495316 08/31/2021 NAME OF PROVIDER OR SUPPLIER

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 11/18/2021FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

495316 08/31/2021STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1000 SHENANDOAH AVENUELYNN CARE CENTER

FRONT ROYAL, VA 22630

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

E 000 Initial Comments E 000

An unannounced Emergency Preparedness

survey was conducted 08/29/2021 through

08/31/2021. The facility was in substantial

compliance with 42 CFR Part 483.73,

Requirement for Long-Term Care Facilities.

F 000 INITIAL COMMENTS F 000

An unannounced Medicare/Medicaid standard

survey was conducted 8/29/2021 through

8/31/2021. Significant Corrections are required

for compliance with 42 CFR Part 483 Federal

Long Term Care requirements. The Life Safety

Code survey/report will follow.

The census in this 120 certified bed facility was

91 at the time of the survey. The survey sample

consisted of 25 current resident record reviews

and three closed resident record reviews.

F 656 Develop/Implement Comprehensive Care Plan

CFR(s): 483.21(b)(1)

§483.21(b) Comprehensive Care Plans

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with the

resident rights set forth at §483.10(c)(2) and

§483.10(c)(3), that includes measurable

objectives and timeframes to meet a resident's

medical, nursing, and mental and psychosocial

needs that are identified in the comprehensive

assessment. The comprehensive care plan must

describe the following -

(i) The services that are to be furnished to attain

or maintain the resident's highest practicable

physical, mental, and psychosocial well-being as

required under §483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be required

F 656 10/5/21

SS=D

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

09/17/2021Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete ZOQM11Event ID: Facility ID: VA0260 If continuation sheet Page 1 of 44

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F 656 Continued From page 1 F 656

under §483.24, §483.25 or §483.40 but are not

provided due to the resident's exercise of rights

under §483.10, including the right to refuse

treatment under §483.10(c)(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with the

findings of the PASARR, it must indicate its

rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals to

local contact agencies and/or other appropriate

entities, for this purpose.

(C) Discharge plans in the comprehensive care

plan, as appropriate, in accordance with the

requirements set forth in paragraph (c) of this

section.

This REQUIREMENT is not met as evidenced

by:

Based on observation, staff interview, facility

document review and clinical record review, it

was determined that the facility staff failed to

implement the comprehensive care plan for two

of 28 residents in the survey sample, Residents

#6 and #73.

The facility staff failed to implement weekly skin

assessments per Resident #6's comprehensive

care plan, and failed to implement Resident #73's

comprehensive care plan for fall mats.

The findings include:

1 - Resident #6's pressure injury is

healing, weekly skin

assessments/observations are being

completed as care planned on 8/30/21.

Resident #73's fall mats were put in place

as care planned on 8/30/21.

2 - All residents may be potentially

impacted. A 100% chart review will be

completed to ensure skin

assessments/observations for all

residents have been completed as care


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1. Resident #6 was admitted to the facility on

1/24/20. Resident #6's diagnoses included but

were not limited to a fractured right leg, heart

failure and muscle weakness. Resident #6's

quarterly minimum data set with an assessment

reference date of 5/31/21, coded the resident's

cognition as moderately impaired.

Review of Resident #6's clinical record revealed a

nurse's note dated 12/9/20 that documented the

resident returned from the emergency

department on 12/9/20 with a right knee

immobilizer due to a right leg fracture.

A physician's order dated 12/9/20 documented an

order for a right knee immobilizer and non-weight

bearing status until further notice from a follow up

with the orthopedist.

Resident #6's comprehensive care plan with a

start date of 12/23/20 documented, "Category:

Pressure Ulcer. (Resident #6) is at risk for

alteration in skin integrity due to history of contact

dermatitis (skin condition), impaired mobility,

weakness, impaired vision, pain, multiple

medication use, and multiple chronic health

conditions. Weekly skin assessments per

protocol."

Review of Resident #6's clinical record revealed

weekly skin assessments dated 12/5/20, 1/1/21,

1/15/21 and 1/30/21.

Further Review of the clinical record revealed the

following documented notes regarding Resident

#6's skin:

- A nurse's note dated 12/11/20 documented the

resident's immobilizer was removed for a skin

planned.

Observations of all residents care planned

as needing fall mats will be completed for

compliance.

3 - The facility has implemented orders for

weekly skin observations and they are

scheduled for completion on the TAR.

Licensed nursing staff sign on the TAR

that they have been completed.

Resident use of fall mats will be added to

the CNA documentation. CNAs will be

required to sign off that fall mats are in

use as care planned.

Nursing staff will be educated on the

above processes and on the need to

implement the comprehensive care plans

for residents related to skin assessments

and the use of fall mats.

4 - The DON or designee will audit five (5)

records per week for 6 weeks to ensure

that skin assessments are completed as

care planned.

The DON or designee will observe five (5)

residents per week for 6 weeks to ensure

that fall mats are utilized as care planned.

The DON or designee will track and trend

weekly audits to identify the need for

additional training or modification of

systems/processes. A summary of weekly

audits will be reported to the QAPI

Committee for additional oversight and

recommendation.


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check and no redness was noted.

- A note signed by a nurse no longer employed at

the facility, dated 12/21/20 documented,

"Received new orders from NP to apply 'blue

boots' to resident's bilateral feet. Also Nursing

noted DTI [deep tissue injury] to distal RLL (right

lower leg). Area is being rubbed by resident's

brace. Applied mepilex border (a dressing used

to treat pressure injuries) to area as a

preventative. MD (medical doctor) notified."

The clinical record failed to evidence a weekly

skin assessment was completed between

12/11/20 and 12/21/20, a period of ten days.

Further review of the clinical record revealed the

following:

- An assessment dated 1/1/21, which

documented, "No changes noted."

- A note signed by the occupational therapist and

dated 1/4/21, which documented, "Skin check

completed to bilat (bilateral) le's (lower

extremities)...Mepilex placed to right lateral calf.

Removed and DTI noted, mepilex for pressure

relief. Applied new."

- A weekly body skin assessment dated 1/15/21,

which documented a change in color to Resident

#6's outer aspect of feet but failed to document

information regarding the DTI acquired on

12/21/20. The clinical record failed to evidence a

weekly skin assessment or check was completed

between 1/04/21 and 1/15/21, a period of 11

days.

The next weekly body skin assessment

completed 15 days later dated 1/30/21


Further review of Resident #6's clinical record

5 - 10/5/2021


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failed to reveal an assessment of the resident's

skin and or pressure injury on Resident #6's

posterior right calf until 2/2/21, when a wound log

documented the wound was an unstageable

pressure injury on the right lower extremity

posterior calf, measuring 5.5 centimeters in

length by 2 centimeters in width. The wound was

documented as yellow and black with 90% slough

(yellow/white skin tissue) and 5% eschar (dead

skin tissue).

On 8/30/21 at 3:07 p.m., an interview was

conducted with RN (registered nurse) #2. RN #2

stated the purpose of the care plan is to allow

staff to know what is put in place.

On 8/31/21 at 8:12 a.m., an interview was

conducted with ASM #2, the director of nursing.

ASM #2 stated residents should receive complete

body assessments each week and newly found

wounds should be measured, documented and

reported to the nurse manager. In regards to

pressure injury assessments, ASM #2 stated

pressure injuries, including DTIs, should be

assessed weekly, including measurements, what

the wound looks like, and drainage. ASM #2

stated documentation of assessments is included

on wound logs and then the wounds are

discussed in a weekly meeting.

On 8/31/21 at 9:48 a.m., another interview was

conducted with RN #2. RN #2 stated weekly skin

assessments should show up on the medication

administration record or treatment administration

record in the computer system when they are due

but this process was implemented after January

2021.


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On 8/31/21 at 10:09 a.m., ASM (administrative

staff member) #1 (the administrator) and ASM #2

(the director of nursing) were made aware of the

above concern.

The facility policy titled, "Person-Centered Care

Planning" documented, "F. The resident will

receive the services and/or items included in the

plan of care."

No further information was provided prior to exit.



were not limited to dementia, chronic kidney

disease and heart failure. Resident #73's annual

minimum data set with an assessment reference

date of 7/23/21, coded the resident's cognition as

severely impaired.

