Friendship Haven Healthcare and Rehabilitation Cen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (CR #2) reviewed for discharge requirements. The facility failed to ensure CR #2 was readmitted to the facility, after being sent to the hospital for evaluations due to change in condition. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.A record review of CR #2's electronic face sheet revealed reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. CR #2's diagnosis included Dementia, type 2 diabetes mellitus, history of falling, peripheral vascular disease (disorder of the blood vessels), dementia, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension (high bleed pressure) heart disease, anemia (low blood pressure), cerebral infarction (a condition that limit blood flow to the brain), muscle weakness and difficulty in walking,Record review of CR#2's progress note dated 1/23/2025 11:27 revealed eINTERACT SBAR Summary for Providers, Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Seems different than usual. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 171/68 - 1/23/2025 09:04 Position: Sitting l/arm - Pulse: P 66 - 1/23/2025 09:04 Pulse Type: Regular; - RR: R 18.0 - 1/22/2025 11:57 - Temp: T 96.7 - 1/22/2025 11:57 Route: Forehead (non-contact) - Weight: W 174.5 lbs - 1/2/2025 11:36 Scale: Wheelchair. - Pulse Oximetry: O2 95.0 % - 1/22/2025 11:57 Method: Room Air. - Blood Glucose: BS 242.0 - 1/23/2025 09:32. During an interview with Resident Responsible party on 09/03/25 at 11:30 am, she said the facility had tried several times to discharge CR # 2 from the facility. She said prior to being sent out to the hospital. She had filed an appeal which she won, but the facility still refused to take CR # 2 back after being sent to the hospital. She said CR #2 was discharged to her home without her wheelchair. During an interview with the DON on 09/03/25 at 11:00am, she said CR #2 was sent to the hospital for change in condition. She said the decision not to re- admit CR #2 back to the facility was from corporate office. She said CR #10's RP harassed staff and other residents at the facility. During an interview the Administrator and the facility's Cooperate staff on 09/03/25 at 2:00pm, the Administrator said the decision was from the Cooperation because CR #2 RP harassed, staffs, other residents, and Physician to a point where no staff wanted to work with CR#2. He said he received complaints and resignations letters from staff due to CR#2's RP's behavior. He said he was aware that CR #2 won the appeal, but he had to watch out for the safety of other residents and staff. He said the facility had multiple meetings with CR #2's RP, but the RP continued to harass staff and other resident. He said something was always wrong with how CR #2 was being cared for.Facility's Clinical Director said the facility had gone above and beyond to accommodate CR # 2's RP, and there was nothing the facility could have done differently because the situation was getting worst.An attempt was made on 09/03/25 at 3:00pm to have an interview with CR #2's physician at the time of discharged , but he refused to communicate without his lawyer and would not comment on CR #2 case because it was in court. An attempt was made to contact the hospital social worker but there was no answer. There was no way to leave message. Record review of Facility's policy titled Discharging the Resident dated 2001 and revised 2016 revealed no evidence of discharge after an appeal process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 9 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control practices. <BR/>1. The facility failed to ensure ADON A and the Restorative Aide applied enhanced barrier precautions while transferring Resident # 1 from her wheelchair to her bed. <BR/>2. The facility failed to ensure that CNA J and CNA G sanitized their hands when providing incontinent care to Resident #2 and Resident #3. <BR/>These failures could place residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet indicated the resident was a 92-year- old female who was readmitted to the facility on [DATE] with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), Dysphagia (a term for difficulty swallowing), and Neuromuscular Dysfunction of Bladder (condition that affects the muscles and nerves that controls the bladder). <BR/>Record review of Resident #1's annual MDS assessment, dated 3/15/2025, revealed a BIMS summary score of 3, indicating severe cognitive impairment. The MDS also indicated Resident #1 was dependent with all activities of daily living (ADL). <BR/>Record review of Resident #1's care plan initiated on 11/05/2024, indicated Resident #1 required enhanced barrier precautions determined by presence of Foley Catheter. Interventions included follow facility's enhanced barrier precaution policy and staff will wear an isolation gown and gloves while providing all contact care. <BR/>During an observation on 3/29/2025 at 1:19 PM, ADON A and the restorative aide was observed transferring Resident #1 from the wheelchair to the bed without wearing proper personal protective equipment. Enhanced barrier precautions signage was posted on outside door and PPE was noted outside room. <BR/>During an interview on 3/29/2025 at 1:49 PM, the restorative aide said she forgot to put on her protective personal equipment (PPE) prior to assisting the ADON with the transfer. The restorative aide said she had been in-serviced a couple of months ago and was aware that she was supposed to wear PPE when transferring Resident #1 to her bed. She said she was in a rush to try to assist ADON A and forgot to put on her gown and gloves. <BR/>During an interview on 3/29/2025 at ADON A said personal protective equipment should be worn when transferring Resident #1. ADON A said wearing PPE protected the resident. ADON A said she had been educated on EBP and PPE and should have donned (to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure) her gloves and gown. ADON A said the infection control training was a couple of weeks ago and included EBP. She said the risk of not wearing PPE was infection. <BR/>Record review of Resident #2's undated face sheet indicated the resident was a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of cerebral infarction (blood flow to the brain is blocked, leading to brain tissue damage), Hemiplegia (paralysis or weakness on one side of the body), and Type 2 Diabetes( long-term condition in which the body has trouble controlling blood sugar). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 12/18/2024, revealed a BIMS summary score of 13, indicating cognitively intact. <BR/>Record review of Resident #2's care plan initiated on 9/05/2024, indicated Resident #2 was at risk for an ADL Self Care Performance Deficit related to decline in health. The interventions included providing total assistance of 1-2 staff participation to use toilet/incontinent care.<BR/>Observation and Interview on 03/29/25 at 11:35 AM Resident #2 said the staff provided incontinent care routinely and as needed. She denied skin break down and said the CNA was about to provide incontinent care because she had a bowel movement. <BR/>Observation of incontinent care on 03/29/25 at 11:45 AM, CNA J was observed performing incontinent care. CNA J introduced herself and explained the incontinent care procedure. CNA J did not wash her hands prior to initiating incontinent care. She double gloved and cleaned Resident #2's abdominal folds times one wipe and proceeded to clean labia per protocol. CNA J removed her 1st set of gloves, as she was doubled gloved. CNA J turned the resident to her left side and cleaned the stool from the resident's buttocks in an upward motion with several wipes using the same gloves. CNA J used the same soiled gloves that held the dirty wipes to reenter the multi-wipe package. Stool was noted on outside of multi-wipe package. She removed and discarded the soiled brief. She opened Resident #2's barrier cream and applied the cream to the resident's buttocks. She applied a new brief and removed her gloves. She discarded the trash and used hand sanitizer once completed. <BR/>During an interview on 3/29/2025 at 11:51 AM, CNA J said she double gloved because Resident #2's bedside table was cluttered and there was no place to setup her supplies. She said there was no hand sanitizer available in the room and would have to go in the hallway to sanitize her hands. She said she did not wash her hands, but she did use sanitizer prior to donning gloves and after completion of incontinent care. CNA J said the risk of using the same gloves and double gloving was spreading infection and cross contamination. <BR/>Record review of Resident #3's undated face sheet indicated the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of acute pyelonephritis (Kidney infection, an illness in one or both kidneys), paraplegia (complete or partial paralysis of the lower half of the body), and Neuromuscular Dysfunction of Bladder (condition that affects the muscles and nerves that controls the bladder). <BR/>Record review of Resident #3's Quarterly MDS assessment, dated 03/10/2025, revealed a BIMS summary score of 15, indicating cognitively intact. Section H indicated Resident #3 had an Indwelling catheter (including suprapubic catheter- a medical device that helps drain urine from your bladder; and, nephrostomy tube - a tube that lets urine drain from the kidney through an opening in the skin on the back)<BR/>Record review of Resident #3's care plan initiated on 9/05/2024, indicated Resident #3 had Indwelling Catheter due to diagnosis of Neurogenic bladder. His interventions included to Observe/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.