Maple Hills Skilled Nursing & Rehabilitation

Based on observation and interview, the facility failed to maintain the floors in a safe manner that prevents fall hazards and keeping a homelike environment. This had the potential to affect three residents (#23, #32, and #135). The facility census was 30.

Findings included:

Observation on 10/31/23 at 9:58 A.M. revealed the floor in Resident #32's room was cracked, uneven, and when stepped on, had two tiles that moved and the linoleum in the bathroom had cracked and risen.

Observation on 10/31/23 at 3:13 P.M. revealed the floor in Resident #135's room was bumpy and uneven.

Observation on 11/01/23 at 3:23 P.M. revealed the transition strip from Resident #23's room to the hallway was missing.

Interview on 11/01/23 at 3:23 P.M. with Licensed Practical Nurse (LPN) #122 confirmed missing transition strip, cracked, bumpy and uneven floors as well as shifting tiles affecting Residents #23, #32, and #135.

Review of a policy titled Preventative Maintenance Program revealed the Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building, grounds and equipment are maintained in a safe and operable manner.

Based on record review, policy review, and interview, the facility failed to provide written notice of discharge to Resident #34 and the ombudsman. This affected one resident (#34) of two residents reviewed for discharge. The facility census was 30.

Findings included:

Record review revealed Resident #34 admitted to the facility on 12/22/22 with diagnoses including chronic osteomyelitis, gastro-esophageal reflux disease, bipolar disorder, anxiety disorder, anemia, hypokalemia, insomnia, major depression, and hyperlipidemia. Further review revealed Resident #34 discharged was discharged on 09/21/23.

Review of the record revealed no documented evidence a written notice was given to Resident #34 or sent to the ombudsman.

Interview on 11/01/23 at 10:15 A.M. with Director of Nursing verified the facility did not have record of a written discharge notice being given to Resident #34 or the Ombudsman.

Review of a policy titled Transfer and Discharge (Including AMA) revealed the facility should provide a transfer/discharge notice to the resident/representative and Ombudsman.

Based on record review and interview, the facility failed to ensure Pre-Admission Screening and Resident Reviews (PASARRs) were accurate, updated, and new mental health diagnoses were sent for a Level II review. This affected four residents (#6, #8, #11, and #13) of four residents reviewed for PASARRs. The facility census was 30.

Findings included:

1. Record review revealed Resident #8 was admitted to the facility on 02/12/10 with diagnoses including type II diabetes, hypertension, gastro-esophageal reflux disease, insomnia, and major depressive disorder. On 08/17/23, Resident #8 received a diagnosis of delusional disorders on 03/02/12, anxiety on 05/12/15, and schizoaffective disorder on 08/17/15.

Review of the medical record revealed Resident #8 had a PASARR completed on 02/11/10. An additional PASARR was not completed to include updated mental health diagnoses.

Interview on 11/06/23 at 3:37 P.M. with the Director of Nursing (DON) confirmed a new PASARR had not been completed to include new mental health diagnoses.

Review of a policy titled Resident Assessment- Coordination with PASARR Program revealed any resident who exhibits newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder where dementia is not the primary diagnosis, or a resident whose intellectual disability or related condition was not previously identified an evaluated through PASARR.

2. Record review revealed Resident #11 was admitted to the facility on 11/02/21 with diagnoses including type II diabetes, gastro-esophageal reflux disease, unspecified mood disorder, anemia, functional quadriplegia, neuromuscular dysfunction of bladder, and chronic pain due to trauma. Resident #11 received additional diagnoses of anxiety disorder on 07/10/22 and major depressive disorder on 03/24/23.

Review of the medical record revealed Resident #11 had a PASARR completed on 11/02/21 which did not include diagnoses of mood disorder, depression or anxiety.

Interview on 11/01/23 at 3:07 P.M. with Licensed Practical Nurse (LPN) #122 confirmed Resident #11's PASARR did not contain diagnoses of depression, anxiety or mood disorder.

3. Record review revealed Resident #13 was admitted to the facility on 11/02/21 with diagnoses including major depressive disorder, gastro-esophageal reflux disease, polyosteoarthritis, schizophrenia, unspecified intellectual disabilities, type II diabetes, hyperlipidemia, hypothyroidism, hypertension, obstructive sleep apnea, insomnia, and mild intellectual disabilities.

Review of the medical record revealed a PASARR was completed on 06/14/12 and did not include diagnoses of major depression, mild intellectual disabilities or unspecified intellectual disabilities.

Interview on 11/06/23 at 3:36 P.M. with the Director of Nursing confirmed PASARR was not updated to included new mental health diagnoses.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with nail care. This affected one resident (#12) of two residents reviewed for activities of daily living (ADL's).

Findings include:

A review of Resident #12's medical record revealed she was admitted to the facility on 02/25/17. Her diagnoses included Parkinson's disease, difficulty walking, muscle wasting and atrophy, and muscle weakness.

A review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated 10/02/23 revealed the resident did not have any communication issues and her cognition was severely impaired. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She had a functional limitation in her range of motion of her bilateral lower extremities. A prior quarterly MDS assessment dated 09/19/23 revealed the resident was totally dependent on two for transfers and was totally dependent on one for personal hygiene/ bathing.

A review of Resident #12's care plans revealed the resident had a care plan in place for an alteration in ADL performance related to Parkinson's disease, anxiety/ depression, and a history of falls. The goal was for the resident's needs to be met with regards to her ADL's. The interventions included for the staff to anticipate needs and assist as needed. A care plan for the resident being at risk for impaired skin integrity included the need to keep the resident's fingernails trimmed to an appropriate length. A personal and cultural preference care plan revealed it was the resident's preference to be showered on Sundays, Wednesdays, and Fridays on the day shift.

A review of Resident #12's shower sheets revealed the resident last received a bathing activity on 11/05/23 (Sunday). The shower sheet did not document what type of bathing activity occurred or what other personal hygiene care was provided as part of that bathing activity. It did document that a skin assessment had been completed and whether the resident needed her toenails cut. It did not document anything regarding the provision of nail care.

On 10/31/23 at 1:32 P.M., an observation of Resident #12 noted her to be sitting in a wheelchair in the dining room for lunch. Her fingernails were noted to be long and in need of being trimmed.

On 11/07/23 at 9:00 A.M., a follow up observation of Resident #12 noted her to be lying in bed in a supine position with her head of the bed up. Her fingernails remained long and were still in need of being trimmed.