Resident #73's comprehensive care plan revised

on 10/29/20 documented, "(Resident #73) is at

risk for falls due to history of (recent) falls,

cognitive & communication deficits, impaired

vision, impaired mobility, weakness, pain, multiple


conditions. Bed in lowest position while Resident

in bed and floor mats @ (at) beside while

Resident in bed..."

Resident #73's physician's orders effective

7/30/21 through 8/30/21 failed to reveal a

physician's order for fall mats.

On 8/29/21 at 4:38 p.m., and 5:34 p.m., Resident

#73 was observed lying in a low bed without any

fall mats beside the bed. Two fall mats were

observed against the wall.


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conducted with CNA (certified nursing assistant)

#3, regarding the purpose of the comprehensive

care plan. CNA #3 stated, "Basically to tell you a

little more about the person; what they may need,

something you don't know, or something new."

CNA #3 stated fall mats are documented on

residents' care plans. CNA #3 further stated

Resident #73 is at risk for falls and tries to sit up

on the side of the bed so fall mats are supposed

to be on both sides of the bed when the resident

is in bed.



stated the purpose of the care plan is to allow

staff to know what is put in place to prevent injury

or incidents. RN #2 stated fall mats are used to

prevent injury and are documented on care plans.

On 8/30/21 at 5:43 p.m., ASM (administrative



above concern.

No further information was presented prior to exit.

F 657 Care Plan Timing and Revision

CFR(s): 483.21(b)(2)(i)-(iii)

§483.21(b) Comprehensive Care Plans

§483.21(b)(2) A comprehensive care plan must

be-

(i) Developed within 7 days after completion of

the comprehensive assessment.

(ii) Prepared by an interdisciplinary team, that

includes but is not limited to--

(A) The attending physician.

F 657 10/5/21

SS=D


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(B) A registered nurse with responsibility for the

resident.

(C) A nurse aide with responsibility for the

resident.

(D) A member of food and nutrition services staff.

(E) To the extent practicable, the participation of

the resident and the resident's representative(s).

An explanation must be included in a resident's

medical record if the participation of the resident

and their resident representative is determined

not practicable for the development of the

resident's care plan.

(F) Other appropriate staff or professionals in

disciplines as determined by the resident's needs

or as requested by the resident.

(iii)Reviewed and revised by the interdisciplinary

team after each assessment, including both the

comprehensive and quarterly review

assessments.


by:

Based on staff interview, facility document review

and clinical record review, it was determined that

the facility staff failed to review and revise the

comprehensive care plan for one of 28 residents

in the survey sample, Resident #6.

The facility staff failed to review and revise

Resident #6's comprehensive care plan when

Resident #6 developed a DTI (deep tissue injury)

pressure injury (1) on 12/21/20.


Resident #6 was admitted to the facility on





1 - Resident #6's comprehensive care

plan is current to include her pressure

injury.

2 - All residents with pressure injuries may

be potentially impacted. The facility will

review comprehensive care plans for

residents with pressure injuries to ensure

care plans are up to date with current

information.

3 - Comprehensive care plans for all

residents with pressure injuries will be

reviewed weekly at the facility risk

meeting to ensure they have been

updated appropriately by the

interdisciplinary team upon identification

and when the residents' pressure injury


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A nurse's note dated 12/21/20 documented,

"Received new orders from NP (nurse

practitioner) to apply 'blue boots' to resident's

bilateral feet. Also Nursing noted DTI to distal

RLL (right lower leg). Area is being rubbed by

resident's brace. Applied mepilex border (a

dressing used to treat pressure injuries) to area

as a preventative. MD (medical doctor) notified."









protocol." Resident #6's comprehensive care plan

failed to reveal documentation regarding the

resident's DTI identified on 12/21/20, as

documented in the note above.



stated care plans should be reviewed and revised

to include pressure injuries. RN #2 stated the

nurses document the problem, interventions put

in place, and who was notified.

On 8/31/21 at 10:09 a.m., ASM (administrative



above concern.

The facility policy titled, "Skin integrity, pressure

ulcers" documented, "If a pressure ulcer/injury

changes.

The interdisciplinary team will be

educated on the above process.

4 - Nurse Managers or designees will

review five (5) care plans per week for 6

weeks to ensure that care plans are

updated when a pressure injury is

identified or when the residents' pressure

injury changes.


weekly audits to identify need for





recommendation.

5 - 10/5/2021


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develops...5. Update the care plan to include

individualized interventions."


Reference:

(1) "A pressure injury is localized damage to the

skin and underlying soft tissue usually over a

bony prominence or related to a medical or other

device. The injury can present as intact skin

or an open ulcer and may be painful. The injury

occurs as a result of intense and/or prolonged

pressure or pressure in combination with shear.

The tolerance of soft tissue for pressure and

shear may also be affected by microclimate,

nutrition, perfusion, co-morbidities and condition

of the soft tissue.

Deep Tissue Pressure Injury: Persistent

non-blanchable deep red, maroon or purple

discoloration: Intact or non-intact skin with

localized area of persistent non-blanchable deep

red, maroon, purple discoloration or epidermal

separation revealing a dark wound bed or blood

filled blister. Pain and temperature change often

precede skin color changes. Discoloration may

appear differently in darkly pigmented skin. This

injury results from intense and/or prolonged

pressure and shear forces at the bone-muscle

interface. The wound may evolve rapidly to reveal

the actual extent of tissue injury, or may resolve

without tissue loss. If necrotic tissue,

subcutaneous tissue, granulation tissue, fascia,

muscle or other underlying structures are visible,

this indicates a full thickness pressure injury."

This information was obtained from the website:

https://cdn.ymaws.com/npiap.com/resource/resm

gr/online_store/npiap_pressure_injury_stages.pdf


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F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer

CFR(s): 483.25(b)(1)(i)(ii)

§483.25(b) Skin Integrity

§483.25(b)(1) Pressure ulcers.

Based on the comprehensive assessment of a

resident, the facility must ensure that-

(i) A resident receives care, consistent with

professional standards of practice, to prevent

pressure ulcers and does not develop pressure

ulcers unless the individual's clinical condition

demonstrates that they were unavoidable; and

(ii) A resident with pressure ulcers receives

necessary treatment and services, consistent

with professional standards of practice, to

promote healing, prevent infection and prevent

new ulcers from developing.


by:

F 686 10/5/21

SS=G

Based on staff interview, facility document review

and clinical record review, it was determined that

the facility staff failed to provide care and services

for the prevention and treatment of a pressure

injury for one of 28 residents in the survey

sample, Resident #6.

On 12/9/20, a knee immobilizer was placed on

Resident #6's right leg in the emergency

department due to a fracture. The facility staff

failed to obtain a physician's order regarding

removal of the immobilizer for

assessments/checks of the resident's skin

beneath and the area surrounding the

immobilizer, failed to conduct weekly body skin

assessments or assessments of the skin

surrounded by the immobilizer from 12/11/20 until

12/21/20. On 12/21/20, documentation

evidenced Resident #6 developed a DTI (deep

tissue injury) pressure injury (1) on the right

1 - Resident #6's pressure injury to

posterior calf is healing, weekly skin

evaluations are being completed, and

treatments are being administered as

ordered by the physician. The resident is

also being followed by the Wound Clinic.

Resident no longer requires the use of the

immobilizer.

2 - All residents may potentially be

impacted. The facility has implemented

systems to ensure that weekly skin

observations are completed, findings of

skin impairments are reported to the

physician/practitioner, and orders are

transcribed and implemented. If a

resident has an immobilizer, orders will be

obtained for clarification for when the

immobilizer can be removed for skin

inspection.


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posterior calf. The facility staff failed to conduct

any assessments of the residents DTI or provide

treatment, to promote healing, with the exception

of two dates, (12/21/20 and 1/4/21), until 2/2/21,

when Resident #6's right posterior calf pressure

DTI injury was documented as having declined to

an unstageable pressure injury (1), resulting in

harm.









Review of Resident #6's clinical record revealed a

nurse's note dated 12/9/20 that documented the

resident returned from the emergency

department on 12/9/20 with a right knee

immobilizer due to a right leg fracture. Review of

emergency department notes failed to reveal

orders for the immobilizer.