<BR/>Observation on 03/29/2025 at 12:49 PM of CNA G and LVN D performing incontinent care on Resident #3. Contact isolation signage on Resident #3's door. It was observed both CNA G and LVN D wearing proper PPE while initiating incontinent care on Resident #3. CNA G and LVN D performed hand hygiene, donned clean gloves, and LVN D provided a barrier on bedside table and added supplies. CNA G began cleaning subpubic Cather per policy. Next, she began wiping Resident #3's abdominal folds, groin, and penial area. CNA D used same soiled gloves that held the dirty wipes to reenter the multi-wipe package. CNA G proceeded to clean Resident #3's left and right groin area multiple times. CNA G turned Resident #3 to his left side and wiped his buttocks in an upward motion. CNA G then turned Resident #3 to the right side, wiped his buttocks in an upward motion until no discoloration was noted on the wipes. CNA G doffed gloves, no hand hygiene was performed, and donned clean gloves. CNA G applied a new brief, while LVN D discarded the soiled brief and wipes. CNA G and LVN D doffed gloves, and they washed their hands. <BR/>During an interview on 3/29/2025 at 1:15 PM, CNA G said that the staff did frequent training and in-services on infection control and incontinent care. She said she did not use hand sanitizer prior to donning new gloves because she did not have any sanitizer to use. She said staff should wash and/or sanitized hands per policy. She said the risk of not washing hands could cause infection to self or other residents. <BR/>During an interview on 3/29/2025 at 5:04 PM, ADON B (Infection Preventionist) said all staff had been in-serviced on enhanced barrier precautions (EBP). She said she did a training every Wednesday on infection control to include handwashing, incontinent care, and EBP. She said PPE should be worn when providing direct care by wearing gowns and gloves. She said the facility would re-educate staff on wearing PPE with residents on EBP and proper handwashing and incontinent care. She said the last in-service on infection control was 12/12/24 (FTG), 02/29/25 (EBP), and 03/13/25 (Infection control concerns for Resident #1). ADON B said the risk of not following EBP and not sanitizing hands could cause infection and cross-contamination. <BR/>During an interview on 3/29/2025 at 5:30 PM, the DON said the facility had frequently in-serviced staff on enhanced barrier precautions (EBP) and infection control. The DON said she expected her staff to wear proper PPE when providing care. She said she would implement peri-care checkoffs and return demonstration with the administrative staff for the next 3 months. She said the risk was cross contamination and infection. <BR/>During an interview on 3/29/2025 at 6:49 PM, the Administrator said he expected the nurses and staff to adhere to the enhanced barrier precautions/infection control policy. He said handwashing was infection control was CNA 101. The Administrator said the risk of not following the infection control policy puts the staff and residents at risk for contracting an infection, passing it on to other residents or staff, which can lead to an outbreak. <BR/>Record review of a policy titled Enhanced Barrier precautions dated April 1, 2024, read in part . Policy: EBP are used in conjunction with standard precautions and expand the use of PPR to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering transferring providing hygiene changing linens, changing briefs or assistance with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care any skin opening requiring a dressing .<BR/>Record review of a policy titled Handwashing/Hand Hygiene revised on August 2015, read in part, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors &. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents .

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to ensure residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences for three of three days (11/04/24, 11/05/24, and 11/06/24) reviewed for frequency of meals. <BR/>-The facility failed to ensure residents received meals at regularly scheduled times for breakfast and lunch on 11/04/24, breakfast and lunch on 11/05/24, and breakfast on 11/06/24.<BR/>This failure could place residents who eat from the facility's kitchen, at risk of loss of appetite, weight loss, increased hunger, thirst, frustration, and decreased feelings of self-worth.<BR/>Findings included:<BR/>Observation and interview with the Dietary Manager on 11/04/24 at 8:25 AM, revealed the posted mealtime was 7:30 AM for breakfast,: 11:30 AM for lunch, and 4:30 PM for dinner. During an interview with the dietary Manager, she said mealtime were 7:30 AM for breakfast, 11:30 AM for Lunch, and 4:30 PM for dinner. <BR/>Observation and interviews on 11/04/24 at 9:00AM revealed no breakfast trays were served on the 500 and 600 halls. During an interview, with 2 anonymous Residents, the first resident said, his main concerns with the facility were the food. He further explained that the trays are were always late, cold, small sizes and no taste.<BR/>Observation on 11/04/24 at 10:30 AM, revealed an Anonymous third anonymous resident was sleeping and her Breakfast tray was covered on her bed side table. Observation indicated she did not eat her breakfast.<BR/>Observation on 11/04/24 at 12:30 PM revealed lunch had not been served on hall 500 and 600 . <BR/>During an interview with the Dietary Manager at 12:35PM, she said lunch was running late because the dining room was served first, and she was in the process of serving the halls . <BR/>Observation and interview on 11/04/24 at 12: 50 PM, Anonymous Resident #4 a (third/fourth) anonymous resident appeared s angry. During an interview, she said the meal trays are always late, sometimes cold, the sizes are small like a child's plate, and no test. She said, she did not eat her breakfast because she was served the wrong food. She said she was waiting for lunch, and it had not arrived. <BR/>Observation and interview on 11/04/24 at 1:00 PM revealed Anonymous Resident #3 was eating her lunch. During an interview she said she did not eat her breakfast because, she was hungry and slept off since she was tired of waiting. She said she had her dinner at about 5:00 PM<BR/>Observation and interview on 11/05/24 at 8:50 AM, revealed Anonymous Resident #2 was observed in his room fully dressed. During an interview he said he was waiting for his breakfast. He said he had his dinner at about 5:00PM. He said the only complaint he had was the food. He said the breakfast and lunch trays are always late and sometimes cold. <BR/>Observation and interview on 11/05/24, revealed breakfast trays were served to the 500 halls at 9:00 AM.<BR/>During an interview, CNA K said the breakfast always arrived between 8:40 AM and 9:00AM. She said the dining room was served first at about 7:50 to 8:00 AM. She said the CNAs on the halls passed the trays out as soon as they are delivered to the floor because the Residents are always waiting for their breakfast trays in the morning.<BR/>Observation on 11/05/24 at 12:50 AM, revealed Residents were having lunch in the dining room. <BR/>Observation on 11/05/24 revealed the lunch trays were delivered to the 500 halls at 1:05 PM and to the 600 halls at 1:08 PM <BR/>In an interview with the Corporate Manager on 11/05/ 24 at 2:00 PM, she said the appearance of the food on the tray needs more color. She said the trays were late because the fish was hand breaded and fried in the kitchen because the company try to cook all meals from scratch to preserve freshness and nutritive value. She said the trays to the hallways are delivered to the hall on time and but not being distributed immediately. She said she would have an in-service with the Dietary Manager and the staff on the delivery time and she would come up with a plan.<BR/>During an interview with the Dietary Manager on 11/05/24 at 3:00 PM, she said the trays to the halls are late because the tickets are printed by the Dietary Manager and send back to the unit Manager for verification. She said sometimes the tickets are returned unsorted and the kitchen aide had to sort out the tickets. <BR/>During the Confidential Resident Council Meeting on 11/05/24 at 2:00PM, 17 anonymous, alert and oriented residents stated that meals were not always on time. All residents said they had to wait up to 1 to 2 hours for a meal be served especially the breakfast. <BR/>During an interview with the Facility Administrator on 11/05/24 at 4:00 PM, he said the food service department had always been a problem and the facility was actively working on the dietary department to turn things around. He said the facility had changed from one food service company to another and was still working with the present company to ensure that the residents are always served with balance nutritive meals. He said not serving meals on time, may lead to increase hungry and cold food may lead to loss of appetite and possible weight loss. <BR/>Observation on 11/06/24 revealed breakfast trays was served to 500 halls at 8:26AM and to 600 halls at 8:28 AM. Observation revealed the DON was assisting with the trays on 400 halls. <BR/>During an interview on 11/06/24 at 9:00 AM LVN D said the meal trays were distributed immediately. LVN D said sometimes the delay comes from the tray arrangement on the cart and the CNA s had to sort through the trays. <BR/>Interview on 11/6/24 at 9:35 AM, with the Dietary Manager said the meal tickets were not being done well and that had contributed to the late trays. She said the temperatures were not being held on the food carts. She said she did not want to eat cold food and residents would not want too either.<BR/>During an interview with the Unit Manager on 11/06/24 at 2:00 PM, she said all tickets are printed out by the dietary Manager and all she does, was to verify that the meal orders are correct, and she returns the ticket back to the Dietary Manager the same way that the tickets were handed to her. She said she had no idea how the dietary department handles the tickets during mealtime.<BR/>A meal service time Facility's policy was requested on 11/06/24 at 10:30 AM. A policy on meal service time was not provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 6 residents (Resident #79) reviewed for abuse.<BR/>The facility failed to keep Resident #79 free from abuse when RN A yelled at and hit the resident while attempting to give her medication on 10/6/24 at 4:00 AM.<BR/>The noncompliance was identified as past noncompliance (PNC). The facility corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk of experiencing and enduring abuse causing a decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident #79's face sheet revealed an original admission on [DATE] and Resident #79 was a [AGE] year-old female. Diagnoses included: acute kidney failure (can't filter waste from the blood), hypertension (force of blood against the artery wall was high), COPD (progressive lung disease), Parkinson's (disorder of the central nervous system that affects movement), and epilepsy (a disorder in the brain that caused seizures).<BR/>Record review of Quarterly MDS assessment dated [DATE] revealed Resident #79's in Section C - Cognitive Pattern her BIMS score was 12 indicating her cognition was moderately impaired. Further review revealed in Section E - Behavior - question B under EO200 for behavioral symptoms, the resident had verbal behavior symptoms directed toward others occurred 1 to 3 days in the 7-day lookback. <BR/>Record review of current care plan revealed Resident #79 was resistive to care and refused medications at times. Interventions included:<BR/> o <BR/>Risk for complications r/t refusing care/meds will be minimized and ongoing thru the next review date. <BR/> o <BR/>Allow the resident to make decisions about treatment regimen, to provide sense of control.