On 11/07/23 at 9:50 A.M., an interview Registered Nurse (RN) #100 revealed the facility documented showers on paper shower sheets when they were completed. She confirmed Resident #12 was to be showered/ bathed every Sunday, Wednesday, and Friday. She verified the resident's last documented shower that she received was on 11/05/23. She reported the resident was generally compliant with care. She described the resident as being passive in her care. She denied she had known the resident to refuse care. The resident may be resistant at times but would allow the task to be completed.

On 11/07/23 at 9:56 A.M., an interview with State Tested Nursing Assistant (STNA) #115 revealed the resident required a total assist with her ADL's. She stated the resident received bed baths on her scheduled shower days and her scheduled days were every Sunday, Wednesday and Friday. Bed baths and other bathing activities should include personal hygiene care that included trimming of fingernails when needed. She denied she was the one that bathed the resident on 11/05/23, as she was off that day. She reported the resident was compliant with care for the most part. She stated if the resident did not want her nails trimmed she would pull her hand away. She verified Resident #12's fingernails were long and had not been trimmed when she was bathed on 11/05/23. She asked the resident, if she would allow her to trim her nails, at the time she was asked to verify her fingernails were long. The resident nodded her head up and down and the aide left the room to obtain a pair of nail clippers to trim her nails. The resident was compliant and allowed the aide to trim them, after her long fingernails were brought to the aides' attention.

A review of the facility's policy on Nail Care (undated) revealed the purpose of the procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, would be provided on a regular schedule. Nail care would be provided between scheduled occasions as the need arose.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident who was receiving hospice services had relevant hospice related records (Comprehensive Assessments and Plan of Care and visit notes) readily accessible and part of the resident's medical record to ensure continuity of the resident's care. This affected one resident (#20) of one resident reviewed for hospice services.

Findings include:

A review of Resident #20's medical record revealed he was admitted to the facility on 11/10/17. His diagnoses included protein-calorie malnutrition, chronic obstructive pulmonary disease, and muscle wasting and atrophy.

A review of Resident #20's physician's orders revealed he was a Do Not Resuscitate Comfort Care Arrest (DNRCC-A). His physician's orders did not include an order for hospice care/ services despite the resident being identified as receiving hospice services on the facility's roster matrix.

A review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated 07/23/23 revealed the resident had unclear speech, but was usually able to make himself and understand others. His cognition was severely impaired. Hospice care was indicated to have been provided while he resided in the facility.

A review of Resident #20's care plans confirmed he was receiving hospice services for an admitting diagnosis of severe protein-calorie malnutrition. The interventions included the need to discuss/ educate/ and inform the resident/ family/ or responsible party of his care plan interventions and goals following admission, quarterly and as needed (prn). Hospice was to collaborate care with the facility's staff.

A review of a hospice binder kept at the nurses' station revealed there was a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for a start of care of 04/21/23. The benefit period identified on that assessment was for 04/21/23 and 07/19/23. The comprehensive assessment and plan of care update report included a list of his terminal diagnosis and other diagnoses related to his terminal prognosis. It also included a current problem list, a plan of care, and medications in place at the time the comprehensive assessment was completed. The binder was absent for an updated Comprehensive Assessment and Plan of Care Update Report for a current benefit period. The binder also included visit notes by the hospice nurse and the home health aide for visits made to the facility when providing hospice visits for the resident. There were no recent visit notes for either the hospice nurse or the home health aide. The last visit note from the hospice nurse was for a visit on 07/03/23 and the last visit note from the home health aide was for a visit on 07/05/23. Findings were verified by the facility's Director of Nursing (DON).

On 11/07/23 at 1:09 P.M., an interview with the DON revealed the hospice agency should be providing them with their visit notes after they visited the resident in the facility. She also reported an updated Comprehensive Assessments and Plan of Care Update Report should be made available to them and part of the resident's medical record. She indicated both of those items should be kept in the hospice binder for that particular resident that was kept at each nurses' station. She denied she had any visit notes or an updated assessment in her office that had not been placed in the binder yet. She asked Licensed Practical Nurse (LPN) #122, who was the nurse on duty and assigned to Resident #20's unit, if hospice had been leaving those visit notes and assessments when they visited. LPN #122 informed her that they have not.

A review of the facility's policy on Hospice Services Facility Agreement (undated) revealed it was the policy of the facility to provide and/ or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. If hospice care was furnished in the facility through an agreement, the facility would have a written agreement with the hospice that was signed by an authorized representative of the hospice and an authorized representative of the long term care facility before hospice care was furnished to any resident. The written agreement would set out a communication process, including how the communication would be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day. A designated member of the facility working with hospice representative was responsible for obtaining the most recent hospice plan of care specific to each resident.

Based on record review and interview, facility failed to ensure new fall prevention interventions were established post-fall for two residents. This affected two residents (#24 and #32) of two residents reviewed for falls. The facility census was 30.

Findings included:

1. Record review revealed Resident #24 was admitted to the facility on 02/03/20 with diagnoses including Alzheimer's disease, hyperlipidemia, muscle weakness, type II diabetes, hypothyroidism, gastro-esophageal reflux disease, heart failure, major depression, hypertension, anemia, and psychotic disorder with delusions.

Review of minimum data set (MDS) completed on 08/16/23 revealed Resident #24 had impaired cognition, no behaviors, is occasionally incontinent of bowel, and required total dependence for activities of daily living (ADLs).

Review of physician orders revealed Resident #24 used quarter bedrails for a mobility enabler, requires a low bed with floor mat to the open side of the bed, non-skid strips to the floor at bedside, and ted hose daily.

Care plan review revealed Resident #24 was at risk for falls related to debilitation, weakness, impaired cognition, an psychoactive medication use with a goal to minimize potentials risk factors related to falls. Fall interventions included bed in low position (05/26/23), encourage non-skid socks when not wearing shoes (05/30/21), floor mat at bedside (05/26/23), non-skid strips on floor at bedside (03/20/23), provide rest periods (11/30/20), and therapy referral PRN (as needed).

Review of nursing notes from 07/30/23 at 1:07 P.M. by Registered Nurse (RN) #215 revealed Resident #24 was noted to be lying on the floor on her left side with her hands under her head. Review of fall investigation report also completed by RN #215 revealed Resident #24 was placed on fifteen minute checks for intervention. Review of fifteen minute check log revealed fifteen minute checks were not completed on 07/30/23 from 6 P.M. to 8 P.M., 07/30/23 from 9 P.M. to 07/31/23 at 6 A.M., or 08/01/23 from 9 A.M. to 10:45 A.M.