A physician's order dated 12/9/20 documented an

order for a right knee immobilizer and non-weight

bearing status until further notice from a follow up

with the orthopedist.

Review of Resident #6's clinical record failed to

reveal any weekly body skin assessments from

12/11/20, until 1/1/21 and 1/15/21. An

assessment dated 1/1/21 documented, "No

changes noted." Further review of Resident #6's

3 - The facility has implemented orders for

weekly skin observations. They are

scheduled for completion on the

Treatment Administration Record [TAR].

Licensed nursing staff sign on the TAR

that the observations have been

completed. Findings of the observations

will be documented in the resident's

medical record.

Observations of new skin impairments will

be communicated to the

physician/practitioner for treatment and

orders will be implemented and

documented by the licensed nurse.

Weekly skin evaluations will be completed

for residents with pressure injuries; when

the pressure injury demonstrates

significant change and/or is observed to

be worsening, the physician/practitioner

will be notified and clarification order for

treatment will be documented. The TAR

will document treatment administration.

Residents who have orders for use of an

immobilizer will have orders clarified to

indicate when the immobilizer may be

removed for skin inspection and/or

treatment. Skin inspections and

treatments will be documented in the

medical record by a licensed nurse.

Physician orders will be clarified as

appropriate to delineate if nursing and/or

therapy are to provide wound care.

The facility protocol for physician

notification of need for clarification of

orders has been refined and instructs the


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clinical record failed to reveal any physician's

orders for skin assessments, of the skin beneath

or surrounding the immobilizer.

A nurse's note dated 12/11/20 documented the

immobilizer was removed for a skin check and no

redness was noted.

A note signed by the NP (nurse practitioner) on

12/11/20 documented the orthopedic office had

been contacted but the orthopedist could not visit

Resident #6 due to quarantine so the nurse

practitioner asked the nursing staff to schedule a

telehealth appointment.

A note signed by the NP on 12/14/20 documented

the NP asked the nursing staff to clarify Resident

#6's weight bearing status with the orthopedist.

A note signed by LPN (licensed practical nurse)

#4 on 12/14/20 documented the orthopedist was

contacted; however, the nursing note did not

evidence any documentation regarding

clarification or orders regarding removal of

Resident #6's immobilizer, for skin

assessments/checks beneath and the area

surrounding the knee immobilizer.

A note signed by LPN #4 on 12/16/21

documented LPN #4 called the orthopedic office

but the office was closed due to snow.

A BRADEN risk for predicting pressure injury

scale dated 12/21/20 documented Resident #6

was at risk for pressure injuries. The score was

15 on a scale from 9 or less indicating very high

risk to 19 and above indicating not at risk.

A note signed by a nurse no longer employed at

nursing staff to contact the Medical

Director for unresolved concerns.

Licensed nursing staff will be educated in

the above processes. Licensed nursing

staff will be educated in documentation

that is to be included in weekly skin

evaluations and requirements for

notification to the physician/practitioners.

Resident care plans for potential risk

and/or actual pressure injuries will be

reviewed and updated appropriately by

the interdisciplinary team upon

identification and when the resident's

pressure injury changes.

4 - The DON/designee will audit five (5)

records per week x 6 weeks to ensure

that weekly skin observations were

conducted, documented, and that

impairments were reported to the

physician/practitioner.

The DON/designee will audit three (3)

records per week x 6 weeks to ensure

that wound logs are being completed, that

changes are reported to the physician,

and that treatments are documented as

administered.

The DON/designee will audit records of

residents with orders for an immobilizer

weekly x6 weeks to ensure that the orders

identify when the immobilizer can be

removed for skin inspection and/or

treatment and that the record reflects that

inspections/treatments are documented in

accordance with provider order.


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the facility, dated 12/21/20 documented,

"Received new orders from NP to apply 'blue

boots' to resident's bilateral feet. Also Nursing

noted DTI [deep tissue injury] to distal RLL (right

lower leg). Area is being rubbed by resident's

brace. Applied mepilex border (a dressing used

to treat pressure injuries) to area as a

preventative. MD (medical doctor) notified."

A physician communication order form dated

12/21/20 and signed by ASM (administrative staff

member) #3 (the nurse practitioner) documented,

"Nursing Request/Information: Noted DTI to RLL

(distal) - area is being rubbed by resident's brace.

Applied mepilex border over area & 'blue boots' to

help offload area. Physician Response/Order:

Agree."

A note signed by the occupational therapist and

dated 1/4/21 documented, "Skin check completed

to bilat (bilateral) le's (lower extremities)...Mepilex

placed to right lateral calf. Removed and DTI

noted, mepilex for pressure relief. Applied new."

A weekly body skin assessment dated 1/15/21

documented a change in color to Resident #6's

outer aspect of feet but failed to document

information regarding the DTI acquired on

12/21/20.

A nurse's note dated 1/26/21 documented

Resident #6 returned from an orthopedist

appointment on that date and the knee

immobilizer was discontinued. A note signed by

the orthopedist on 1/26/21 was mostly illegible but

documented to discontinue the knee immobilizer

and weight bearing as tolerated.

The DON/designee will track and trend

the weekly audits to identify need for


systems/processes. A summary of the

weekly audits will be reported to the QAPI


recommendation.

5 - 10/5/2021


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A weekly body skin assessment dated 1/30/21


Further review of Resident #6's clinical record

failed to reveal an assessment of the pressure

injury on Resident #6's posterior right calf until

2/2/21, when a wound log documented the wound

was an unstageable pressure injury on the right

lower extremity posterior calf, measuring 5.5

centimeters in length by 2 centimeters in width.

The wound was documented as yellow and black

with 90% slough (yellow/white skin tissue) and

5% eschar (dead skin tissue).

A note signed by RN (registered nurse) #2, dated

2/2/21 documented, "Resident with wound with

irregular edges to RLE (right lower extremity)

posterior calf with 90% slough peri wound with

redness and warmth. NP notified ok with

treatment of cleansing with normal saline and pat

dry apply maxsorb (a wound dressing) and cover

with Mepilex every 3 days and PRN (as

needed)..."

A physician communication order form dated

2/2/21 documented, "Nursing/Pharmacist

Request/Information: Wound Noted to RLE

posterior calf (with) 90% slough, redness &

warmth noted. (No) c/o (complaint of) pain or

discomfort. Physician Response/Order. 1.

Arterial Doppler of RLE dx (diagnosis) wound. 2.

Cleanse wound to RLE posterior calf (with)

normal saline, pat dry apply maxsorb and cover

(with) mepilex q (every) 3 days & prn (as

needed)."






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protocol. 2/2/21 UTS (Unstageable) noted to r

(right) lateral posterior calf..." The care plan

failed to document information regarding the DTI

observed on 12/21/20.


conducted with RN #2, the unit manager for the

unit where Resident #6 resided during the survey.

RN #2, stated typically nurses check the skin

around an immobilizer but the nurses did not

have a physician's order to remove Resident #6's

immobilizer. RN #2 stated she thought LPN #4

attempted to obtain orders from Resident #6's

orthopedist and in-house physicians to remove

the immobilizer but there was not an order to do

so. RN #2 stated an order for mepilex was

written for Resident #6's DTI on 12/21/20 but the

order was not transcribed. RN #2 stated there

was documentation that mepilex was applied to

the DTI on 12/21/20 and one other day by a

therapist but there was no documentation to

evidence the dressing was applied any other

days.


conducted with OSM (other staff member) #3, a

physical therapist. OSM #3 stated Resident #6's

knee immobilizer was placed on the resident on

12/9/20. OSM #3 stated the therapy department

did not begin treatment until 12/21/20 because

they had to wait for clarification regarding the

resident's weight bearing status. OSM #3 stated

she felt the therapy and nursing staff should have

been checking the skin around Resident #6's

immobilizer better but they did not remove the


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immobilizer due to not having specific orders or

instructions.


conducted with LPN #4, the unit manager for the

unit Resident #6 resided on while she had the

knee immobilizer, regarding the facility process

for skin assessments when a resident has a knee

immobilizer. LPN #4 stated the nurses should

check the skin around an immobilizer every shift

based on orders from the physician and if the

immobilizer can be removed. LPN #4 stated the

skin should still be assessed as far as nurses can

see if the immobilizer cannot be removed. LPN

#4 stated she called Resident #6's orthopedist

and left a message for the physician on 12/14/20

to obtain clarification for the resident's weight

bearing status, any further orders and x-rays.

