on MAR were pain assessments prior to the administration of morphine to Resident #32. Staff #244 verified the MAR and confirmed that the medication was given outside of the parameters of 4-10 pain scale on those selected dates. Staff #244 stated it was inappropriate and giving the medication for the documented pain level was over medicating Resident #32.

An interview was conducted on October 10, 2023 at 12:29 P.M. with the Director of Nursing (DON/Staff #190). During this meeting, RN Case Manager (Staff # 111) joined in the interview at 12:55 PM.

The DON stated, "I expect nurses are trained and oriented on administration, educated one-time a year and refresh training, regarding doctors' orders, I expect nurses to follow medication order as written." Staff #190 stated, "pain scale should be followed" when asked about pain medication administration. Staff #190 reviewed the electronic medical records, including MAR, and agreed that the pain levels 2, 3, 0, were below the required parameters for morphine.

Staff #190 invited Staff #111 to join the meeting and requested full review of medical record including the MAR and progress notes for Resident #32. Staff #111 confirmed that morphine was given at a 2-pain level on September 18th, 3-pain level on September 19th, and 0-pain level on September 29th. Staff #111 stated that the risks for giving morphine outside of the parameters were sedation and fatigue.

The document Policy & Procedure # CLIN 165 titled, "Medication Administration" (revised August 23, 2022) was reviewed and revealed, "Medications will be administered within written parameters, I.e.: pain levels".

Based on documentation, staff interviews, and facility procedures, the facility failed to ensure that the information posted on the daily staff posting was complete and correct.

Findings include:

Review of the daily staff posting dated July 4, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m.

Review of the daily staff posting dated August 6, 2023 did not reveal the number of registered nurses or licensed practical nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m. The total number of hours worked for one certified nursing assistant (CNA) documented was 24 hours for the night shift, 6:00 p.m. to 6:30 a.m.

Review of the daily staff posting dated September 16, 2023 did not reveal the number of registered nurses scheduled to work on the day shift, 6:00 a.m. to 6:30 p.m., or the night shift, 6:00 p.m. to 6:30 a.m.

During an interview conducted on October 5, 2023 at 8:36 a.m. with Staff Development Coordinator (staff #102), she reviewed the daily staff postings dated July 4, 2023, August 6, 2023, and September 16, 2023 along with the time cards for all the staff scheduled to work. She stated that the daily staff posting dated August 6, 2023 showed one CNA worked a total of 24 hours was incorrect and should have been 12 hours. She stated that the daily staff posting is supposed be updated and corrections made as changes occur.

An interview was conducted on October 5, 2023 at 11:04 a.m. with the Staff Development Coordinator (staff #102), Administrative Assistant (staff #62) and the Administrator (staff #90). Staff #90 stated that the night shift supervisor completes the daily staff posting and everything that is required on the posting is on it. Staff #90 and staff #102 agreed that the total number of each category of staff should be documented on the posting. Staff #102 also stated that the total number of hours worked by each staff should be documented on the posting and staff #90 stated that it is her expectation that any changes regarding the information on the posting are penned in by the supervisor as changes occur. Staff #90 stated there is a regulation that the staffing information is posted and the facility doesn't have a policy regarding the posting.

Based on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for Resident #32 by failing to administer medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm.

Resident #32 was admitted into the facility on August 8, 2023 with diagnoses that included fracture of upper end of left humerus, pain, Alzheimer's, dementia, anxiety, and constipation.

Review of the physician orders revealed the following: Morphine Sulfate Oral Solution 20 milligram (mg) / 5 milliliters (ml) (Morphine Sulfate) to give 0.125 milliliters sublingually every 4 hours as needed for pain 4-10 with start date of August 21, 2023.

Review of Medication Administration Records (MAR) revealed that this medication was administered outside of physician ordered parameters (pain 4-10) on:

Thursday August 24, 2023 pain level of 3.
Monday September 18, 2023 pain level of 2.
Tuesday September 19, 2023 pain level of 3.
Friday September 29, 2023 pain level of 0.

An interview was conducted on October 10, 2023 at 12:03 PM with LPN (Licensed Practical Nurse) Staff #244. Staff #244 was asked about the process of administering medication and explained that medication is given to residents as per written orders. Staff #244 confirmed that written pain levels on MAR were pain assessments prior to the administration of morphine to Resident #32. Staff #244 verified the MAR and confirmed that the medication was given outside of the parameters of 4-10 pain scale on those selected dates. Staff #244 stated it was inappropriate and giving the medication for the documented pain level was over medicating Resident #32.

An interview was conducted on October 10, 2023 at 12:29 P.M. with the Director of Nursing (DON/Staff #190). During this meeting, RN Case Manager (Staff # 111) joined in the interview at 12:55 PM.

The DON stated, "I expect nurses are trained and oriented on administration, educated one-time a year and refresh training, regarding doctors' orders, I expect nurses to follow medication order as written." Staff #190 stated, "pain scale should be followed" when asked about pain medication administration. Staff #190 reviewed the electronic medical records, including MAR, and agreed that the pain levels 2, 3, 0, were below the required parameters for morphine.