Interview on 11/07/23 at 1:39 P.M. with Assistant Director of Nursing confirmed Resident #24's fall care plan did not contain a new interventions from the fall on 07/30/23 and the immediate intervention of being placed on fifteen minute checks was not completed as ordered.

2. Record review revealed Resident #32 was admitted to the facility on 09/22/23 with diagnoses including Alzheimer's disease, dementia without behaviors, heart failure, chronic kidney disease, hyperlipidemia, occlusion and stenosis of right carotid artery and left vertebral artery, and chronic obstructive pulmonary disease.

Review of a MDS completed on 09/29/23 revealed Resident #32 had impaired cognition, no behaviors, was dependent on staff for bathing, limited assistance of one staff member for all ADLs, and was always continent. Review of orders revealed an order to monitor bump to forehead.

Review of care plan revealed Resident #32 was at risk for falls related to Alzheimer's dementia, weakness, wanders, stroke, chronic obstructive pulmonary disease, and impaired communication with a goal of being free from falls through the next review date. Interventions implemented included anticipate and meet resident's needs (10/04/23); be sure the resident's call light is within reach in the room and encourage use, decrease clutter, commonly used items in reach (10/04/23); ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (10/04/23); physical therapy to evaluate and treat as ordered or PRN (10/04/23); encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (10/04/23); the resident needs activities that minimize the potential for falls while providing diversion and distraction (10/04/23); educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (10/04/23); follow facility fall protocol (10/04/23); and the resident needs a safe environment with: even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, handrails on wall, personal items within reach (10/04/23).

Observation on 10/31/23 at 9:49 A.M. revealed Resident #32 was sitting in her recliner asleep with scattered purple bruising to her right cheek and eye as well as uneven floors in resident's room and the linoleum in the bathroom split and rising.

Interview on 11/01/23 at 9:50 A.M. was attempted with Resident #32, due to impaired cognition Resident #32 was unable to recall what happened to her eye.

Review of nursing notes from 10/22/23 revealed Resident #32 had an unwitnessed fall. Fall investigation completed by RN #215 revealed Resident is confused and new to using a walker which caused the fall. Resident #32 was placed on fifteen minute checks for an immediate intervention.

Interview on 11/01/23 at 3:23 P.M. with Licensed Practical Nurse (LPN) #122 confirmed the uneven flooring in Resident #32's room.

Interview on 11/02/23 at 2:27 P.M. with Assistant Director of Nursing confirmed no new interventions had been put in place for Resident #32 regarding fall on 10/22/23 or bruising that occurred due to the fall.

Review of a policy titled Fall Prevention Program revealed fall interventions will be monitored for effectiveness, the plan of care will be revised as needed, and when any resident experiences a fall the facility should review the resident's care plan and update as indicated.

2. Record review revealed Resident #24 was admitted to the facility on 02/03/20 with diagnoses including Alzheimer's disease, hyperlipidemia, muscle weakness, type II diabetes, hypothyroidism, gastro-esophageal reflux disease, dysphagia, heart failure, major depression, hypertension, anemia, and psychotic disorder with delusions.

Review of minimum data set (MDS) completed on 08/16/23 revealed Resident #24 has impaired cognition, no behaviors, is always incontinent of bladder and occasionally incontinent of bowel, requires total dependence for activities of daily living (ADLs), and had a weight loss that was not a result of a physician prescribed weight loss regimen.

Review of orders revealed Resident #24 uses lipped plates with meals, kennedy cups, a regular diet with pureed texture, and ted hose daily.

Review of Resident #24's care plan revealed resident has potential for nutrition deficits/weight changes related to advanced age, multiple chronic health problems, altered consistency diet, psychoactive medication use, overweight status, self-feeding difficulties, chronic edema, history of weight gain or losses, and variable meal intake. One new intervention was added in 04/24/23 for adaptive equipment with meals as ordered.

Review of Resident #24's weight records revealed a 13.02% weight loss between 09/06/23 with a weight of 184 pounds to 10/30/23 with a weight of 160 pounds.

Review of dietary note from 09/06/23 revealed Resident #24 had a significant weight loss which was determined to be related to edema and nutritional services will continue to follow to monitor.

Review of dietary note from 10/02/23 revealed Resident #24 continued to have a weight loss but current nutrition regimen remained appropriate and dietary will continue to monitor.

Review of dietary note from 10/30/23 reviewed and Resident #24 continued with weight loss with decreased consumption of meals. A new recommendation was given for house supplement 240 milliliters once a day per family member recommendation.

Review of nursing notes from 09/06/23 through 10/30/23 revealed no notes regarding Resident #24 having edema.

Interview on 11/07/23 at 1:31 P.M. with Director of Nursing confirmed there was no documentation regarding edema being a concern with nursing staff from 09/06/23 to 10/30/23 therefore the resident's weight loss would not be contributed to edema and there was no nutritional intervention for the weight loss that began on 09/06/23 until a supplement was implemented on 10/30/23..

Based on record review, observation and interview, the facility failed to ensure artificial nutrition via gastrostomy tube (g-tube) was completed per professional standards. This affected one resident (#135) of one resident reviewed for tube feeding. The facility census was 30.

Findings included:

Record review revealed Resident #135 was admitted to the facility on 10/11/23 with diagnoses including aphasia, down syndrome, autistic disorder, type II diabetes, respiratory disorders, hypertension, gastrostomy status, major depression, anemia, dysphagia, gastro-esophageal reflux disease, and hyperlipidemia.

Review of minimum data set assessment from 10/18/23 revealed Resident #135 was dependent on staff for eating and had a feeding tube.

Review of orders revealed Resident #135 had an order from 10/11/23 for a nothing by mouth (NPO) diet.

On 10/11/23 the resident was ordered enteral feed order every six hours for g-tube, flush peg tube with 200 cubic centimeters (cc's) every six hours, enteral feed order every day and night shift for g-tube flush peg tube with 30 milliliters (ml) of warm water prior to medication administration and flush peg tube with 10 ml of warm water in between each medication then flush peg tube with 30 ml of warm water after final dose of medication administered, and check for g-tube placement every shift.