LPN #4 stated she called the orthopedist on

12/16/20 and left a message but the office was

closed due to snow. LPN #4 stated she called

the orthopedist on 12/21/20 and waited for a fax

or call concerning the resident's weight bearing

status. LPN #4 was asked if she specifically

asked about removal of the immobilizer for skin

assessments. LPN #4 stated she asked for

follow up orders. In regards to identification of a

pressure injury, LPN #4 stated the nurses should

fill out a wound sheet, write a note to the doctor,

initiate treatment, discuss the wound in a weekly

meeting and continue to assess the wound each

week. LPN #4 stated a pressure injury

assessment should include measurements, what

the wound looks like, a description of the wound

bed, drainage, type of tissue, stage and whether

the wound has improved or deteriorated. In

regards to the identification of Resident #6's DTI

on 12/21/20, LPN #4 stated an order for mepilex

was written on that day but a continuation of


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treatment was missed. LPN #4 stated normally

mepilex should be applied every three days or

every one or two days depending on what the

pressure injury looks like and what the nurse

practitioner prescribes. LPN #4 stated the

mepilex order should have been noted in the

computer and the nurses should have obtained

clarification about continuation and frequency of

the treatment from the nurse practitioner. LPN #4

stated the nurses were not removing Resident

#6's immobilizer and she did not really know if

treatment was provided for the DTI.


conducted with OSM #5 (an occupational

therapist). OSM #5 stated she initially evaluated

Resident #6 on 12/21/20. OSM #5 stated there

was no physician order to remove Resident #6's

immobilizer for skin checks and this was part of

the reason she kept requesting for the

orthopedist to be called. OSM #5 stated that on

1/4/21 she felt that it was more of a benefit than

risk for her to check Resident #6's skin so she

opened and loosened the immobilizer. OSM #5

stated she noticed mepilex on the resident's right

calf so she peeled it back and observed a DTI.

OSM #5 stated the mepilex was wrinkled so she

applied new mepilex and told the nurse. OSM #5

stated there was no further documentation in

therapy notes regarding the assessment of

Resident #6's skin or DTI. OSM #5 stated she

assumed the nurses were handling treatment of

the DTI because she had notified them.

On 8/30/21 at 4:45 p.m., a telephone interview

was conducted with ASM #3, the nurse

practitioner who signed the 12/21/20 mepilex

order. ASM #3 stated she did not recall the

nurses asking her what should be done in


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regards to Resident #6's knee immobilizer and

skin assessments but did recall questions

regarding the resident's weight bearing status.

ASM #3 stated typically when she receives

communication from nurses about a wound and a

treatment that was implemented, she looks at the

wound, but she did not recall observing Resident

#6's DTI. ASM #3 stated the expectation is for

the nurses to communicate with her so she

probably assumed the DTI was better, then all of

a sudden there was "this wound." ASM #3 stated

she expects the nurses to follow the wound

protocol and communicate with her if a wound is

not healing. ASM #3 stated she assumed the

nurses initiated the protocol for mepilex every

three days for Resident #6's DTI.

The facility standing orders/protocol for wound

care documented instructions for skin tears, red

perineal/buttock areas and boney prominences

but did not document instructions for DTIs.

On 8/30/21 at 5:50 p.m., ASM #1 (the

administrator) and ASM #2 (the director of

nursing) were made aware of the above concerns

and the concern for harm.


conducted with ASM #2. ASM #2 stated

residents should receive complete body

assessments each week and newly found

wounds should be measured, documented and

reported to the nurse manager. In regards to

pressure injury assessments, ASM #2 stated

pressure injuries, including DTIs, should be

assessed weekly, including measurements, what

the wound looks like, and drainage. ASM #2

stated documentation of assessments is included

on wound logs and then the wounds are


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discussed in a weekly meeting. ASM #2 was

asked about the facility process regarding

immobilizers and assessment of skin surrounded

by immobilizers. ASM #2 stated nurses should

follow whatever orders are received and contact

the orthopedist office if orders do not address

removal of the immobilizer and/or assessment of

the skin surrounded by the immobilizer. ASM #2

stated nurses should address this with residents'

primary care physicians if they do not receive

response from the orthopedist. ASM #2 stated if

a pressure injury is found, it should be reported to

the physician then a treatment can be

determined. ASM #2 stated a nurse did write a

treatment order for Resident #6's DTI observed

on 12/21/20 and the nurse practitioner did sign

the order but the order was not complete and did

not follow the facility standing order for mepilex

every three days. ASM #2 stated the night nurse

is responsible for checking orders and should

have noticed the order wasn't complete so the

unit manager could have corrected the order.


conducted with LPN #4, regarding a description

of Resident #6's immobilizer and location of the

resident's DTI that declined to an unstagble

pressure injury. LPN #4 stated the immobilizer

came down approximately 12 inches below

Resident #6's knee and the pressure injury was

located on the resident's right lower calf, under

the immobilizer.

On 8/31/21 at 8:59 a.m., ASM #1 reported the

facility did not have a policy regarding

immobilizers and skin assessments.

On 8/31/21 at 11:30 a.m., a facility action plan

with a completion date of 2/22/21 was provided


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and reviewed with ASM #2. The action plan

documented, "(Resident #6) noted to have a

Stage III (1) wound RLL (right lower leg) [Note:

this contradicts the documentation in the clinical

record on the wound log dated 2/2/21, which

documented the wound as an unstageable

pressure injury on the right lower extremity

posterior calf. See citation above]. Resident had

been ordered a knee immobilizer with no clear

orders for skin care. Ortho (Orthopedist) had

been notified several times with no response. A

DTI was noted on 12/21/20 and note placed in

MD folder notifying physician of area. No follow

up on 12/22 after physician had signed order.

Nurse who noted order failed to transcribe to the

EMAR (electronic medication administration

record). Therapy noted a mepilex on area during

treatment and spoke with nurse. Mepilex

remained in place with no order for doing so.

When resident was transferred to another unit the

mepilex came off during shower and there was

noted to be a Stage III area RLL. Skin

assessments are to be completed weekly but

there is no standard protocol for all

units...CORRECTION: 1. Skin checks performed

on all residents. 2. An audit was completed for

any resident with orders with orders for any

devices, i.e., casts, tubi-grips, blue boots, etc.

and was forwarded to nurse managers. 3. New

forms for CNAs [certified nursing assistant] to use

during residents routine shower that will then be

given to nursing staff. Signing of EMAR when

weekly assessment is completed. 4. Complete

Braden Scale upon admission and follow

protocols and recommendations. 5. Discuss all

new admissions at risk meeting to include skin.

SYSTEM CHANGES: Weekly skin checks placed

in EMAR to ensure continuity of care throughout

units. Skin care assessment sheets made


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available for all staff to document any issues

dealing with skin. Developed a new skin

assessment form for CNAs to keep on clipboard

in shower room and then pass on to nurses.

Form also available in CNA book on each unit.

Updated skin assessment tool in EMAR

[electronic medication administration record].

MONITORING/QA (quality assurance)

OVERSIGHT: (blank)..." The action plan did not

contain complete measures put into place or

complete systemic changes made to ensure that

the deficient practice would not recur, including

staff training regarding immobilizers, wound

assessments or transcription/continuation of

treatment orders, and did not contain evidence

that the facility monitored its performance to

make sure that solutions were sustained. ASM #2

was made aware the concern for harm remained.

On 8/31/21 at 11:50 a.m., ASM #1 was made

aware the action plan was reviewed with ASM #2

and the concern for harm remained for the above

reasons. ASM #1 stated she had no further

information to provide.