<BR/> o <BR/>Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or <BR/> o <BR/>Give clear explanation of all care activities prior to an as they occur during each contact.<BR/> o <BR/>Praise the resident when behavior is appropriate.<BR/>Further record review of current care plan revealed Resident #79 had inappropriate behaviors and was resistive to care. Interventions included:<BR/> o <BR/>Will comply with care routine/medical regimen and ongoing thru the next review date. <BR/> o <BR/>Discuss with resident implications of not complying with therapeutic regimen<BR/> o <BR/>If resident refused care, leave resident and return in 5-10 minutes<BR/> o <BR/>Maintain consistency in timing of ADL's, caregivers, and routine as much as possible<BR/> o <BR/>Monitor behaviors and document number of episodes.<BR/> o <BR/>Resident gives self a bed bath daily<BR/>Record review of incident report for 10/6/24 revealed an altercation between Resident #79 and RN A. It was reported by witness, LVN B, that RN A had threatened and slapped the resident.<BR/>Observation and interview with Resident #79 on 11/6/24 at 11:28 AM revealed she was in her bed talking to the SW, who came in to talk work with her from another agency. She refused to talk but said she would talk after the SW said it was okay. She said she was not safe, and she was not safe every day. She said she was not afraid though. She was unable to state why she did not feel safe and did not say anything about anyone specific. She said the staff was mean to her every day, but no one had ever hurt her. She would not let them. <BR/>Interview with the SW on 11/6/24 at 11:25 AM revealed she did psychotherapy with Resident #79 from an agency outside of facility. The resident yelled and constantly said she was not safe . This was her normal behavior, but never related being afraid or what made her unsafe. She stated Resident #79 yelled at the staff but had not mentioned any staff hitting her. She did not see any residual effects from the incident that transpired with RN A.<BR/>Interview with a police officer on 11/6/24 at 11:04 AM via telephone revealed when he arrived at the facility when he was called for the incident with RN A, the accused staff member was already sent home. He said he and the detective believed it happened , but Resident #79 did not want to press charges . <BR/>Interview with a detective on 11/6/24 at 12:45 PM revealed the incident did not elevate to assault. He stated there was verbal yelling going on, but there was no injury from being hit. He stated the witness was in the room, and she stated the nurse hit the Resident #79. The resident did not want to press charges. <BR/>Interview with the DON on 11/6/24 at 11:20 AM revealed the incident was witnessed by LVN B. She said RN A was terminated. Resident #79 told the police officer when interviewed she did not want to press charges. She was unable to tell exactly what happened. Resident said she was hit, but she said she was in her wheelchair but the bed. According to the witness she was in her bed.<BR/>Interview with LVN B on 11/16/24 at 11:45 AM stated she was with Resident #79 in her room on 10/6/24. The LVN B asked the RN A for help give medication to the resident. Resident was refusing her medications. He came into the room and threatened her with giving her a shot, and he hit the resident on the forearm with his open hand. She was surprised that he did that in front of her. She said she never saw him hit anyone else. She went and reported it immediately to the Charge Nurse and they called the DON. She said no one should hit or abuse the residents. The job was about the residents. When asked about trainings, LVN B said they are trained monthly.<BR/>Interview with the Administrator on 11/6/24 at 11:55 AM revealed RN 1 was terminated for not following ANE policy . They had the witness statement and Resident #79 said she was hit. Resident #79 was assessed and there were no negative effects from the incident. When asked about risk of abuse to the residents, he stated a resident could have mental, physical, or emotional abuse from being hit by a staff member. <BR/>The facility took the following action to correct the non-compliance on 10/6/24.<BR/>Record review of the facility investigation revealed the staff was retrained on ANE, witness statement was taken, and assessment was completed. The police, family and physician were contacted. RN A was sent home and suspended immediately.<BR/>Record review of the facily investigation revealed safe surveys were conducted with residents and no concerns found.<BR/> Record review of RN A's personnel file found no concerns or any write ups for abuse or neglect. Background checks were current with no concerns. Termination was completed an in the file. RN A was suspended when DON was notified of the incident. He left facility immediately. His temination was on 10/10/24 at the completion of facility investigation.<BR/>Record Review of Abuse Prevention Program policy, revised December 2016) read in part, .Our residents have the right to be free from abuse .)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for four (Residents #49, #77, #209, and #7) of seven residents reviewed for receiving enteral feeding via a pump.<BR/>The facility failed to clean enteral feeding pumps, which were observed to be dirty on 06/14/22, 06/15/22, and on 06/16/2022 for Residents #49, #77, #209, and #7.<BR/>The facility failed to clean Resident #5's room, and floor mat which was observed to be dirty on 06/16/22. <BR/>These failures could affect residents, who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination and possible infection.<BR/>This failure could affect residents who rely on the facility to maintain their rooms in a sanitary, orderly, and comfotable manner , by placing them at risk for spreading disease-causing organisms, cross-contamination and possible infection.<BR/>Findings included:<BR/>Observation on initial rounds of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/14/22 beginning at 10:05 AM and ending at 10:45 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. <BR/>Observation of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/15/22 beginning at 9:00 AM and ending at 9:15 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. <BR/>Observation of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/16/22 beginning at 8:45 AM and ending at 8:55 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. <BR/>Observation of Resident #5's on 06/16/2022 at 12:30 PM, of room [ROOM NUMBER] C, revealed his bed in a low position with fall mats on both sides of the bed with trash debris, used napkins from the kitchen, bread, red spots on the fall mat to the right approximately 10 splatters. On the left side of the bed was a second fall mat that had splattered liquid spots approximately 5 spots were observed on the fall mat.<BR/>Review of Resident #49's electronic health record on 06/16/22 at 3:16 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia, Moderate Protein-Calorie Malnutrition, Myelodysplastic Syndrome, Gastrostomy Malfunction, Cognitive Communication Deficit, Gastro-Esophageal Reflux Disease, Adult Failure to Thrive, Chronic Gout, Anorexia, Alzheimer's Disease, Anemia, Dyspnea, Dysphagia, Oral Phase, Hypothyroidism, Major Depressive Disorder, Mild Cognitive Impairment, Hypertension, and Osteoarthritis. Review of resident's annual MDS dated [DATE] revealed a BIM's score of 4. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 55ml/hr with water flush 35 ml/hr x 22 hours.<BR/>Review of Resident #77's electronic health record on 06/16/22 at 3:35 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Occlusion and Stenosis of Unspecified Cerebral Artery, Anemia, Unspecified Protein-Calorie Malnutrition, Dementia without Behavioral Disturbance, Hypertension, Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis, and Aphasia. Review of resident's quarterly MDS dated [DATE] revealed a BIM's score of 00. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 55ml/hr with water flush 25 ml/hr x 22 hours.<BR/>Review of Resident #209's electronic health record on 06/16/22 at 3:50 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Malignant Neoplasm Unspecified Ovary, Anemia, Hyperlipidemia, Polyneuropathy, Metabolic Encephalopathy, Hypertension, Atrial Fibrillation, Peripheral Vascular Disease, Pneumonia, Acute Respiratory Failure with Hypoxia, Gastro-Esophageal Refluz Disease, Chronic Hepatitis, Pressure Ulcer of Sacral Region, Stage 3, Chronic Kidney Disease, and Unspecified Fracture of Right Femur. Review of resident's admission MDS dated [DATE] revealed a BIM's score of 10 . Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 50cc/hr with water flush 35 cc/hr x 23 hours.<BR/>Review of Resident #7's electronic health record on 06/16/22 at 4:15 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Acute and Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes, Pneumonia, Abnormal Weight Loss, Dementia In Other Diseases Classified Elsewhere with Behavioral Disturbance, Esophageal Obstruction, Dysphagia, Oral Phase, Other Reduced Mobility, Osteoporosis, Adult Failure to Thrive, Gastrostomy Status, Hypothyroidism, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder, Gastro-Esophageal Reflux Disease, Insomnia, Unspecified Mononeuropathy of Unspecified Lower Limb, and Hypertension. Review of resident's quarerly MDS dated [DATE] revealed a BIM's score of 01. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump give glucernia 1.2 @ 55ml/hr cc/hr per GT x 22 hours water flush at 40 ml/hr x 22 hours every shift.<BR/>During an interview and observation on 06/16/22 at 8:58 AM with LVN A, of the condition of the enteral feeding pumps and pole of residents #49 and #77, LVN A stated, no one has ever told me who is responsible for cleaning them. She stated residents #49 and #77's peg tube pumps and poles looked really bad and I will clean them. LVN A also stated dirty feeding pumps and poles can affect residents by having infection control issues and it is a dignity issue.