On 10/23/23, resident was ordered enteral tube feed order every shift for g-tube external feed phone diabeta source via g-tube at 60 ml per hour for 22 hours delivered via g-tube and total volume to be infused is 1320 ml per 24 hours; turn off at 12 P.M. and turn on at 2 P.M. may turn off for care/services and to remain off from 12 P.M. to 2 P.M. daily.

Review of care plan revealed Resident #135 was at risk for alteration in nutrition and hydration related to alternative nutrition via feeding tube, chronic disease, and active diagnosis of protein calorie malnutrition.

Observation on 11/02/23 at 2:34 P.M. revealed Resident #135 was lying in bed and alert and feeding tube was not started.

Observation on 11/02/23 at 3:03 P.M. revealed the tube feeding was not in place for Resident #135 while she rested in her room.

Interview on 11/02/23 at 3:50 P.M. with Licensed Practical Nurse (LPN) #122 revealed she had thought the tube feeding was supposed to start again at 4 P.M. for Resident #135, she did confirm the order stated tube feeding should have started at 2 P.M. and the time must have changed when the order for amount of feeding had changed.

Observation on 11/02/23 at 4:00 P.M. revealed LPN #122 was preparing to administer tube feed to Resident #135. The feeding tubing was noted to be on the floor. LPN #122 prepared warm water for flush prior to administering tube feed. When LPN #122 administered the flush, only approximately one third of the flush went through the g-tube. LPN #122 then removed the remaining water from the uncapped syringe, then reconnected the syringe and applied it to resident's g-tube to push air through and did not check placement of the g-tube with a stethoscope before proceeding. LPN #122 then connected the tube to Resident #135's g-tube and began to feed her. Interview with LPN #122 immediately following observation confirmed she did not check proper placement of the feeding tube prior to administering the tube feed formula.

Interview on 11/02/23 at 4:25 P.M. with the Director of Nursing confirmed LPN #122 should have checked placement of g-tube before proceeding with feeding Resident #135.

Review of a policy titled Appropriate Use of Feeding Tubes revealed feeding tubes will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.

Based on observation, review of the menu's spreadsheet, staff interview, and policy review, the facility failed to ensure appropriate serving sizes were provided in accordance with the facility's menu's spreadsheet. This affected 19 residents (#1, #3, #4, #5, #6, #8, #9, #11, #13, #14, #15, #17, #18, #21, #26, #29, #31, #32, and #136) who the facility identified as receiving regular/ no added salt/ and carbohydrate controlled diets.

Findings include:

On 11/01/23 at 12:40 P.M., an observation of the lunch meal process served from the facility's kitchen revealed residents receiving regular diets, no added salt diets, and carbohydrate controlled diets did not receive the appropriate serving size of zucchini and summer squash vegetable blend on their meal tray. Multiple residents' trays (for those residents on those types of diets) were observed to only receive one scoop of the vegetable blend by Dietary Cook #177 using a 2 oz spoodle, before being placed in a food cart to be delivered to the units. Prior to the tray line, Dietary Cook #177 indicated the serving size of the zucchini and summer squash blend was four ounces and she would have to give two scoops to each resident to equal a four ounce serving.

A review of the menu's spreadsheet for cycle day 11's lunch meal revealed the residents on a regular/ no added salt/ carbohydrate controlled diet was to receive four ounces of zucchini and summer squash with their meal. The utensil specified to provide the proper serving size of the vegetable blend was to be a 4 ounce spoodle.

On 11/01/23 at 12:46 P.M., findings were verified by Dietary Manager #200. She consulted with Dietary Cook #177 and confirmed the residents on a regular diet/ no added salt diet/ carbohydrate controlled diet were to receive a 4 ounce serving. She informed Dietary Cook #177 that she should be using a 4 ounce spoodle or giving each resident two scoops of the vegetable blend if using a two ounce spoodle. Dietary Cook #177 was noted to pull out another metal tray of the zucchini and summer squash from the oven and placed it in the pan on the steam table. She commented that she would give out 4 ounce servings until she ran out as that was all she had.

A review of the facility's policy on Menus and Adequate Nutrition (undated) revealed the purpose of the policy was to assure menus were developed and prepared to meet resident choices including their nutritional needs, while using established guidelines. The facility would ensure that menus met the nutritional needs of residents in accordance with established national guidelines. Menus were to be followed as posted. The facility's dietician or other clinically qualified nutrition professional would review all menus for nutritional adequacy and approve the menus.

Based on observation, staff interview, and policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all residents that received meals from the facility's kitchen. The facility's census was 30.

Findings include:

On 11/01/23 at 11:02 A.M., a visit to the facility's kitchen was made to observe the pureed food process, obtain food temperatures prior to tray line and to observe the meal process. During the pureed food process, Dietary Cook #177 was observed to pull her N-95 mask down by grasping the outside of her mask with her bare hands. She would then raise her mask after talking to re-cover her mouth and nose. She would then handle food equipment such as pans and food processing equipment with her same bare hands without performing hand hygiene. She was also noted to touch the outside of her N-95 mask when she had gloves while handling trays used to place the residents' food on. She did not remove her gloves or performing hand hygiene before she continued with the serving of the residents' food. Findings were verified by Dietary Manager #200.

On 11/01/23 at 12:36 P.M., an interview with Dietary Manager #200 revealed she was not aware of Dietary Cook #177 touching the outside of her N-95 mask without performing proper hand hygiene during the preparation and serving of food during the lunch meal process. She acknowledged the outside of the N-95 mask was considered contaminated and hand hygiene should have been performed after each contact the dietary cook had with the outside of her N-95 mask.

A review of the facility's policy on Handwashing Guidelines for Dietary Employees (undated) revealed handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees should keep their hands and exposed portions of their arms clean. Dietary employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils. They should also wash their hands after they had touched anything unsanitary, after hands had touched bare human body parts other than clean hands such as the face, nose, hair etc.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents call lights were maintained within reach, a resident's assist bar was properly secured to his bed so it did not present as an accident hazard, and a resident who was on seizure precautions had his assist bars padded as ordered. This affected two (Resident #14 and #18) of two residents reviewed for accidents.

Findings include:

1. A review of Resident #14's medical record revealed he was admitted to the facility on 07/03/19. His diagnoses included unspecified dementia, history of a stroke with hemiplegia/ hemiparesis affecting his left, non-dominant side, and seizure disorder.