The facility policy titled, "Skin integrity, pressure

ulcers" documented, "A. Prevention of Pressure

ulcers/injuries. 1. Evaluate the resident and

identify whether the resident is at risk for

developing or has pressure ulcers upon

admission then weekly skin assessments by a

licensed nurse will be completed thereafter...2.

Evaluate resident specific risk factors and

changes in the resident's condition that may

impact the development and/or healing of a

pressure ulcer...B. If a pressure ulcer/injury

develops. 1. Stage and measure the ulcer:

length, width, and depth. 2. Initiate a wound log;

then update weekly. 3. Notify the MD/NP


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(medical doctor/nurse practitioner) and obtain a

treatment order...D. Care of Pressure

Ulcers/Wounds. 1. Care is planned according to

the stage and location of the pressure ulcer or

thickness and location of the wound...3.

Treatment for the pressure ulcer is based on

physician orders...5. Pressure ulcers will be

measured and thoroughly assessed at least

weekly by a licensed nurse..."


Reference:

(1) "A pressure injury is localized damage to the

skin and underlying soft tissue usually over a

bony prominence or related to a medical or other

device. The injury can present as intact skin

or an open ulcer and may be painful. The injury

occurs as a result of intense and/or

prolonged pressure or pressure in combination

with shear. The tolerance of soft tissue for

pressure and shear may also be affected by

microclimate, nutrition, perfusion, co-morbidities

and condition of the soft tissue.

Deep Tissue Pressure Injury: Persistent

non-blanchable deep red, maroon or purple

discoloration: Intact or non-intact skin with

localized area of persistent non-blanchable deep

red, maroon, purple discoloration or epidermal

separation revealing a dark wound bed or blood

filled blister. Pain and temperature change often

precede skin color changes. Discoloration may

appear differently in darkly pigmented skin. This

injury results from intense and/or prolonged

pressure and shear forces at the bone-muscle

interface. The wound may evolve rapidly to reveal

the actual extent of tissue injury, or may resolve

without tissue loss. If necrotic tissue,


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subcutaneous tissue, granulation tissue, fascia,

muscle or other underlying structures are visible,

this indicates a full thickness pressure injury.

Stage 3 Pressure Injury: Full-thickness skin loss

Full-thickness loss of skin, in which adipose (fat)

is visible in the ulcer and granulation tissue and

epibole (rolled wound edges) are often present.

Slough and/or eschar may be visible. The depth

of

tissue damage varies by anatomical location;

areas of significant adiposity can develop deep

wounds. Undermining and tunneling may occur.

Fascia, muscle, tendon, ligament, cartilage

and/or

bone are not exposed. If slough or eschar

obscures the extent of tissue loss this is an

Unstageable

Pressure Injury.

Unstageable Pressure Injury: Obscured

full-thickness skin and tissue loss: Full-thickness

skin and tissue loss in which the extent of tissue

damage within the ulcer cannot be confirmed

because it is obscured by slough or eschar. If

slough or eschar is removed, a Stage 3 or Stage

4 pressure injury will be revealed. Stable eschar

(i.e. dry, adherent, intact without erythema or

fluctuance) on the heel or ischemic limb should

not be softened or removed." This information

was obtained from the website:

https://cdn.ymaws.com/npiap.com/resource/resm

gr/online_store/npiap_pressure_injury_stages.pdf

F 689 Free of Accident Hazards/Supervision/Devices

CFR(s): 483.25(d)(1)(2)

§483.25(d) Accidents.

The facility must ensure that -

F 689 10/5/21

SS=D


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§483.25(d)(1) The resident environment remains

as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate

supervision and assistance devices to prevent

accidents.


by:

Based on observation, staff interview, facility

document review and clinical record review, it

was determined that the facility staff failed to

provide adequate supervision and implement a

fall intervention for two of 28 residents in the

survey sample, Resident #41 and 73.

1. On 7/21/21, staff observed Resident #73

inappropriately touch Resident #41 on the thigh.

The facility staff failed to provide adequate

supervision to ensure Resident #41 was not

inappropriately touched again by Resident #73.

Within a half hour of the first incident, Resident

#73 was observed by staff with his hand inside of

Resident #41's shirt.

2. The facility staff failed to implement fall mats

per the plan of care for Resident #73 who had a

history of falls and who was assessed and as

being high risk for falls.








severely impaired. Section G coded Resident

1 - Resident #41 was moved to a

different unit on 8/31/21. She is no longer

is at risk for contact with resident #73.

Resident #73 has had no further incidents

of inappropriately touching other

residents. He continues to be monitored

closely by staff and has multiple

interventions in place to address his

behavior.

Resident #73's fall mats were put in place

as per care plan on 8/30/21.

2 - Other female residents residing on the

same unit as Resident #73 may be

potentially impacted. The social worker or

designee will meet with alert residents and

remind them of their right to be free from

inappropriate touching by others and

encourage them to report any incidents of

inappropriate touching to the nurse, social

worker, or other staff member. If any

resident expresses concern, the resident's

plan of care will be reviewed for safety

interventions and all reports of

inappropriate touching will be thoroughly

investigated and reported. To identify

residents who may not be able to report

concerns, the social worker or designee

will meet with staff on that unit to


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#73 as requiring supervision with locomotion.


a nurse's note dated 7/21/21 that documented,

"Reported to this nurse by staff member resident

[Resident #73] found to be inappropriately

touching another female resident [Resident #41]

after being redirected numerous times. Resident

[Resident #73] moved and educated not to touch

other residents. Non-pharmacological

interventions in place and continue..."



were not limited to diabetes, dementia and heart

failure. Resident #41's quarterly minimum data

set assessment with an assessment reference


severely impaired. Section G coded Resident

#41 as requiring total assistance with locomotion.


a note signed by the social worker on 7/23/21 that

documented, "This social worker followed up with

[Resident #41] after her encounter with another

resident earlier in the week. She did not express

any fear or concern over the incident. When

asked if she felt safe she replied 'yes.' She had

no questions in regards to the incident and at this

time seems to have no adverse affects (sic) as a

result. Social services will intervene as

appropriate moving forward and continue to

monitor."

A FRI (facility reported incident) submitted by the

facility to the state agency on 7/21/21

documented, "At approximately 11:00 a.m., this

writer witnessed [Resident #73] touching

[Resident #41's] upper thigh. I immediately

determine if they have observed or are

aware of any other inappropriate touching.

Any concerns will be investigated

thoroughly and reported, with safety

interventions added to the resident plan of

care.

Observations of all residents care planned

as needing fall mats will be completed to

ensure compliance.

3 - Residents at risk for resident to

resident incidents will be discussed at the

weekly facility risk meeting. Any safety

interventions, including increased

supervision, will be communicated to the

interdisciplinary team and the unit staff, as

well as added to the comprehensive care

plan. Safety interventions will be added to

the CNA documentation and CNAs will be

required to document that these

interventions are in place.

Resident use of fall mats will be added to

the CNA documentation and CNAs will be

required to sign off that fall mats are in

place as care planned.

The interdisciplinary staff and nursing staff

will be educated on the above processes.

Should an incident of inappropriate

touching occur, staff will be educated on

the need to monitor residents and

implement safety interventions as care

planned.

4 - The social worker or designee will

interview three (3) residents or staff

members weekly for 6 weeks to


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separated [Resident #73] from [Resident #41],

who was asleep. Staff were notified to keep

residents separated. Shortly thereafter (11:30), a

physical therapist saw [Resident #73] with his

hand inside of [Resident #41's] shirt on or near

her breast."

A final report submitted by the facility to the state

agency on 7/28/21 documented, "I am writing as

a follow up to a FRI submitted on [Resident #73]

and [Resident #41], residents of (name of facility),

on July 21, 2021. It was reported at that time that

[Resident #73] was witnessed touching [Resident

#41] first on her thigh and then under her shirt in

a short period of time. Both residents were near

the nursing station and were separated

immediately....The incident was witnessed so we

did substantiate this resident-to-resident incident

occurred..."

Resident #41's comprehensive care plan

reviewed and revised on 7/21/21, 7/22/21 and

7/23/21 documented, "7/21/21 (Resident #41

incident (with) another resident. Residents

separated. Assessed for injury none noted.