<BR/>During an interview and observation on 06/16/22 at 9:12 AM with LVN B, of the condition of the enteral feeding pumps and pole of resident #209, LVN B stated, there was no specific person assigned to cleaning them but anyone that notices it should clean them, either way it falls back on the nurse at some point. LVN B stated regarding dirty feeding pumps and poles, there is always a risk of infection, with anything that is dirty, and it doesn't look good nor reflective of good care. LVN B also stated it is a dignity issue for residents. <BR/>During an interview and observation on 06/16/22 at 9:27 AM with LVN C, of the condition of the enteral feeding pumps and pole of resident #7, LVN C stated, everyone was responsible for keeping peg tube poles and pumps clean, saying if you see it you should clean it. LVN C stated regarding dirty feeding pumps and poles, there is always a risk of cross-contamination and the residents have a right to have their medical equipment clean. <BR/>During an interview on 06/17/22 at 11:30 AM with the DON, of the condition of the enteral feeding pumps and pole of four residents, the DON stated anyone can clean the poles and the pumps and tubing nurses need to clean those. She stated there was no schedule for cleaning poles and pumps however, she expects poles and pumps to be cleaned as soon as it is noticed they are dirty. The DON stated the adverse effect on residents could be infection control, environmental, cleanliness, and dignity issues.<BR/>A Review of Resident #5's Face sheet dated 06/16/2022 revealed he was a [AGE] year-old male that was admitted on [DATE] with a diagnosis of Malignant Neoplasm of Unspecified part of the Unspecified Bronchus or Lung (Cancerous Tumor, Acute Embolism and thrombosis of Unspecified Deep Veins of Lower Extremity Bilateral (Blood Clot).<BR/>Review of Resident #5 MDS dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment.<BR/>A review of Resident #5's Care plan dated 6/5/22 revealed the resident has behaviors of throwing items at staff and yelling obscenities, impaired mobility, non-compliance with care and therapy, difficulty adjusting to new environment.<BR/>In an interview with Resident #5 on 06/16/2022 at 12:32 PM revealed that he could not get up out of bed without assistance from staff. He stated that the facility had not cleaned his room today and leaves the room dirty often.<BR/>Interview on 06/16/2022 at 12:40 p.m., LVN C said housekeeping had been on the 500 hall a little before noon spraying the handrails, cleaning rooms, floors, and door handles. LVN C said she saw housekeeping removing trash and soil linen but did not see them cleaning the floors. <BR/>In an interview with CNA T on 06/16/22 at 3:00 PM, revealed that the resident #5 was throwing food earlier, and that this was common behaviors for Resident #5, so it was possible that the facility cleaned the room but during lunch he became angry and three through items on the floor.<BR/>Interview on 06/16/2022 at 1:00 PM, the Housekeeping Director revealed that she was assigned to this building 2 weeks ago and that a housekeeper was assigned to go every day to clean the resident rooms, floors, bathrooms, and mats. The Housekeeping Director said it was important to keep the rooms clean not only for appearance but for infection control. The Housekeeping Director said that she saw the housekeeping staff cleaning that room. The Housekeeping Director said the that the staff that cleaned Resident #5's room had left for the day, and that she has cleaned the room herself and will conduct an in-service with her staff. She reviewed the room chore task for residents and importance of cleaning and disinfecting. She stated that the facility staff were tenured, and the facility do not need a checklist as the facility know the expectations. She provided an Inservice on 06/17/202 at 9: 00 AM. She stated that it was her expectation for housekeeping staff to maintain a clean and sanitary environment for residents, to prevent self-determination and be free of infections and bacteria.<BR/>A review of the facility housekeeping list revealed that staff enter the rooms, disinfect bathrooms, clean and dust blinds, floors, toilets, high touch areas, bed rails, remotes control to bed and television , call lights.<BR/>Interview with Director of Maintenance, revealed he has worked at facility for almost a year. He stated he is was responsible for all the cosmetic issues and appearance/functionality of resident's rooms/furniture. He stated he gets most of his requests for these issues through feedback from residents, nursing and other staff. Director of Maintenance stated these types of issues affect residents by not providing them a happy, safe homelike environment.<BR/>Record review of the Job Description for Housekeeper/Floor Care Technician revealed in part:<BR/> .Heavy housekeepers/floor care technicians are generally responsible for the overall floor maintenance of hard surfaces and carpet (dusting and wet mopping, stripping, waxing, buffing, shampooing . <BR/>Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated August 2011, revealed Policy Interpretation and Implementation 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue or the vascular system are considered critical items and must be sterile.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 4 of 8 residents (Resident #91, Resident #11, Resident #50 and, Resident #4) reviewed for ADLs.<BR/>1. <BR/>The facility failed to ensure Resident #91 was provided shower or bed bath for two weeks which caused the resident's skin to be dry and flaky.<BR/>2. <BR/>The facility failed to ensure Resident # 11 was provided grooming (shaving and nail care).<BR/>3. <BR/>The facility failed to ensure Resident # 50 was provided grooming (nail care).<BR/>4. <BR/>The facility failed to ensure Resident #4 was provided grooming (shaving)<BR/>These failures could place residents at risk for discomfort, and dignity issues.<BR/>Findings included:<BR/>Resident #91<BR/>Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were diabetes mellitus (elevated levels of blood glucose), Morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), atherosclerotic heart disease (thickening or hardening of the arteries), and anxiety disorder (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident # 91's quarterly MDS dated [DATE] revealed BIMS of 12 indicating moderate impaired cognition. It also revealed the resident required extensive to total care with bed mobility, and toilet use, with 2 staff assist. Further review revealed resident needed total care with one person assist for bath. It also revealed the resident was incontinent of bowel and bladder. <BR/>Record review of Resident # 91's progress note dated 05/15/23 b y the DON read Resident requesting shower every Sunday 2 -10 shift. Nurse to document why not given.<BR/>Record review of Resident #91 for August 2023 POC (point of care) for showers revealed it was not signed or had any comments the resident refused showers or if showers were given. <BR/>Record review of Resident # 91's care plan date initiated 09/28/21 revealed resident has ADL self-care performance deficit relater to muscle weakness, interventions: shower every day 2 - 10 shifts, nurse to document why it was not given.<BR/>During an interview on 09/29/23 at 11:04 a.m., Resident #91 said she had not had any shower or bed bath for the past 16 days. She said the aide had not washed her hair, and her scarp was dry, flaking off and falling on her face. She said her whole body was dry and itching, making her feel dirty . Resident #91 said she asked CNA Q why she did not give her shower on08/27/23(Sunday) she said she forgot was the respond she gave for not showering her. She said she had body odor because she could smell herself; it was awful.<BR/>During an observation and interview on 08/29/23 at 12:01 p.m., the treatment nurse and LVN T did a head to toe assessment on Resident #91. It revealed the resident's scalp was dry and covered with flaking, dry skin, and when the treatment nurse ran her hand on her hair, the dry skin fell off the resident's face. The treatment nurse said the aides had not been showering the resident. Then LVN T said yes, maybe the aides did not shower her because most of her skin was dry and flaking off, and that is why she had a dry scalp because her hair had not been washed for a while by the aides. <BR/>During an interview on 08/29/23 at 2:21 p.m., CNA P said she needed help to shower Resident #91 because other aides were busy attending to their residents, and the shower bed was always in use. CNA P told Resident # 91 she could take showers only on Sunday because she needed help to shower, and since other residents are not showered on Sunday, she could get another aide to help her. She said the resident agreed and told the DON that Resident #91 agreed to shower on Sundays. She said she gave the resident a bed bath most of the time by herself on weekdays. She said if she refused to shower on Sundays, it was because she was sick, and she would give her a bed bath. She said she had not worked in 400 hall for ten days and wondered if the aides showered Resident # 91. She said Resident #91 did not initiate the Sunday, showers she initiated it, and she agreed to it.<BR/>During an interview on 08/31/23 at 11:00 a.m., the DON said she spoke to the resident and she wanted to shower on Sundays only. She said she documented in the resident progress note and put it on the nurse's MAR to remind the aide that would work with Resident #91 on Sunday to shower her, but at the end of July, corporate told her to take it off the nurse's MAR. She said the resident refused to shower, and they talked about it during morning meetings. She did not respond to what intervention was put in place after they discussed it during the morning meeting. The DON stated Resident #91 was doing all this because the aide she liked was removed from her hall, and she thought the state was in the building because of her. She said residents are offered a shower or bed bath three times a week, and if the resident refuses, the nurse should talk to the resident, and if the resident refused, the nurse should document it. She said there was no documentation of refusal by Resident #91's progress notes until 08/28/23, and she care planed on 09/29/23 that Resident #91 refused shower on 08/29/23 . She said if a resident was not showered, the resident skin would become dry flaky, rashes, redness, body odor, and even infection.