A review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated 04/20/23 revealed he had unclear speech, but was usually able to make himself understood and was usually able to understand others. His cognition was moderately impaired. He was known to display physical behaviors directed at others and other behaviors not directed at others one to three days of the seven day assessment period. Delusions and hallucinations were not noted to have occurred and he was not known to reject care. He was dependent on two for bed mobility and transfers. Ambulation was not known to occur. He had a functional limitation in his range of motion in his upper and lower extremities on one side.

A review of Resident #14's care plans revealed he had a care plan in place for being at risk for falls. The care plan was initiated on 07/03/19. The interventions included the need to have commonly used articles within easy reach, which included a call light. He was also to have bilateral half side rails on his bed. A care plan for an alteration in health maintenance related to having a seizure disorder was initiated on 07/17/19. The interventions included seizure precautions as ordered and to pad his half side rails on his bed.

A review of Resident #14's physician's orders revealed the resident had an order for padded half side rails as part of his seizure precautions every shift. That order originated on 01/11/22.

On 07/07/23 at 9:11 A.M., an observation of Resident #14 noted him to be lying in bed in a supine position with the head of his bed elevated. His call light box was noted to have been ripped off his wall and was sitting on his bedside table. The resident was holding it and tapping it on his bedside table that was in front of him. The call light was not working properly as it could not be activated when the button on the box was pushed. It did not have a call light cord plugged into it at the bottom of the box where a plug in was noted. His bed had an assist bar on each side of the bed. The assist bar on the right side of the bed was not properly secured and the top half had been pushed away from the bed. Neither the right or left side assist bar was padded as ordered.

On 07/07/23 at 9:27 A.M., an interview with Licensed Practical Nurse (LPN) #11 confirmed Resident #14's call light box was not working properly as it should. She stated the the facility's call light system had not been working for the four months she had been at the facility. The resident's call light box had not been working for at least a week now, but he did have a bell that was provided to him to use in its place. She denied she was able to find the bell in his room that he had last Friday when she worked. She was not sure how long the assist bar on the right side of his bed was not properly secured. She stated, when she worked last Friday, it was in the up position. She confirmed his physician's orders and plan of care indicated he was to have half side rails on his bed as part of his fall prevention interventions and his half side rails were to be padded as part of his seizure precautions.

On 07/07/23 at 9:28 A.M., an interview with Resident #14 revealed his call light box had been off his wall for about six months now. The call light box that was sitting on his bedside table had not worked for about two weeks now. He did have a bell that was provided to him, but he claimed a nurse had taken it away from him about a week ago because he said she was tired of him using it. He stated the staff were still coming in to check on him and he could knock on the table when needing help.

On 07/07/23 at 9:56 A.M., an interview with State Tested Nursing Assistant (STNA) #15 revealed Resident #14 has had multiple call lights but he just kept breaking them when banging on his side rails with it. It was her understanding that the call light he had was not working, but she was not sure how long ago it quit working properly. She thought he may have been given a bell instead but was not certain of that as she was a float aide and not always in his unit.

2. A review of Resident #18's medical record revealed she was admitted to the facility on 11/02/21. Her diagnoses included schizophrenia, chronic obstructive pulmonary disease, adult onset diabetes mellitus, and heart failure.

A review of Resident #18's quarterly MDS assessment dated 07/27/23 revealed she had clear speech and was able to make herself understood and was able to understand others. She was indicated to be cognitively intact and was not known to display any behaviors or reject care. She was dependent on staff and required the assist of two for bed mobility and transfers. Ambulation did not occur. She had a functional limitation in her range of motion to her lower extremities bilaterally.

A review of Resident #18's care plans revealed she was at risk for falls and potential injury related to dementia and impaired balance. Her care plan was initiated on 12/10/21. Her interventions included the need to have commonly used articles within easy reach to include her call light.

On 07/07/23 at 1:40 P.M., an observation of Resident #18 noted her to be lying in bed in a supine position with her eyes open. She was noted to be moaning out. Her room was not noted to have a call light system in place and she did not have a bell present to use to summon staff if assistance was needed. Findings were verified by the Director of Nursing (DON).

On 07/07/23 at 1:42 P.M., an interview with the DON revealed she was not able to find a call light in Resident #18's room and denied she had a bell in her room to call for staff assistance. She confirmed Resident #18 was capable of using a call light and should have one made available to her. She was not sure what happened to her call light or why she did not at least a call bell to use in its place.

This deficiency represents non-compliance investigated under Complaint Number OH00143514.

Based on review of resident council meeting minutes, review of maintenance request forms, review of quotes for the purchase of a new call light system, observation, resident interview and staff interview, the facility failed to ensure they maintained a working call light system in the residents' rooms and bathrooms. This affected 26 of 32 residents (six residents (Resident #2, #9, #12, #17, #19, and #24) the facility identified as not being able to comprehend how or why to use their call light. The facility census was 32.

Findings include:

A review of the resident council meeting minutes from 04/24/23 through 06/19/23 revealed the residents were complaining of their call lights not functioning properly during the meeting minutes for April 2023. Resolutions to those concerns revealed residents were given bells and a quote was obtained and submitted to fix and/ or replace the call light system. Call lights remained a concern in the May 2023 meeting and the residents reported the staff were not hearing their bells. Doors to the residents' rooms were to be left open so staff could hear the bells. There were no concerns regarding call lights voiced in the June 2023 meeting.

A review of maintenance request forms revealed the facility's Administrator indicated a call light issue in room 201 was needing to be addressed on 04/24/23. Maintenance department indicated the call light seemed to be working properly and replaced the battery just to be safe. A second maintenance request form was filled out by the Administrator again on 05/17/23 regarding a call light that needed to be looked at. The Administrator indicated she went and turned it on and off and the call light worked, but she wanted it to be double checked. The maintenance director indicated he checked it on 05/17/23 and the call light was working properly. A third maintenance request form from the Administrator on 06/24/23 revealed the call light in room 201 was needing to be checked again. She indicated it was working when she checked it. The maintenance director indicated he checked it the same day and found it to be working but the resident in that room preferred to use her bell.

A review of a quote from Securitas Healthcare dated 05/09/23 revealed the facility obtained a quote to address the issues they were having with their call light system. The quote included a aerial server upgrade bundle with server, aerial network manager (Comtrol), and installation of a call light system for the total amount of $7,064.06. The quote was signed off by the facility's Administrator on 06/28/23 to approve the work to be done.