7/22/21 RR (resident representative) notified of

incident- stating understanding. 7/23/21 SW

(social worker) F/U (followed up) (with) Resident

& (no) concerns noted." The revisions failed to

document information regarding supervision.

Resident #73's comprehensive care plan

reviewed and revised on 7/21/21 documented,

"(Resident #73) (with) noted inappropriate

touching. Resident removed from situation &

placed on (an upward arrow indicating

'increased') supervision. Continue @ (at) this

time (with) (an upward arrow indicating

'increased') supervision and diversional

determine if inappropriate touching or

inappropriate resident to resident contact

has occurred. If concerns are identified

they will immediately be investigated,

reported, and interventions implemented

to protect the residents.

The DON or designee will observe five (5)

residents per week for 6 weeks to ensure

that fall mats are utilized as care planned.


the above interviews, audits, and

observations to identify need for additional

training or modification of


interviews and audits will be reported to

the QAPI committee for oversight and

recommendations.

5 - 10/5/2021


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activities..."


conducted with OSM (other staff member) #3, the

physical therapist who observed Resident #73

with his hand inside of Resident #41's shirt. OSM

#3 stated on 7/21/21, she was walking with

another resident and observed Resident #73

leaning forward in his wheelchair toward Resident

#41 who was sitting and had her eyes closed.

OSM #3 stated once she assisted the resident

who she was walking with into a chair, she went

to remove Resident #73 away from Resident #41

and Resident #73 had his hand in Resident #41's

blouse. OSM #3 stated she separated both

residents and walked down the hall to inform a

CNA (certified nursing assistant) of the incident.

On 8/30/21 at 11:10 a.m., a telephone interview

was conducted with OSM (other staff member)

#4, the social worker who observed Resident #73

with his hand on Resident #41's thigh. OSM #4

stated on 7/21/21 she was leaving her office to go

to a meeting and she observed Resident #73 and

Resident #41 behind the nurse's station. OSM #4

stated she observed Resident #73's hand on

Resident #41's thigh so she separated the

residents. OSM #4 stated she told at least one

CNA that she was going to a meeting and there

were no circumstances where Resident #73 could

be near Resident #41. OSM #4 stated she told

the CNA that staff had to keep both residents

separated from each other. OSM #4 stated within

20 minutes, she was still in the meeting and it

was reported that a physical therapist observed

Resident #73 with his hand inside of Resident

#41's shirt.



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was conducted with CNA #1, the CNA who OSM

#4 told to keep Resident #73 and Resident #41

separated. CNA #1 stated on 7/21/21 she was

sitting at the nurse's station and it was reported

that Resident #73 grabbed Resident #41's leg.

CNA #1 stated she did not observe this incident

but she was instructed to keep both residents

separated as best as she could. CNA #1 stated a

little later, she was down the hall answering a call

bell and was told Resident #73 had touched

Resident #41 again.


was conducted with LPN (licensed practical

nurse) #3, the nurse caring for Resident #73 and

Resident #41 on 7/21/21. LPN #3 stated she did

not witness either incident on 7/21/21 because

she was providing treatments for other residents.

When asked if Resident #73 was placed on one

to one supervision between the first incident and

the second incident, LPN #3 stated, "Not to my

knowledge."




above concern.

The facility policy titled, "Abnormal Behaviors &

Interventions" documented, "B. Sexual acts

involving residents who no longer have the

capacity to give informed consent: 1. Immediately

upon observation, calmly separate the residents

from each other, relocate them to a communal

area and distract with an activity...3. Monitor

residents for 24 hours. Try to keep the residents

separated..."



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severely impaired.

A nurse's note dated 8/29/20 documented

Resident #73 was observed on the floor. A

nurse's note dated 10/29/20 documented

Resident #73 was observed on a mat.

Resident #73's comprehensive care plan revised

on 10/29/20 documented, "(Resident #73) is at

risk for falls due to history of (recent) falls,

cognitive & communication deficits, impaired

vision, impaired mobility, weakness, pain, multiple


conditions. Bed in lowest position while Resident

in bed and floor mats @ (at) beside while

Resident in bed..."

A fall risk assessment dated 6/9/21 documented

Resident #73 was at a high risk for falls.

Resident #73's physician's orders effective

7/30/21 through 8/30/21 failed to reveal a

physician's order for fall mats.

On 8/29/21 at 4:38 p.m., and 5:34 p.m., Resident

#73 was observed lying in a low bed without fall

mats beside the bed. Two fall mats were

observed against the wall.




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#3, regarding the purpose of fall mats. CNA #3

stated, "In case they come out of the bed; I guess

so they don't really hit the floor- kinda break their

fall if they were to come out of the bed." CNA #3

stated Resident #73 is at risk for falls and tries to

sit up on the side of the bed so fall mats are

supposed to be on both sides of the bed when

the resident is in bed.



stated fall mats are used to prevent injury. RN #2

stated the need for fall mats is communicated to

nurses and CNAs via the care plan, verbal

communication and usually a physician's order.




above concern.

The facility policy titled, "Falls-Prevention &

Intervention" documented, "PURPOSE: To

identify, develop, implement, monitor and

evaluate an interdisciplinary team falls prevention

approach and management strategy that fosters

resident independence and quality of life while

ensuring safety...F. The care plan will identify

needs of residents such as: 1. interventions in

place in an attempt to reduce falls or prevent

injuries from falls..."


F 698 Dialysis

CFR(s): 483.25(l)

§483.25(l) Dialysis.

The facility must ensure that residents who

F 698 10/5/21

SS=D


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require dialysis receive such services, consistent

with professional standards of practice, the

comprehensive person-centered care plan, and

the residents' goals and preferences.


by:

Based on staff interview, resident interview,

facility document review and clinical record

review, it was determined the facility staff failed to

evidence of ongoing communication and

collaboration with the dialysis facility for one of 28

resident in the survey sample, Resident #29.

The dialysis communication records for Resident

#29, from 7/28/21-8/25/21, evidenced a total of

three missing communication forms for the dates

of: 8/11, 8/16, and 8/27.




were not limited to: end stage renal disease

'ESRD' (end stage of renal failure-inability of the

kidneys to excrete wastes and function in the

maintenance of electrolyte balance) (1) and

chronic obstructive pulmonary disease (chronic,

non-reversible lung disease) (2), dementia

(progressive state of mental decline especially of

memory function and judgement and often

accompanies by disorientation and loss of ability

to plan and organize) (3) and Parkinson's (slowly

progressive neurological disorder) (4).

Resident #29's most recent MDS (minimum data

set) assessment, a quarterly assessment, with an

assessment reference date of 6/23/21, coded the

resident as scoring 10 out of 15 on the BIMS

1 - Resident #29's dialysis

communication records will be kept

current.

2 - Any residents receiving dialysis may

be potentially impacted. There are

currently no other residents receiving

dialysis residing in the facility.

3 - The administrator will communicate

with the dialysis center to stress the

importance of returning the dialysis

communication records to the facility after

the resident receives treatment and

returns. Licensed nursing staff will be

re-educated on the dialysis

communication process including the

need to complete and send with the

resident to dialysis and the need to

receive and review when resident returns.

The licensed nursing staff will be

educated to contact the dialysis center if

the communication record is not returned

with the resident.

4 - Nurse Manager or designee will

complete weekly audit of dialysis folders

for six (6) weeks to ensure

communication sheets are received and

reviewed.


weekly audits and observations to identify


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(brief interview for mental status) score, indicating

the resident was moderately cognitively impaired.

MDS Section G- Functional Status: coded the

resident as requiring limited assistance for

mobility, transfers, dressing, bathing, hygiene and

walking. Independence was coded for eating and

locomotion. A review of MDS Section H- Bowel

and Bladder: coded the resident as frequently

incontinent for bowel and occasionally incontinent

for bladder. Section O-Special Treatments and

Procedures: coded the resident 'yes' for dialysis.

A review of the comprehensive care plan revised

6/30/21, documented in part, "PROBLEM:

Resident has altered kidney function due to

ESRD with current hemodialysis and bilateral

renal cysts. APPROACH: Provide dialysis as

ordered three times weekly. Check bruit and thrill

per shift. Monitor for complications to AV

(arteriovenous) fistula site."