<BR/>During an interview on 08/31/23 at 2:30 p.m., CNA Q said she worked with Resident # 91 on 08/27/23, and she did not shower because it was a Sunday, and they do not shower residents on Sunday. She said Resident #91 had refused to shower about two months before, and she told her change nurse, who no longer works in the facility, and she was not sure if she documented it. She said she did not document because the shower days are not popping up POC(point of care)for the aides to enter if the resident was showered or refused to shower. CNA Q stated she had told the DON about it and said it would corrected, but it is still not fixed . She said residents are offered shower or bed baths three times a week, and if the aides did not shower Resident 91, she could have a skin breakdown, body odor, or infection. She said she could not tell if the resident had body odor. <BR/>During an interview on 09/01/23 at 10:42 a.m., the unit manager said she was the manager for 400 hall and none of the nurses or aides had told her Resident #91 had refused to shower. She said she could not remember if they had talked about Resident #91 refusing to shower. She said maybe somebody spoke about it, and maybe she missed it. She said it was the facility protocol to document if a resident refused care, and she did not see any documentation in the progress note that indicated she refused to shower.<BR/>Resident #11<BR/>Record review of Resident #11 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses were Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (blood vessels have persistently raised pressure).<BR/>Record review of Resident # 11's admission MDS dated [DATE] revealed BIMS of 10 indicating moderate impaired cognition. It also revealed the resident required limited to extensive assistance with one staff assist with ADL. It also revealed the resident was occasionally incontinent of bowel and bladder. <BR/>Record review of Resident # 11's care plan dated 06/21/23 revealed resident is at risk for ADL self-care performance deficit related to decline in health. Interventions: personal hygiene: the resident required limited to extensive assist with one to two staff assist. <BR/>During an observation on 08/29/23 at 10:28 a.m. revealed Resident #11 had long nails on all fingers, and it was about 1.5 cm long, and she had facial hair on her chin.<BR/>During an interview on 08/29/23 at 10:31 a.m., Resident #11 said she wanted her fingernails cut and the facial hair shaved or plucked. Resident #11 said she could break her skin when she scratched herself with the long fingernail, and she does not feel well-groomed with the long nails. <BR/>During an interview on 08/29/23 at 10:45 a.m., CNA S said Resident #11 fingernails and facial hair are cut by the aides on shower days and as needed. CNA S said she was Resident #11's aide for today, and she came to work today at 6:00 a.m. She said she saw the resident when she gave the resident water but did not notice that her fingernails were long or her facial hair. She said Resident #11 could give herself a skin tear if she scratched herself. She said if the resident did not want the facial hair, it would be a dignity issue, and the resident would feel uncared for by the staff. She said she had skills - check off and in service on personal hygiene, which included nail care and shaving. She stated the nurse monitors the aides when the nurses make rounds.<BR/>During an observation and interview on 08/29/23 at 10:49 a.m., CNA S said Resident # 11 fingernails on both hands were very long, and the resident said she had been asking for her nails to be cut, but the aides had not done so. She also said the resident had facial hair on her chin.<BR/>During an observation and interview on 08/29/23 at 10:54 a.m., LVN T said Resident #11's fingernails on both hands were long, and she had facial hair on his chain. LVN T said she was Resident #91's nurse and had made rounds but did not see the long nails and facial hair on the resident's face. She said the resident could feel unkempt and could cut her skin (skin tear) by herself unintentionally. LVN T stated the podiatrist cut the resident's fingernails and toenails. She said she was unsure when the podiatrist would cut her nails because she was alert, and she guessed the aides would be responsible for cutting the resident's fingernails and shaving the resident on shower days. LVN T said the nurses monitored the aide when the nurse signed off on the shower sheet.<BR/>During an interview on 09/31/23 at 12:45 p.m., the ADON said fingernails are done any day of the week, and the aides do not cut diabetic resident fingernails. She said only the nurses cut diabetic resident fingernails. She said Resident #11 would infect her skin if she broke her skin with her long nails. She stated the nurse managers monitored the nurses when they made random rounds on the residents, while the charge nurse monitored the aide during rounding.<BR/>Resident # 50 <BR/>Record review of Resident #50 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were spondylosis (degeneration of the intervertebral disk), scoliosis (abnormal lateral curvature of the spin), hypertension (blood vessels have persistently raised pressure), and asthma (a chronic condition that affects the airways in the lung).<BR/>Record review of Resident # 50's quarterly MDS dated [DATE] revealed BIMS of BIMS of 09 indicating moderate impaired cognition. It also revealed the resident required limited to extensive assistance with one staff assist with ADL. It also revealed the resident was occasionally incontinent of bowel and bladder. <BR/>Record review of Resident # 50's care plan dated initiated 09/28/21 revealed resident has ADL self-care performance deficit relater to muscle weakness, interventions: shower every day 2 - 10 shifts, nurse to document why it was not given.<BR/>During an observation and interview on 08/29/23 at 11:27 a.m., revealed Resident 50's fingernails on the left hand were long; several of the nails were chipped and had a brown substance under the fingernails, and the right hand had two long fingernails. Resident #50 said she had asked some of the aides to cut her nails, but they did not. She said look at my nails. They are dirty.<BR/>During an interview on 09/29/23 at 11:49 a.m., LVN T said Resident #50 had long fingernails on both hands, and some fingernails had dirt under the fingernails. She stated the aide was responsible for cutting the resident fingernails, and she did not see her fingernails when she made rounds. LVN T said Resident #50 could scratch herself and get an infection from the dirt if any open area on her skin or mouth. She said the unit manager monitored the nurses when she made rounds on the residents while the nurses monitored the aides.<BR/>During an interview on 08/29/23 at 11:52 a.m., CNA R said she was Resident #50's aide for the morning shift . She said she had seen the resident when she made rounds but just noticed the fingernails now. She said most of Resident #50 fingernails were long and had dirt under the fingernail's tips. She said the resident's fingernails are cut on shower days and as needed. She said the resident could give herself skin tears because of her long fingernails. She stated the nurses monitored the aides when they made random rounds. She said she had in-service on ADL, and grooming was part of ADL.<BR/>During an interview on 09/01/23 at 8:21 a.m., the DON said the aide should cut Resident # 50 on shower days or at least offer to cut the resident's nails on shower days. She also said the activity director does nails, too. The DON said the aides and nurses should cut the resident's fingernails. At the same time, the unit managers and ADON monitored the nurses and CNA by making random rounds, and they brought up any issues they found during the morning meeting. The DON said Resident #50 could scratch herself or another resident. She also said if the resident had dirt under her fingernails, she could get an infection.<BR/>Resident #4<BR/>Record review of Resident #4 face sheet revealed an [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), cerebral infraction (disrupted blood flow to the brain due to problems with blood vessels), and hypertension (blood vessels have persistently raised pressure).<BR/>Record review of Resident # 4's annual MDS dated [DATE] revealed BIMS of 03 indicating severely impaired cognition. It also revealed the resident required extensive assistance with one staff assist with ADL. It also revealed the resident was incontinent of bowel and bladder. <BR/>Record review of Resident # 4's care plan-initiated date 07/18/17 revealed resident is at risk for ADL self-care performance deficit related to decline in health. Interventions: personal hygiene: the resident required limited to extensive assist with one staff assist. <BR/>During an observation on 08/29/23 at 1:05 p.m. revealed, Resident # 4 had facial hair on her chin and above her lips. The resident did not respond to the surveyor's greetings.<BR/>During an observation and interview on 08/29/23 at 1:07 p.m., CNA Y said the aides should have shaved Resident #4 on shower days and needed to know the resident's shower days. She then looked at the shower schedule and said her shower days were Tuesday, Thursday, and Friday during the evening shift. She said Resident #4 would be shaved when the evening aides came. She said if Resident #4 wanted to be shaved and she was not, the aides were not taking care of the resident. She said she had skills check-off ADL care, which included grooming.<BR/>During an interview on 9/01/23 at 7:31 a.m., the administrator said Resident # 4 should be saved when the resident wanted to be shaved and when there was visible facial hair. She said the direct care nursing staff are responsible for shaving Resident #4. She said the ambassadors and the charge nurses monitored the aides by rounding and looking at the residents. The administrator said she was not sure how Resident #4 would have felt if she had not been shaved.<BR/>During an interview on 09/01/23 at 7:40 a.m., the regional clinical director said the aides, medication aides, and the nurses are responsible for shaving Resident #4. He said shaving is offered during showers and as needed, and the resident would have to give permission to be shaved. He said the first line of monitoring the aides would be the nurse, then the unit manager, ADON, DON, and the IDT team by making random rounds. He said he would not know how Resident #4 felt if she did not want the facial hair.<BR/>During an interview on 09/01/23 at 10:00 a.m., the ADON said all nursing staff are responsible for shaving Resident # 4. She also said if the resident were a female like Resident #4, the CNAs would ask her if she wanted to be shaved or plucked. The ADON said the aides are supposed to shave Resident #4 on shower days and PRN. She said the charge nurse monitors the aides by random rounds, and then the unit manager monitors the nurses. The ADON said she could not tell how Resident #4 felt but would feel bad because she did not want facial hair.<BR/>During an interview on 09/01/23 at 10:39 a.m., the Unit manager said shaving should be done daily, but the aides did it on shower days. She said Resident #4 would feel pretty bad if she wanted to be shaved and she was not shaved. The unit manager said the nurse monitors the aide by making rounds and checking on the residents.