On 07/07/23 at 9:11 A.M., an observation of the facility noted some of the residents to have the use of a call light system that allowed them to push a button on a call light cord to summon assistance. Other residents were noted to have the use of a bell to ring for staff assistance. Resident #18 was noted to have his call light box off his wall and sitting on his bedside table. He was using his call light to tap on his bedside table. An attempt to activate his call light by pushing a button on the front of his call light box was unsuccessful in getting his call light to activate. He was not noted to have a bell or any other means to alert staff of any assistance he may need.

On 07/07/23 at 9:27 A.M., an interview with Licensed Practical Nurse (LPN) #11 revealed Resident #18's call light had been off his wall for at least four months now. That was how long she had worked at the facility. She stated the staff just sets it on his bedside table to he could push the button when he needed something. She confirmed his call light box did not activate a signal when the button on the front of it was pushed. She indicated it had not worked for about a week now. He had a bell in his room that he could ring if needing assistance but it was not currently in his room when she was asked to check. She claimed it was there last Friday when she worked, but she was not sure what happened to it.

On 07/07/23 at 9:28 A.M., an interview with Resident #18 revealed the call light box had been off his wall for about six months now. The call light box that was sitting on his bedside table had not been working for about two weeks now. He confirmed he did have a bell to ring but claimed it had been taken away by a nurse a week ago because she was tired of him using it. He indicated he used his call light when he needed changed after being incontinent, but stated the staff still came in and checked him and changed him every couple of hours.

On 07/07/23 at 9:56 A.M., an interview with State Tested Nurse Aide (STNA) #15 revealed Resident #18 required total assist for care. She confirmed he was incontinent of his bowel and bladder and the aides checked and changed him every two hours. She denied he knew when he was incontinent and did not use his call light for assistance with incontinence care as reported by the resident. He had been given multiple call lights but he broke them while banging them on his side rails. They had multiple call lights in the building that were off the walls and being placed on the residents' bedside tables. Some of the residents wanted it like that. She thought his call light box had been ripped off the wall but was not sure how. She claimed it was on the wall when she went into maternity leave back in December 2022 and when she came back to work it was off. They had it sitting on his bedside table and he broke it while hitting it on his bedside table. It was her understanding that it was not working. She was not sure on the length of time it had not been working. She thought he had a bell to use but was not certain of that as she was a float aide and was not always on the second floor where the resident resided.

On 07/07/23 at 11:46 A.M., an interview with Resident #31 revealed his call light system in his room had not been working for about two months now. He had been given a bell to use in its place. He had to ring it a couple of times to get the staff to assist him. He would give it a couple of rings, wait five to 10 minutes and then ring it again if the staff had not come by then. It was usually answered after the first time he rang it without him having to ring it a second time.

On 07/07/23 at 11:51 A.M., an interview with Resident #23 revealed his call light in his room was not working either. He had been given a bell to ring in place of his call light. He would ring his bell, wait five minutes and then ring it again. Staff usually responded by his second time ringing the bell.

On 007/07/23 at 11:56 A.M., an interview with Resident #13 revealed she had a bell to use if she needed anything but denied she ever used it. She stated she was able to take care of herself for the most part. They have been using the bell for about three months now. The call light system in her room was still in place and appeared to be activated when the button on the call cord was pushed. The call for assistance was transmitted and showed on a computer screen down at the first floor nurses' station. The second floor's nurses station (the floor the resident resided on) did not have a computer screen to show a call light had been activated. The call light system used by the facility did not have a light over the door, nor did it have an audible alarm that sounded.

On 07/07/23 at 12:01 P.M., further interview with LPN #11 revealed the residents on the second floor calls for assistance was to go to the pagers carried by the aides. She confirmed Resident #13's call light did not send a message to the aides' pager to show it had been activated. Without them having a computer screen at the nurses' station that showed where a call light was activated from and pagers not always receiving a message when a call light was activated they would not know if a resident needed assistance unless they rang their bells. She again indicated the problems with the call lights had been going on since she started working and she was not sure what was being done to fix it. She denied all the residents who were capable of using a call light had access to the bells. They had only given them out to the residents who could use them and were known to have an issue with the call light system in their rooms. She recalled Resident #5 had an issue where her call light was showing as if it was going off when no one in the room activated the call light. She took the surveyor back to the room and further questioned Resident #5 about the problems she was having. She checked the call light in that room and confirmed it was not currently working. Resident #5 was noted to have a bell in her room to use in place of her call light, but her roommate Resident #20 did not have one. Resident #20 was reported to be a recent admission and had not been given a bell to use in place of her call light. Resident #5 offered to ring her bell on behalf of Resident #20 when she needed assistance but acknowledged she was not always present in the room to be able to ensure Resident #20 had access to means of calling for staff assistance. The bathroom in room 201, that was shared with the room across the hall, did not have a call light system in the bathroom. The mount on the wall, where the call light box was supposed to be, was without a call light box. There was no bell in the bathroom for the residents and/ or staff to use, if they needed assistance. LPN #11 then reported she had talked with the facility's DON and was told to get Resident #18 a bell for his room as he needed one. She obtained a cow bell from the desk at the nurses' station and took it to his room. Resident #18 was confirmed to have a cow bell and was able to demonstrate how to use it for staff assistance if needed.

On 07/07/23 at 12:14 P.M., an interview with Maintenance Director #19 revealed he had been the facility's maintenance director since November 2021. He reported they initially had one resident in room 201 that had concerns about her call light. She complained of her call light a lot. He would check it and found it to be working and would just change the battery as a precaution. Since then, they have had other complaints. They got a quote to update their call light system and recently was approved. They were going to be replacing the current system they had. He has replaced multiple batteries in the call light boxes and it was getting expensive to change. He had been pushing just to get the system replaced and they will be replacing the current Bluetooth system as they were two operating systems behind. If a resident had an issue with their call light, they gave them a bell. Most of the residents' call lights were still working. Some of the residents that had bells still had working call lights. He denied he was doing any weekly monitoring or audits to ensure those residents who were still using the old call light system had a proper functioning call light. They waited until a resident complained before they checked it out.

On 07/07/23 at 12:29 P.M., an interview with the DON confirmed the call light issue had been going on since the end of April/ beginning of May 2023. They talked to maintenance about it and was told the system was outdated. They then talked to the regional office and was told to have maintenance get a quote, which he did. She confirmed Resident #18 should have had access to a call light or at least a bell if his call light was not working in his room. She confirmed only those residents with call light issues were given bells. She did a whole house audit in May 2023 to identify which residents did not have a functioning call light. Those that were not working properly received a call bell. She denied she was performing any ongoing audits to ensure those residents whose call lights were found to be working in May 2023 were still working properly today. The residents usually let them know if there was a problem with their call light, so she would just check then. She was asked to provide a list of residents who were capable of using their call light and still had the use of the facility's old call light system. She identified 16 of the 32 residents as fitting that category. She was asked to assist with determining if those 16 residents call lights were still functioning properly.