A review of the physician orders dated 6/11/21,

documented in part, "Dialysis every Monday,

Wednesday and Friday at dialysis center."

On 8/29/21 at 3:39 PM, a review of Resident

#29's dialysis binder was reviewed. The dialysis

binder contained the "Dialysis Communication

Form" with the top section to be completed by the

facility and the bottom portion to be completed by

the dialysis center. The dialysis communication

records reviewed for Resident #29, were from

7/28/21-8/25/21 and evidenced a total of three

missing communication forms for the dates of:

8/11, 8/16, and 8/27.

A request was made for the facility to provide

dialysis communication forms for Resident #29

from 6/1/21-7/27/21.

need for additional education or

modification of systems/processes. A

summary of weekly audits will be reported

to the QAPI Committee for oversight and

recommendations.

5 - 10/5/2021


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On 8/30/21 at 2:45 PM, LPN (licensed practical

nurse) #4, the unit manager provided additional

dialysis communication forms from

6/2/21-7/26/21. On 8/31/21 ASM (administrative

staff member) #2, the director of nursing,

provided a final batch of dialysis communication

forms. There were three missing dialysis

communication forms for the dates of 6/9, 8/11

and 8/27.

An interview was conducted on 8/29/21 at 3:39

PM with LPN #8. When asked the purpose of the

dialysis communication form, LPN #8 stated, "To

maintain communication between the dialysis

center and the facility." LPN #8 stated, "It is to be

completed each time the resident goes out for

dialysis." When asked about the missing forms

for Resident #29, LPN #8 stated, "It could mean

they were thinned out, got lost or they weren't

filled out."

On 8/30/21 at 5:29 PM, ASM (administrative staff

member) #1, the administrator, ASM #2, the

director of nursing and LPN #4, the unit manager

were made aware of the above findings.

A review of the facility's "Dialysis contract,

documented the following: "Communication:

Shall include medications, problems vital signs or

any change in condition in the communication

between the long-term care facility and the ESRD

end stage renal disease) dialysis unit."

A review of the facility's "Hemodialysis; Care of

the End Stage Renal Disease Resident" revised

5/21, documented in part, "Each resident

receiving hemodialysis will have a folder

individualized for them. This folder will


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accompany the resident to and from dialysis with

each appointment. The folder will contain a

communication form to enhance communication

between the facility and the dialysis center."

No further information was provided prior to exit.

References:

(1) Barron's Dictionary of Medical Terms for the

Non-Medical Reader, 7th edition, Rothenberg and

Chapman, page 498.



Chapman, page 120.



Chapman, page 154.



Chapman, page 435.

F 732 Posted Nurse Staffing Information

CFR(s): 483.35(g)(1)-(4)

§483.35(g) Nurse Staffing Information.

§483.35(g)(1) Data requirements. The facility

must post the following information on a daily

basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours worked

by the following categories of licensed and

unlicensed nursing staff directly responsible for

resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed

vocational nurses (as defined under State law).

(C) Certified nurse aides.

(iv) Resident census.

F 732 10/5/21

SS=C


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§483.35(g)(2) Posting requirements.

(i) The facility must post the nurse staffing data

specified in paragraph (g)(1) of this section on a

daily basis at the beginning of each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible to

residents and visitors.

§483.35(g)(3) Public access to posted nurse

staffing data. The facility must, upon oral or

written request, make nurse staffing data

available to the public for review at a cost not to

exceed the community standard.

§483.35(g)(4) Facility data retention

requirements. The facility must maintain the

posted daily nurse staffing data for a minimum of

18 months, or as required by State law, whichever

is greater.


by:

Based on observation and staff interview, it was

determined that the facility staff failed to post

current nurse staffing information. Nurse staffing

information for 8/29/21 was not posted on

8/29/21. Instead, nurse staffing information for

8/27/21 was posted.


On 8/29/21 at 2:14 p.m., and 4:50 p.m.,

observation of the nurse staff posting was

conducted beside the elevator on the first and

second floors. The nurse staffing information

was dated 8/27/21 and contained staffing

information for that date.

1 - The current staffing information sheet

was updated and posted on 8/30/21.

2 - All residents may have potentially been

impacted by this practice. Nurse staffing

information is posted in visible locations

for residents to see and will be updated

daily.

3 - A nurse will be assigned to update and

post staffing sheets in the absence of the

staffing coordinator on the weekend.

The nursing staff on the Garden level will

be educated regarding this new process.


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#2, the person responsible for posting the nurse

staffing information. CNA #2 stated she works

Monday through Friday and places the weekend

nurse staffing information behind the Friday

posting on Fridays. CNA #2 stated there was no

one designated to post the nurse staffing

information on Saturdays and Sundays.




above concern.

The facility policy titled, "Staffing/Attendance

Policy" failed to document information regarding

nurse staff postings.


4 - The manager on duty will monitor the

presence of the posted staffing

information one day per weekend for six

(6) weeks.

The posted staffing information will be

added to the environmental rounding

sheet. This rounding sheet will be

completed by the Administrator or

designee one time per week for six (6)

weeks.

The Administrator or designee will track

and trend weekly audits and observations

to identify need for additional training or

modification of systems/processes. A

summary of weekly audits will be reported

to the QAPI committee.

5 - 10/5/2021

F 761 Label/Store Drugs and Biologicals

CFR(s): 483.45(g)(h)(1)(2)

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility must be

labeled in accordance with currently accepted

professional principles, and include the

appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and

Federal laws, the facility must store all drugs and

biologicals in locked compartments under proper

temperature controls, and permit only authorized

personnel to have access to the keys.

F 761 10/5/21

SS=D


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§483.45(h)(2) The facility must provide separately

locked, permanently affixed compartments for

storage of controlled drugs listed in Schedule II of

the Comprehensive Drug Abuse Prevention and

Control Act of 1976 and other drugs subject to

abuse, except when the facility uses single unit

package drug distribution systems in which the

quantity stored is minimal and a missing dose can

be readily detected.


by:

Based on observation, staff interview and review

of facility documentation it was determined the

facility staff failed to ensure expired medications

were not available for resident administration on

two of six medication carts, (Blue Ridge Terrace

Unit medication cart, and Sycamore Terrace Unit

medication cart).

Observation revealed four Prosource (1) 1.5

milliliter pouches, with an expiration date of

10/24/220 were available for administration on

the Blue Ridge Terrace Unit medication cart and a

bottle of polyethylene glycol (2) with an expiration

date of 08/24/2021, was available for resident

administration on the Sycamore Terrace Unit

medication cart.


On 8/30/21 at 11:00 AM, an observation of the

facility's Blue Ridge Terrace Unit medication cart

was conducted with LPN (licensed practical

nurse) #8. This medication cart was located in

the red portion of the Blue Ridge Terrace Unit. In

the bulk medication drawer, four -Prosource (1)

1.5 milliliter pouches were found with an

expiration date of 10/24/220.

1 - The expired medications were

discarded immediately.


impacted. An audit of all medication carts

will be completed to ensure no expired

medications remain in the carts.

3 - An audit tool has been developed for

licensed nursing staff to check medication

carts on a weekly basis to ensure expired

medications have been removed and

discarded appropriately. This audit tool

will be submitted weekly to the DON or

designee.

Education regarding the above process

will be provided to the licensed nursing

staff.

4 - The DON or designee will audit two (2)

medication carts weekly for six (6) weeks

to ensure expired medications are

removed and discarded appropriately.




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On 08/30/2021 at approximately 2:30 PM, an

observation of the facility's Sycamore Terrace

Unit medication cart was conducted with RN

(registered nurse) #1. Observation of the bottom

drawer of the medication cart revealed the

following: a bottle of polyethylene glycol (2) with

an expiration date of 08/24/2021 available for

use. When asked how much polyethylene glycol

was remaining in the bottle, RN # 1 measured the

remaining amount by pouring it into the

measuring cap and stated that there was 68

grams remaining.

On 8/30/21 at 11:15 AM, an interview was

conducted with LPN #8. When asked about the

facility process staff follows for ensuring expired

medications are not available for resident use,

LPN #8 stated, "We look in the medication

drawers to ensure the meds are not expired.