<BR/>Record review of the facility policy on fingernails and toenails 2001 MED - PASS, Inc. (Revised April 2007) read in part . the purpose of this procedure are to clean the nail bed, keep nails trimmed, and to prevent infections .<BR/>Record review of the facility policy on shaving 2001 MED - PASS, Inc. (Revised December 2007) read in part .the purpose of this procedure is to promote cleanliness and to provide skin care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #91) reviewed for notification of changes in that:<BR/>The facility failed to notify Resident #91's physician when Resident #91 presented with skin tear under her skin fold before the abdomen, rashes on the abdomial folds and peri - area.<BR/>This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health.<BR/>Findings include:<BR/>Resident #91<BR/>Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were diabetes mellitus (elevated levels of blood glucose), Morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), atherosclerotic heart disease (thickening or hardening of the arteries), and anxiety disorder (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident # 91's quarterly MDS dated [DATE] revealed BIMS of 12 indicating moderate impaired cognition. It also revealed the resident required extensive to total care with bed mobility, and toilet use, with 2 staff assist. Further review revealed resident needed total care with one person assist for bath. It also revealed the resident want incontinent of bowel and bladder. Further review revealed section M had no indication of skin tear.<BR/>Record review of Resident # 91's care plan date initiated 09/28/21 revealed resident has ADL self-care performance deficit relater to muscle weakness, interventions: shower every day 2 - 10 shifts, nurse to document why it was not given. Bathing: resident requires total assist with 2 staff participation with bathing. She also potential for pressure ulcer development related to impaired mobility. Interventions: notify family of any signs of skin breakdown, redness, blister, or discoloration. Notify nurse immediately of any skin breakdown: redness, blister, bruises and discoloration during bath.<BR/>Record review of Resident # 91's skin assessment from 08/03/23 through 08/24/23 did not reveal any skin issues.<BR/>During an interview on 09/29/23 at 11:04 a.m., Resident # 91 said she felt pain under the skin fold before her abdomen. Resident #91 stated one of the aides told her she had an open area, but she could not see it, and she had been feeling pain under her skin fold. She said she had told the nurses about the pain, but the nurses did nothing about it. <BR/>During an observation on 08/29/23 at 11:15 a.m., CNA R answered the call light in Resident # 1's room. The resident asked her to check under her skin fold on the left side, and when CNA R lifted the fold between the breast and abdomen., she said Resident #91 had a skin tear, which may be why she was having pain because the resident pointed to the area. <BR/>During observation on 08/29/23 at 12:01 p.m., the treatment nurse and LVN T performed a head toe assessment of Resident #91, which revealed the resident had a skin tear on the left fold between the breast and the abdomen, which measured 3.4 x o.4cm., and it had dried blood. There was an area on the right abdominal fold with pale reddish rashes, and it was scaly and measured 3.5 x 2.3 cm. The wound treatment nurse measured another spot on the right side, measuring 1 x 1.2 cm. Three areas had rashes in the groin, measuring 5.4 cm x 3. 0cm, 0.9cm x 1.00 cm, and 1.5cm x 1.4 cm.<BR/>During an interview on 09/29/23 at 12:45 p.m., LVN T said she was unaware Resident #91 had a skin tear under her left fold close to the abdomen and rashes that looked like ringworm. She said today was her first or second day working with Resident #91, and the resident aide did not tell her about the skin tear or the rashes. She said skin assessment are done on residents once a very week by the charge nurse. <BR/>During an interview on 08/29/23 at 2:40 p.m., LVN U said she was the nurse who did Resident # 91's skin assessment, and she did not document that Resident #91 had redness under her breast, groin, and abdomen.<BR/>During an interview on 08/30/23 at 9:03 a.m., the treatment nurse said she did not provide any wound care or skin care for Resident #91. She said she had not done any head-to-toe assessment on the Resident. She said she had not seen or was made aware of the skin tear and the rashes on her skin. She said the staff usually notified her if a resident had redness, skin tears, or rashes, but, in this case, she was not notified. She said if Resident #91's skin tear and rashes were not treated promptly, the skin tear could get worse or get infected, or the rashes could spread to other areas.<BR/>During an interview on 08/30/23 at 11:29 a.m., the NP said she was unaware Resident #91 had the perianal rash (irritated skin looks like patches of inflamed skin) for the past two or three weeks, a skin tear, or rashes on her abdominal folds. She said she treated Resident #91 with Keflex 500 mg for five days prophylactically (guarding against or preventing the spread or occurrence of disease or infection) for the fungi in her groin area. The NP said the nurses did not notify her that the area she treated was not cleared after the antibiotic, and the resident still felt pain and itching in her peri area. The NP said if the staff did not keep those areas on Resident #91 clean and dry, she could prescribe all the medications for the resident and the the areas would not heal. The rashes would not heal the areas because Resident #91 was not getting her showers, and she talked to the nurses about it. She said the area on the peri area started as dermatitis (conditions that cause inflammation of the skin) and progressed to fungi. She said the spots on her abdominal fold were wet dermatitis.<BR/>During an interview on 08/30/23 at 2:15 p.m., LVN U said she was the Nurse for Resident # 91 for the past three days for the evening shift, and she was not aware the resident had any skin tear on her left abdominal fold. She said if the skin tear was not treated right away, the area could get infected, and the resident would be in pain.<BR/>During an interview on 08/31/23 at 11:00 a.m., the DON said she was not aware the resident had a skin tear and rashes on her abdominal folds, but she was aware she was on oral fungal infection, and she was treated with Keflex 500mg three times a day for five days. She said the nurses did not tell her the fungi in the peri area was not cleared after taking the antibiotic. She said all the skin issues should have been documented on weekly skin assessments by the nurses. The DON said the rashes should have been reported to the resident doctor, and the doctor's recommendation followed. She said the skin tear could become infected, and the rashes could worsen. <BR/>During an interview on 08/31/23 at 2:30 p.m., CNA Q said she worked with Resident#91 on Sunday (08/17/23). She stated she did not check the resident's skin folds because she did not shower the resident on Sunday. She said she could not remember if the resident complained about pain on her left side, but she complained about itching on her peri area, and she had rashes, too. She said she could not remember if she told the nurse.<BR/>Record review of the facility policy on skin tear 2001 MED - PASS, Inc. (Revised September 2013) read part . the purpose of this procedure is to guide to prevention and treatment of skin tear .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that the residents received treatment and care in accordance with professional standards of practice, the comprehensive Person - centered care plan, and the resident's choices for one out of three residents (Resident number # 91) reviewed for quality of care.<BR/>- The facility failed to promptly assess, identify, and treat skin tear under the left fold before the abdomen, rashes close to the under-abdomen fold, and groin on Resident #91 and failed to ensure interventions were implemented to treat and prevent further skin deterioration.<BR/>This failure could place residents at risk for a delay of care or treatment, pain, and suffering.<BR/>Findings include:<BR/>Resident #91<BR/>Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were diabetes mellitus (elevated levels of blood glucose), Morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), atherosclerotic heart disease (thickening or hardening of the arteries), and anxiety disorder (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident # 91's quarterly MDS dated [DATE] revealed BIMS of 12 indicating moderate impaired cognition. It also revealed the resident required extensive to total care with bed mobility, and toilet use, with 2 staff assist. Further review revealed resident needed total care with one person assist for bath. It also revealed the resident want incontinent of bowel and bladder. Further review revealed section M had no indication of skin tear.<BR/>Record review of Resident # 91's care plan date initiated 09/28/21 revealed resident has ADL self-care performance deficit relater to muscle weakness, interventions: shower every day 2 - 10 shifts, nurse to document why it was not given. Bathing: resident requires total assist with 2 staff participation with bathing. She also potential for pressure ulcer development related to impaired mobility. Interventions: notify family of any signs of skin breakdown, redness, blister, or discoloration. Notify nurse immediately of any skin breakdown: redness, blister, bruises and discoloration during bath.<BR/>Record review of Resident # 91's skin assessment from 08/03/23 through 08/24/23 did not reveal any skin issues.<BR/>During an interview on 09/29/23 at 11:04 a.m., Resident # 91 said she felt pain under the skin fold before her abdomen. Resident #91 stated one of the aides told her she had an open area, but she could not see it, and she had been feeling pain under her skin fold. She said she had told the nurses about the pain, but the nurses did nothing about it. <BR/>During an observation on 08/29/23 at 11:15 a.m., CNA R answered the call light in Resident # 1's room. The resident asked her to check under her skin fold on the left side, and when CNA R lifted the fold between the breast and abdomen., she said Resident #91 had a skin tear, which may be why she was having pain because the resident pointed to the area. <BR/>During observation on 08/29/23 at 12:01 p.m., the treatment nurse and LVN T performed a head toe assessment of Resident #91, which revealed the resident had a skin tear on the left fold between the breast and the abdomen, which measured 3.4 x o.4cm., and it had dried blood. There was an area on the right abdominal fold with pale reddish rashes, and it was scaly and measured 3.5 x 2.3 cm. The wound treatment nurse measured another spot on the right side, measuring 1 x 1.2 cm. Three areas had rashes in the groin, measuring 5.4 cm x 3. 