Staff #190 invited Staff #111 to join the meeting and requested full review of medical record including the MAR and progress notes for Resident #32. Staff #111 confirmed that morphine was given at a 2-pain level on September 18th, 3-pain level on September 19th, and 0-pain level on September 29th. Staff #111 stated that the risks for giving morphine outside of the parameters were sedation and fatigue.

The document Policy & Procedure # CLIN 165 titled, "Medication Administration" (revised August 23, 2022) was reviewed and revealed, "Medications will be administered within written parameters, I.e.: pain levels".

Based on observation the facility failed to prevent the fire alarm pull station to be accessible and unobstructed. Obscuring the fire alarm pull stations from view may prevent or delay the initiating of the fire alarm system in an emergency and this has potential harm to the patients and/or staff during a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.4.2.1 "Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system water flow alarms, detection devices, or detection systems, unless otherwise permitted by 19.3.3.2.2 through 19.3.4.2.4." Chapter 9, Section 9.6.2.7, "Each manual fire alarm box on a system shall be accessible, unobstructed, and visible."

Findings include;

Observation made while on tour on October 11, 2023, revealed a large book shelf partially blocking the manual fire alarm pull station on the third floor HUC.

During the exit conference on October 11, 2023, the above finding was again acknowledged by management team.

Based on record review and interview, the facility failed to maintain the batteries on the fire alarm system or have repairs completed in a timely manner. Failure to maintain the alarm system and batteries could cause harm to patients and/or staff during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system".

Based on record review and interview on October 11, 2023, revealed to facility received documentation for their alarm inspection company, Climatec, that there were documented deficiencies with the system on March 15, 2023 and the same documented deficiencies on September 25, 2023. I was told the purchase orders to repair the deficiencies had been recently approved.

During the exit interview conducted on October 11, 2023, the above finding was acknowledged by the management team.

1) Based on record review and interview, the facility failed to ensure that a five (5) year internal inspection was completed in the sprinkler system.
2) Based on observation several dirty sprinkler heads were seen in the second and third floor satellite kitchens. Failing to inspect, test and maintain the sprinkler system could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," Chapter 6, Section 6.3.4.1 states "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge." Chapter 14, Section 14.2.1 states "Except as discussed in 14.2.1 and 14.2.1.4 an inspection of piping and branch lines conditions shall be conducted every 5 years by opening a flushing connection at the the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage."

Findings include;

1) Based on record review and interview October 11, 2023 revealed, the facility failed to provide documentation that a five (5) year internal inspection had been performed. The last documented five (5) year internal inspection was November 1, 2017.

2) Based on observation while on tour on October 11, 2023 revealed, four (4) out of eight (8) sprinkler heads in the second floor satellite kitchen. Also observed were three (3) out of eleven (11) sprinkler heads in the third floor satellite kitchen.

During the exit conference on October 11, 2023 the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain rated fire doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 8, Section 8.3.3.1 Fire Doors and Windows, "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protective's, except as otherwise specified in this Code."

NFPA 80, Fire Doors and Other Opening Protective's Section 5.1.5 Repairs and Field Modifications. 5.1.5.1 Repairs shall be made, and defects that could interfere with operation shall be corrected without delay. Section 5.1.5.2.1, "In cases where a field modification to a fire door or a fire door assembly is desired, the laboratory with which the product or component being modified is listed shall be contacted and a description of the modifications shall be presented to that laboratory." Section 5.1.5.2.2 "If the laboratory finds that the modifications will not compromise the integrity and fire resistance capabilities of the assembly, the modifications shall be permitted to be authorized by the laboratory with a field visit from the laboratory."

Findings include;

Observations made while on tour on October 11, 2023, revealed the following;

1) the rated fire doors on the second floor identified as 2-56, failed to latch secure when tested three of three times
2) the rated fire doors on the third floor identified as 3-50, failed to latch secure when tested three of three times

During the exit conference conducted on October 11, 2023, the above findings were again acknowledged by the management team.

Based on interview and record review the facility failed to inspect and maintain the facilities fire /smoke dampers or fusible links. Failing to inspect and maintain the facility smoke dampers may cause harm to patients and/or staff during an emergency.

NFPA 101 Life Safety Code, 2012 Edition Chapter 21, section 21.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years. Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's. NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years. Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Findings include;

Based on interview and record review on October 11, 2023, the facility was unable to provide documentation the fire/smoke dampers had been inspected. The last documented inspection was September 4, 2019.

During the exit conference conducted on October 11, 2023, the above findings were again acknowledged by the management staff.

Based on record review and interview, the facility failed to provide documentation of the annual fire door inspection in accordance with NFPA 80, 2010 Edition on four (4) rolling fire doors. Failing to inspect and test fire rated door assemblies annually could cause harm to the patients and/or staff.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding,Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

Based on record review and interview on October 11, 2023, revealed the facility failed to provide documentation for an annual fire door inspection for four (4) rolling fire doors. There were two (2) rolling doors on each floor at the nurses stations located on the second and third floors

During the exit conference on October 11, 2023, the above findings were again acknowledged by the management staff.