On 07/07/23 from 1:28 P.M. to 1:45 P.M., those 16 residents call lights were checked for proper functioning. Resident #1's call light was tested and was able to be activated but it showed a different room's call light had been activated when checking the computer screen at the first floor nurses' station. Resident #26's room also was able to be activated, but it too gave a different location of where the call light originated from other than the resident's room. Resident #28's call light was found not to be working when she was indicated to be able to use and was still using the facility's old call light system that was thought to be in proper working order. Resident #30's call light in her room did not work. She had been given a bell but her bell was not within reach as it was on top of her wardrobe. She indicated she had pushed her call light several times last night and did not receive a response from the staff. Resident #18, who resided on the second floor, was not noted to have a call light , nor did she have a bell to use to call for assistance. The DON identified her as being a resident that was able to use a call light and was still using the facility's old call light system. She did not know why the resident did not have a call light or a bell present in her room. Resident #16's call light did not send a message to the aides' pager when her call light was activated. She resided on the second floor and staff on the second floor would not know that she needed assistance without a message being received on the pager. Resident #15's call light did not activate when pushed but the DON discovered she had the call light for bed B and not the call light for bed A where she resided. The call light for bed A did activate when it was activated after being placed on Resident #15's side of the room. Resident #11's call light did not activate when pushed and Resident #10's call light showed that it was coming from room 211's bathroom when Resident #10 resided in room 213. Some of the call lights tested on the second floor did show up as a message on the aides pager after a significant delay, while others did not. The DON acknowledged the call lights they thought were still functioning properly were found not to be when tested. She stated the Administrator was going to go out and purchase some bells to ensure all residents that were capable of using a call light had access to one and they had one in every bathroom.

This deficiency represents non-compliance investigated under Complaint Number OH00143514.

Based on record review and interview, the facility failed to ensure comprehensive care plans were implemented timely following the completion of the admission Minimum Data Set (MDS) assessment. This affected one resident (#21) out of three residents reviewed for careplans. The facility census was 32.

Findings include:

Record review for Resident #21 revealed this resident was admitted to the facility on 02/03/23 and had diagnoses including chronic obstructive pulmonary disease, age-related osteoporosis without current fracture, anxiety disorder, insomnia, vascular dementia, type two diabetes mellitus, bipolar disorder, fibromyalgia, and intervertebral disc degeneration. This resident was transferred out to the hospital on 03/31/23.

Review of the admission MDS assessment, dated 02/13/23, revealed this resident had intact cognition. This resident was assessed to require supervision with setup help only for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for personal hygiene.

Review of the comprehensive care plans for this resident revealed the care plans were not implemented until 03/30/23, 45 days after the completion of the admission MDS assessment.

Interview with the Director of Nursing (DON) and Administrator on 04/19/23 at 12:35 P.M. verified the comprehensive care plans for Resident #21 had not been implemented until 03/30/23.

Based on record review, interviews, and review of facility policy, the facility failed to ensure areas of bruising were appropriately assessed, documented, and monitored. This affected one resident (#21) out of three residents reviewed. The facility census was 32.

Findings include:

Record review for Resident #21 revealed this resident was admitted to the facility on 02/03/23 and had diagnoses including chronic obstructive pulmonary disease, age-related osteoporosis without current fracture, anxiety disorder, insomnia, vascular dementia, type two diabetes mellitus, bipolar disorder, fibromyalgia, and intervertebral disc degeneration. This resident was transferred out to the hospital on 03/31/23.

Review of the admission Minimum Data Set (MDS) assessment, dated 02/13/23, revealed this resident had intact cognition as evidenced by a brief interview for mental status (BIMS) assessment score of 15 out of 15. This resident was assessed to require supervision with setup help only for bed mobility, transfers, and toileting and to require extensive assistance from one staff member for personal hygiene.

Review of the facility Weekly Skin Assessment, dated 03/30/23, revealed this resident was assessed to have bruises to her bilateral upper extremities, bilateral lower extremities, and upper back related to a fall on 03/12/23.

Further record review for this resident revealed no additional documentation of areas of bruising on weekly skin assessments, shower sheets, or in progress notes.

Interview with State Tested Nursing Assistant (STNA) #195 on 04/18/23 at 10:39 A.M. revealed Resident #21 had a bruise to her arm, maybe some bruising to her back, and her legs were awful and were covered with a lot of bruises. STNA #195 stated Resident #21 was combative, would not stay in bed, and had other behaviors which likely caused the bruises.

Interview with STNA #139 on 04/18/23 at 11:22 A.M. revealed Resident #21 had a lot of bruising. STNA #139 stated the resident became really combative as her disease got worse and would hit the side rails on the bed and flop down hard on the toilet which likely caused the bruises to the residents hips.

Interview with the Director Of Nursing (DON) and Licensed Practical Nurse (LPN) #299 on 04/18/23 at 12:03 P.M. revealed they were unaware of Resident #21 having any areas of bruising.

Interview with Resident #4 on 04/18/23 at 10:35 A.M. revealed Resident #21 had been her roommate before being sent to the hospital. Resident #4 stated Resident #21 had a huge bruise on the underside of her left arm due to falling and hitting it on the bar on the side of the bed and had multiple bruises everywhere. Resident #4 stated she constantly heard staff talking about Resident #21's bruises while they were providing care. Resident #4 stated Resident #21's son came in to the facility and saw all the residents bruises and Resident #4 informed him they had came from her falling.

Interview with STNA #195 on 04/19/23 at 12:10 P.M. revealed Resident #21 had a lot of bruises which STNA #195 had assumed other staff had already seen and were aware of.

Interview with the DON and Administrator on 04/19/23 at 12:35 P.M. verified there was no additional documentation of bruises for Resident #21 other than the documentation on the Weekly Skin Assessment dated 03/30/23.

Telephone interview with Registered Nurse (RN) #401 on 04/19/23 at 10:09 P.M. verified Resident #21 was observed on 03/30/23 to have several bruises to her arms and legs and an area of bruising on her back. RN #401 stated the bruises were yellow and purple and looked older.