0cm, 0.9cm x 1.00 cm, and 1.5cm x 1.4 cm.<BR/>During an interview on 09/29/23 at 12:45 p.m., LVN T said she was unaware Resident #91 had a skin tear under her left fold close to the abdomen and rashes that looked like ringworm. She said today was her first or second day working with Resident #91, and the resident aide did not tell her about the skin tear or the rashes. She said skin assessment are done on residents once a very week by the charge nurse. <BR/>During an interview on 08/29/23 at 2:40 p.m., LVN U said she was the nurse who did Resident # 91's skin assessment, and she did not document that Resident #91 had redness under her breast, groin, and abdomen .<BR/>During an interview on 08/30/23 at 9:03 a.m., the treatment nurse said she did not provide any wound care or skin care for Resident #91. She said she had not done any head-to-toe assessment on the Resident. She said she had not seen or was made aware of the skin tear and the rashes on her skin. She said the staff usually notified her if a resident had redness, skin tears, or rashes, but, in this case, she was not notified. She said if Resident #91's skin tear and rashes were not treated promptly, the skin tear could get worse or get infected, or the rashes could spread to other areas.<BR/>During an interview on 08/30/23 at 11:29 a.m., the NP said she was unaware Resident #91 had the perianal rash (irritated skin looks like patches of inflamed skin) for the past two or three weeks, a skin tear, or rashes on her abdominal folds. She said she treated Resident #91 with Keflex 500 mg for five days prophylactically (guarding against or preventing the spread or occurrence of disease or infection) for the fungi in her groin area. The NP said the nurses did not notify her that the area she treated was not cleared after the antibiotic, and the resident still felt pain and itching in her peri area. The NP said if the staff did not keep those areas on Resident #91 clean and dry, she could prescribe all the medications for the resident and the the areas would not heal. The rashes would not heal the areas because Resident #91 was not getting her showers, and she talked to the nurses about it. She said the area on the peri area started as dermatitis (conditions that cause inflammation of the skin) and progressed to fungi. She said the spots on her abdominal fold were wet dermatitis.<BR/>During an interview on 08/30/23 at 2:15 p.m., LVN U said she was the Nurse for Resident # 91 for the past three days for the evening shift, and she was not aware the resident had any skin tear on her left abdominal fold. She said if the skin tear was not treated right away, the area could get infected, and the resident would be in pain.<BR/>During an interview on 08/31/23 at 11:00 a.m., the DON said she was not aware the resident had a skin tear and rashes on her abdominal folds, but she was aware she was on oral fungal infection, and she was treated with Keflex 500mg three times a day for five days. She said the nurses did not tell her the fungi in the peri area was not cleared after taking the antibiotic. She said all the skin issues should have been documented on weekly skin assessments by the nurses. The DON said the rashes should have been reported to the resident doctor, and the doctor's recommendation followed. She said the skin tear could become infected, and the rashes could worsen. <BR/>During an interview on 08/31/23 at 2:30 p.m., CNA Q said she worked with Resident#91 on Sunday (08/17/23). She stated she did not check the resident's skin folds because she did not shower the resident on Sunday. She said she could not remember if the resident complained about pain on her left side, but she complained about itching on her peri area, and she had rashes, too. She said she could not remember if she told the nurse.<BR/>Record review of the facility policy on skin tear 2001 MED - PASS, Inc. (Revised September 2013) read part . the purpose of this procedure is to guide to prevention and treatment of skin tear .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure resident was free from significant medication errors for Resident #109 reviewed for significant medication errors. <BR/>-The facility failed to ensure that Resident #109's anticonvulsant medications was administered as ordered by his physician.<BR/>This failure could affect residents who received medication placing them at risk of not receiving the therapeutic effect of the mediations and could result in declining health status.<BR/>Findings included: <BR/>Record review of Resident #109 's admission face sheet dated 09/01/2023 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was initially admitted on [DATE]. Her diagnoses included Seizure disorder or Epilepsy, type 2 diabetes mellitus without complications, hypertensive heart disease without heart failure, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety<BR/>Record review of Resident #109's quarterly Minimum Data Set (MDS) dated [DATE] revealed her BIMS was 00 out of 15 indicating she was with severe impaired cognition. The resident required extensive assistance of 2 staff for bed mobility, transfers, and personal hygiene. She has retention of urine and is always incontinent of bowel.<BR/>Record review of Resident #109's Medical Administration Record (MAR) dated 08/01/2023-08/31/2023, revealed the following medication: start date 07/28/2023 at 0600 Keppra Oral Tablet 500 milligram (Levetiracetam) Give 1 tablet by mouth two times a day, related to OTHER SEIZURES-D/C Date 08/23/2023 at 2301. <BR/>Record review of Resident #109's Medical Administration Record (MAR) dated 08/01/2023-08/31/2023, revealed the following medication: start date 08/28/2023 at 7:00 pm Levetiracetam (Keppra) Give 1 tablet by mouth every 12 hours for seizures.<BR/>Interview on 09/01/2023 at 8:50 DON with administrator and Clinical Services Director in the room regarding complaint 448021. DON stated resident was sent to the hospital on [DATE]. admitted to facility 08/25/2023. Record review showed resident had not receive Keppra Saturday 08/26/2023 or Sunday 08/27/2023. The DON stated the resident did not receive seizure medication Saturday 08/26/2023 or Sunday 08/27/2023 and the resident could have seizures due to not having the correct medication level in her body. <BR/>Called admission nurse 9/1/2023 at 11:38 am; she did not answer or return the call.<BR/>Interview on 9/1/2023 at 12:25 pm with Clinical Service Director regarding resident #109 missing seizure medication on Saturday 08/26/2023 and Sunday 08/27/2023. He stated it is important that resident get medications to prevent resident decline and increased seizure activity.<BR/>Record review of the facility policy titled Administering Medications Policy Statement - Medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation - 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and or have related functions. 3. Medications must be administered in accordance with the orders, include any required time frame.<BR/>Record review of the facility policy titled Pharmacy Services Overview Policy Statement - The facility shall accurately and safely provide or obtain pharmacy services, including the provision of route and emergency medications and biologicals, and the services of a licensed pharmacist. Policy interpretation and implementation - #3 The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers; g. Give the facilities Director of Nursing Services, Medical Director, and staff feedback about performance and practices related to medication administration and medication errors; h. Collaborate with staff and practitioners to address and resolve medication related needs or problems;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #91) observed for accuracy of medical records in that:<BR/>The facility failed to discontinue Resident #91's skin tear and rashes on progress notes and weekly skin assessment. <BR/>This deficient practice could place residents at risk for errors in care and treatment.<BR/>Findings include:<BR/>Resident #91<BR/>Record review of Resident #91 face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses were diabetes mellitus (elevated levels of blood glucose), Morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), atherosclerotic heart disease (thickening or hardening of the arteries), and anxiety disorder (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident # 91's quarterly MDS dated [DATE] revealed BIMS of 12 indicating moderate impaired cognition. It also revealed the resident required extensive to total care with bed mobility, and toilet use, with 2 staff assist. Further review revealed resident needed total care with one person assist for bath. It also revealed the resident want incontinent of bowel and bladder. Further review revealed section M had no indication of skin tear.<BR/>Record review of Resident # 91's care plan date initiated 09/28/21 revealed resident has ADL self-care performance deficit relater to muscle weakness, interventions: shower every day 2 - 10 shifts, nurse to document why it was not given. Bathing: resident requires total assist with 2 staff participation with bathing. She also potential for pressure ulcer development related to impaired mobility. Interventions: notify family of any signs of skin breakdown, redness, blister, or discoloration. Notify nurse immediately of any skin breakdown: redness, blister, bruises and discoloration during bath.<BR/>Record review of Resident # 91's skin assessment from 08/03/23 through 08/24/23 did not reveal any skin issues.<BR/>During an interview on 09/29/23 at 11:04 a.m., Resident # 91 said she felt pain under the skin fold before her abdomen. Resident #91 stated one of the aides told her she had an open area, but she could not see it, and she had been feeling pain under her skin fold. She said she had told the nurses about the pain, but the nurses did nothing about it. <BR/>During an observation on 08/29/23 at 11:15 a.m., CNA R answered the call light in Resident # 1's room. The resident asked her to check under her skin fold on the left side, and when CNA R lifted the fold between the breast and abdomen., she said Resident #91 had a skin tear, which may be why she was having pain because the resident pointed to the area. <BR/>During observation on 08/29/23 at 12:01 p.m., the treatment nurse and LVN T performed a head toe assessment of Resident #91, which revealed the resident had a skin tear on the left fold between the breast and the abdomen, which measured 3.4 x o.4cm., and it had dried blood. There was an area on the right abdominal fold with pale reddish rashes, and it was scaly and measured 3.5 x 2.3 cm. The wound treatment nurse measured another spot on the right side, measuring 1 x 1.2 cm. Three areas had rashes in the groin, measuring 5.4 cm x 3. 