These were in the bulk drawer and were missed."

On 08/30/2021 at 5:30 p.m., ASM [administrative

staff member] #1, the administrator and ASM #2,

director of nursing, were made aware of the

above findings.

According to the facility's "Medication Cart &

Medication Refrigerator" policy dated 4/2021,

which documents in part, "Medications will be

checked for expiration dates and discarded if

outdated."


References:

(1) Liquid Protein. This information was obtained

from the website: https://medtrition.com

need for additional training or modification

of systems/processes. A summary of


committee for oversight and

recommendations.

5 - 10/5/2021


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(2) Used to treat occasional constipation. This

information was obtained from the website:

https://medlineplus.gov/druginfo/meds/a603032.h

tml.

F 770 Laboratory Services

CFR(s): 483.50(a)(1)(i)

§483.50(a) Laboratory Services.

§483.50(a)(1) The facility must provide or obtain

laboratory services to meet the needs of its

residents. The facility is responsible for the quality

and timeliness of the services.

(i) If the facility provides its own laboratory

services, the services must meet the applicable

requirements for laboratories specified in part 493

of this chapter.


by:

F 770 10/5/21

SS=D

Based on observation, and staff interview, it was

determined that the facility staff failed to ensure

expired laboratory medical supplies were not

available for resident use in one of two facility

medication storage rooms, Blue Ridge Terrace

Unit medication storage room.

The first floor medical supply cabinet was

observed to contain multiple expired laboratory

tube supplies that were available for resident use.


On 8/30/21 at 11:15 AM, an observation of the

facility's Blue Ridge Terrace Unit medication

storage room was conducted with LPN[licensed

practical nurse] #8. This medication storage

room was located in the yellow portion of the Blue

Ridge Terrace Unit. Expired laboratory [lab] tubes

1 - The expired laboratory tubes were

discarded immediately.

2 - An audit of all medication rooms will be

completed to ensure expired laboratory

supplies are not available for resident use.

3 - An audit tool has been developed for

licensed nursing staff to check medication

rooms on a weekly basis to ensure

expired laboratory tubes have been

removed and appropriately discarded.

These completed audits will be submitted

weekly to the DON or designee.

Education regarding this process will be

provided to the licensed nursing staff.

4 - The DON or designee will audit two (2)


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available for use were observed and included the

following: three pink top 6.0 milliliter tubes with

expiration date of 2/28/21, four yellow top 5.0

milliliter tubes with expiration date of 3/31/21,

seven yellow top 5.0 milliliter tubes with expiration

date of 4/30/21 and 13 red top 6.0 milliliter tubes

with expiration date of 7/31/21.


conducted with LPN #8. When asked the facility

process staff follows to ensure laboratory [lab]

supplies and tubes available for resident use are

not expired, LPN #8 stated, "We should check

them when we open the package and when we fill

the lab draw box." When asked if there was a

standard time of the month to check lab supplies,

LPN #8 stated, "No, there is not."


conducted with LPN #4, the unit manager. When

asked to review the above observed expired

laboratory tubes, LPN #4 stated, "These are all

expired." When asked if there was a standard

process to ensure lab tubes available for use

were not expired, LPN #4 stated, "There is not a

set process."


staff member] #1, the administrator and ASM #2,

director of nursing, were made aware of the

above findings. Policies for checking laboratory

supplies for expiration were requested.

No policy on expired lab tubes was provided.

According to applicable requirements for

laboratories specified in Part 493 of this chapter:

§ 493.1252 Standard: Test systems, equipment,

instruments, reagents, materials, and supplies.(4)

medication room weekly for six (6) weeks

to ensure expired laboratory supplies are

removed and discarded appropriately.



need for additional training or modification

of systems/processes. A summary of


committee for oversight and

recommendations.

5 - 10/5/2021


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(d) Reagents, solutions, culture media, control

materials, calibration materials, and other

supplies must not be used when they have

exceeded their expiration date, have deteriorated,

or are of substandard quality.

F 812 Food Procurement,Store/Prepare/Serve-Sanitary

CFR(s): 483.60(i)(1)(2)

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources

approved or considered satisfactory by federal,

state or local authorities.

(i) This may include food items obtained directly

from local producers, subject to applicable State

and local laws or regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with applicable

safe growing and food-handling practices.

(iii) This provision does not preclude residents

from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and

serve food in accordance with professional

standards for food service safety.


by:

F 812 10/5/21

SS=E

Based on observation and staff interview, it was

determined facility that the facility staff failed to

store food in a sanitary manner.

In the walk in freezer one nine pound half full box

of crab cakes and one half full one pound box of

frozen egg patties were observed open to the

environment, and in the walk in refrigerator one

40 ounce package of provolone cheese was open

1 - The cheese, egg patties, and crab

cakes were discarded immediately.

The mixing bowls and pitcher were

immediately cleaned and the blender was

cleaned and covered.


impacted. An environmental audit will be


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to the environment. A mixer and blender on a

food preparation table available for use were

observed with food debris in the mixer bowl and

the blender pitcher.


On 08/29/2021 at approximately 2:00 p.m., an

observation of the facility's kitchen was conducted

with OSM [other staff member] # 1, dietary clerk.

Observation of the walk-in freezer in the facility's

kitchen revealed the following: One - nine pound

box of frozen crab cakes approximately half full,

open to the environment. One - 11.25 pound box

of frozen egg patties approximately half full,

sitting on the middle shelf open to the

environment available for use.

Observation of the walk-in refrigerator in the

facility's kitchen revealed one 40 ounce package

of provolone cheese on a middle shelf open to

the environment with approximately

three-quarters of the cheese remaining available

for use.

Further observation of the facility's kitchen

revealed a mixer and blender on a food

preparation table. When asked if the mixer and

blender were cleaned and ready for use OSM # 1

stated yes. Observation of the mixing bowl

revealed food like debris in the bottom of the

bowl. OSM # 1 was asked to observe the mixing

bowl. When asked if it was clean OSM # 1 stated

no and agreed that there was food like debris in

the bottom of the bowl. Observation of the

blender revealed food debris in the pitcher. OSM

# 1 was asked to observe the picture attachment

for the blender. OSM # 1 agreed that it had food

debris inside the pitcher and stated that it should

completed in the kitchen to ensure all food

items are covered and stored as required

in the refrigerator and freezer and food

preparation equipment is clean and free of

food debris.

3 - The environmental audit will be

developed/revised to include proper food

storage in the refrigerator and freezer,

including the need for food to be properly

covered. The audit will also include an

observation of food preparation

equipment for cleanliness. The blender

will be covered when not in use. The

Nutrition Service Director or designee will

conduct these audits three days per week.

Nutrition service staff will be educated on

the above.

4 - The administrator or designee and the

Nutrition Services Department director or

designee will complete weekly audits of

the kitchen for six (6) weeks to ensure

food is stored properly in the refrigerator

and freezer and equipment is clean and

covered properly. Results of audits will be

reported to the QAPI Committee.

The Administrator or designee will track

and trend weekly audits to identify need

for additional training or modification of




recommendations.

5 - 10/5/2021


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have been cleaned.

On 08/30/2021 at 9:20 a.m. an interview was

conducted with OSM # 2, dietary director. When

asked to describe the procedure for cleaning the

blender and the mixer OSM # 2 stated that it is

put in the three compartment sink after each use.

When asked to describe the procedure for storing

food after it was opened OSM # 2 stated, "It

should be sealed in plastic wrap or bag, labeled

and put back in the box." When asked why the

food should be sealed or covered OSM # 2

stated, "To prevent contamination."

After review of the facility's "Food Storage

Guidelines" and the observation of the above

items found in the facility walk-in refrigerator,

OSM # 1 agreed that that the items should not

have been available for use. When asked to

describe the process to prevent expired food

items being available for use OSM # 1 stated that

the facility's sous-chef and lead cook conduct

inspections of food items every Friday and look

for expired items and ensure that there are

correct dates on all food items.


staff member] # 1, the administrator and ASM #

2, director of nursing, were made aware of the

above findings.



Documents

495316 08/31/2021 NAME OF PROVIDER OR SUPPLIER