Review of the facility policy titled Skin Assessment, not dated, revealed policy to perform a full body skin assessment as part of the systematic approach to pressure prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toe, skin assessment will be conducted weekly by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Documentation of skin assessment to include date and time of the assessment, observations, type of wound, measurements, color, type of tissue in wound bed, drainage, odor, pain, if the resident refused the assessment and why, and other information as indicated or appropriate.

This deficiency represents non-compliance investigated under Complaint Number OH00141839 and OH00142027.

Based on observation, record review and interview the facility failed to ensure food, dishwasher and refrigeration temperatures were routinely/consistently monitored to prevent contamination and/or food borne illness. This had the potential to affect 32 of 32 residents who received meal trays from the kitchen. The facility identified one resident (#24) who received nothing by mouth. The facility census was 33.

Findings include:

On 11/02/22 at 1:35 P.M. interview with Maintenance #71 revealed the 100 gallon hot water tank feeding the kitchen had been broken and the facility used Styrofoam dishes until a new one was installed. The tank was replaced with two 50 gallon tanks on 07/13/22. Maintenance #71 revealed as far as he knew, the hot water issue in the kitchen was resolved. Maintenance #71 indicated he had the water temperature set at C. He was not sure what the water temperature would be on the C setting.

On 11/02/22 at 2:48 P.M. interview with Resident #30 revealed residents were still receiving food/meals using Styrofoam dishes from the kitchen.

On 11/02/22 at 3:10 P.M. observation of the kitchen revealed a low temperature dishwasher that was to reach 120 degrees Fahrenheit for washing and rinsing. Observation of four cycles of the dishwasher running revealed the temperature gauge on the dishwasher stayed at 110 degrees Fahrenheit. The water temperature was measured with a manual thermometer at 100 degrees. The facility had no recorded dishwasher temperatures from 11/01/22 or 11/02/22. Review of the October 2022 Low Temperature Dish Machine Log revealed the water temperature and sanitation levels were recorded the first five days of October. The water temperature was documented to range from 120 to 136 degrees Fahrenheit. There were no recorded temperatures from 10/06/22 through 10/25/22 except for a supper temperature of 108 degrees on 10/07/22. On 10/26/22, 10/27/22 and 10/28/22 the supper meal water temperatures and sanitation levels were recorded for the supper meal only. There were no water temperatures or sanitation levels recorded for 10/29/22 or 10/30/22.

Review of the temperature logs revealed no logs from 11/01/22 or 11/02/22 for the freezer, refrigerator or milk cooler temperatures. Review of the October 2022 refrigeration log included the seven refrigerators and a freezer at the facility. There were temperatures recorded for 13 of 30 days in October 2022.

Review of the tray line temperature logs revealed there were 14 days in October 2022 when there were no breakfast or lunch tray line temperatures recorded.

On 11/02/22 at 3:15 P.M. interview with Dietary #52 verified the dishwasher temperatures and sanitation levels were not recorded each meal. She stated staff had been using both regular dishes and Styrofoam. Dietary #52 indicated on this date, they used Styrofoam because the manager said the temperature was not reaching what it needed to be. She indicated if the water temperature was below 120 degrees they were to use Styrofoam dishes. She verified the water temperatures and sanitation levels were not routinely being recorded so there was no way to tell if the required temperature of 120 degrees Fahrenheit and 50 parts per million sanitation were met. Dietary #52 verified there was not a Refrigerator Temperature Log started for November 2022. In addition, Dietary #52 verified the logs that were provided were incomplete and temperatures were not routinely/consistently being obtained and documented. Dietary #52 revealed the Dietary Manager was the cook on day shift. Dietary #52 also indicated meal tray line temperatures were to be taken before each meal was served.

On 11/02/22 at 4:00 P.M. interview with Maintenance #71 revealed the thermometer on the dishwasher was broken and stuck on 110 degrees. Maintenance #71 revealed no one had told him the kitchen dishwasher temperature was not reaching 120 degrees Fahrenheit. He stated he turned the hot water tank to the kitchen up and the water at the dishwasher was currently was 140 degrees.

Review of the Dishwasher Temperature policy, revised 11/2017 revealed for low temperature dishwashers (chemical sanitation) the wash shall be at 120 degrees Fahrenheit and sanitizing solution at 50 parts per million hypochlorite (chlorine) on dish surface in final rinse.

This deficiency represents non-compliance investigated under Complaint Number OH00137081.

Based on observation, facility policy and procedure review and interview the facility failed to ensure the dining room was timely cleaned after meals. This had the potential to affect eleven residents (#2, #9, #13, #18, #19, #23, #27, #28, #30, #32 and #33) who utilized the dining room for meals and activities. The facility census was 33.

Findings include:

On 11/02/22 at 1:20 P.M. observation of the dining room revealed an activity of Bible study was taking place around a large table with a printed vinyl type table cloth. There were eight residents around the table. There were five additional tables around the larger table. Three other tables with table cloths, one with a puzzle on it and one uncovered. A large square table and and the uncovered table tops were observed to be dirty with food debris. The large table had an orange thick wet sticky spill where a resident was sitting. There was spilled food, crumbs, and spillage on the table cloth at the seats where the residents sat for Bible study. The uncovered table as well as a second table covered with a table cloth had food and spilled drinks. The floor looked unswept with scraps of bread type dropping and crumbs.

On 11/02/22 at 3:10 P.M. observation of the dining room revealed the tables and floor remained soiled.

On 11/02/22 at 4:01 P.M. interview with the Director of Nursing (DON) and the Administrator verified the dining room tables were soiled with food debris and spills.

On 11/02/22 at 5:55 P.M. interview with Dietary #52 revealed day turn staff do not routinely clean/wipe off the tables after meals. The tables were often found dirty when she arrived to assist with the supper meal. Dietary #52 indicated she would have to clean the tables off after the supper meal.

The facility identified eleven residents, Resident #2, #9, #13, #18, #19, #23, #27, #28, #30, #32 and #33 who utilized the dining room for meals and activities

Review of the undated Dining Room Cleaning Policy revealed the day shift housekeeper was to clean and sanitize the dining room after breakfast and lunch. If activities had an activity in the dining room, the activities department was to clean and sanitize the area after use. Midnight shift State Tested Nursing Assistant (STNA) staff were to clean and sanitize the dining room after dinner.

This deficiency represents non-compliance investigated under Complaint Number OH00137081.