0cm, 0.9cm x 1.00 cm, and 1.5cm x 1.4 cm.<BR/>During an interview on 09/29/23 at 12:45 p.m., LVN T said she was unaware Resident #91 had a skin tear under her left fold close to the abdomen and rashes that looked like ringworm. She said today was her first or second day working with Resident #91, and the resident aide did not tell her about the skin tear or the rashes. She said skin assessment are done on residents once a very week by the charge nurse. <BR/>During an interview on 08/29/23 at 2:40 p.m., LVN U said she was the nurse who did Resident # 91's skin assessment, and she did not document that Resident #91 had redness under her breast, groin, and abdomen.<BR/>During an interview on 08/30/23 at 9:03 a.m., the treatment nurse said she did not provide any wound care or skin care for Resident #91. She said she had not done any head-to-toe assessment on the Resident. She said she had not seen or was made aware of the skin tear and the rashes on her skin. She said the staff usually notified her if a resident had redness, skin tears, or rashes, but, in this case, she was not notified. She said if Resident #91's skin tear and rashes were not treated promptly, the skin tear could get worse or get infected, or the rashes could spread to other areas.<BR/>During an interview on 08/30/23 at 11:29 a.m., the NP said she was unaware Resident #91 had the perianal rash (irritated skin looks like patches of inflamed skin) for the past two or three weeks, a skin tear, or rashes on her abdominal folds. She said she treated Resident #91 with Keflex 500 mg for five days prophylactically (guarding against or preventing the spread or occurrence of disease or infection) for the fungi in her groin area. The NP said the nurses did not notify her that the area she treated was not cleared after the antibiotic, and the resident still felt pain and itching in her peri area. The NP said if the staff did not keep those areas on Resident #91 clean and dry, she could prescribe all the medications for the resident and the the areas would not heal. The rashes would not heal the areas because Resident #91 was not getting her showers, and she talked to the nurses about it. She said the area on the peri area started as dermatitis (conditions that cause inflammation of the skin) and progressed to fungi. She said the spots on her abdominal fold were wet dermatitis.<BR/>During an interview on 08/30/23 at 2:15 p.m., LVN U said she was the Nurse for Resident # 91 for the past three days for the evening shift, and she was not aware the resident had any skin tear on her left abdominal fold. She said if the skin tear was not treated right away, the area could get infected, and the resident would be in pain.<BR/>During an interview on 08/31/23 at 11:00 a.m., the DON said she was not aware the resident had a skin tear and rashes on her abdominal folds, but she was aware she was on oral fungal infection, and she was treated with Keflex 500mg three times a day for five days. She said the nurses did not tell her the fungi in the peri area was not cleared after taking the antibiotic. She said all the skin issues should have been documented on weekly skin assessments by the nurses. The DON said the rashes should have been reported to the resident doctor, and the doctor's recommendation followed. She said the skin tear could become infected, and the rashes could worsen. <BR/>During an interview on 08/31/23 at 2:30 p.m., CNA Q said she worked with Resident#91 on Sunday (08/17/23). She stated she did not check the resident's skin folds because she did not shower the resident on Sunday. She said she could not remember if the resident complained about pain on her left side, but she complained about itching on her peri area, and she had rashes, too. She said she could not remember if she told the nurse.<BR/>Record review of the facility policy on skin tear 2001 MED - PASS, Inc. (Revised September 2013) read part . the purpose of this procedure is to guide to prevention and treatment of skin tear .<BR/>Record review of the facility policy on charting and documentation 2001 MED - PASS, Inc. (Revised July 2017) read in part . all service provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional . documented in the resident medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two (Residents #158 and #79) of 17 residents reviewed for accommodation of needs.<BR/>The facility failed to put Resident #158 and #79's call light within reach.<BR/>This failure could affect all residents by placing them at risk of not being able to call for help, a delay in receiving care and treatment, and anxiety and fear.<BR/>Findings included:<BR/>An observation on 6/14/22 at 10:20 AM revealed Resident #158 was sitting reclined in a chair with her call light on her bed, on furthest side from the resident and behind her. When asked at that time if she could reach the call light, Resident #158 stated, I can't reach it. She also stated she would yell out for help if she needed it and was unable to reach her call light. <BR/>An observation on 6/14/22 at 10:25 AM revealed Resident #79 was sitting up in bed and his call light was on the floor behind the head of his bed. When asked at the time if he could reach his call light he looked around and said, I don't even know where it is can you see it? When informed where the call light was located Resident #79 stated he could not reach it. He also stated when he can not reach his call light he calls out for help. <BR/>An observation on 6/15/22 at 9:15 AM revealed Resident #158 sitting reclined in a chair on the far side of her bed and her call light was clipped to the call light cord on the wall. Resident #158's call light was not within her reach. When asked at that time if she could reach the call light, Resident #158 looked around for the call light and said, I can't even see it, where is it? <BR/>An observation on 6/15/22 at 9:22 AM revealed Resident #79 sleeping in bed and his call light was on the floor behind the head of his bed. <BR/>Review of Resident #158's electronic health record on 06/16/22 at 4:30 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia without Behavioral Disturbance, Irritable Bowel Syndrome without diarrhea, Dysphagia, Hypertension, Gastro-Esophageal Reflux Disease, and Rheumatoid Arthritis. Review of resident's admission MDS dated [DATE] revealed a BIM's score of 9. <BR/>Review of Resident #79's electronic health record on 06/16/22 at 4:50 PM, reflected he was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart Disease without Heart Failure, Pure Hypercholesterolemia, Radiculopathy, Cognitive Communication Deficit, Aphasia, Mixed Hyperlipidemia, Insomnia due to Medical Condition, Unspecified Intellectual Disabilities, Osteoarthritis, Right Ankle and Foot, and Vitamin D Deficiency. Review of resident's annual MDS dated [DATE] revealed a BIM's score of 12. <BR/>During an interview and observation on 6/15/22 beginning at 2:15 pm with LVN D regarding the location of Resident #158's call light being clipped to call light cord on the wall, he stated the resident's call light is not supposed to be there and that it should always be within reach of the resident so the resident can call for help if she needs it. LVN D went around Resident 158's bed and removed call light from wall and placed within reach of resident. LVN D stated regarding Resident #79's call light being on the floor behind resident, the resident's call light ends up on the floor behind resident often and staff on this floor know that and are supposed to be checking often to make sure it is within reach and clipped to his pillow. LVN D reached under Resident #79's bed to retrieve call light and clipped call light to resident's pillow. LVN D stated both residents are able to use their call lights. He also stated when staff are making rounds call lights should be checked to make sure they are within reach of residents. <BR/>During an interview on 06/17/22 at 11:45 AM with the DON, she stated all staff are responsible for making sure residents call lights are within reach and any staff person who enters a resident's room should be making sure call lights are placed within reach. DON stated if call lights are not within reach a resident would not be able to call for help in an emergency or at any time, therefore they need to in within reach at all times. <BR/>Review of facility policy titled Answering the Call Light, dated March 2012 . Purpose; The purpose of this procedure is to respond to the resident's requests and needs .General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for four (Residents #49, #77, #209, and #7) of seven residents reviewed for receiving enteral feeding via a pump.<BR/>The facility failed to clean enteral feeding pumps, which were observed to be dirty on 06/14/22, 06/15/22, and on 06/16/2022 for Residents #49, #77, #209, and #7.<BR/>The facility failed to clean Resident #5's room, and floor mat which was observed to be dirty on 06/16/22. <BR/>These failures could affect residents, who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination and possible infection.<BR/>This failure could affect residents who rely on the facility to maintain their rooms in a sanitary, orderly, and comfotable manner , by placing them at risk for spreading disease-causing organisms, cross-contamination and possible infection.<BR/>Findings included:<BR/>Observation on initial rounds of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/14/22 beginning at 10:05 AM and ending at 10:45 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. <BR/>Observation of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/15/22 beginning at 9:00 AM and ending at 9:15 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. <BR/>Observation of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/16/22 beginning at 8:45 AM and ending at 8:55 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. <BR/>Observation of Resident #5's on 06/16/2022 at 12:30 PM, of room [ROOM NUMBER] C, revealed his bed in a low position with fall mats on both sides of the bed with trash debris, used napkins from the kitchen, bread, red spots on the fall mat to the right approximately 10 splatters. On the left side of the bed was a second fall mat that had splattered liquid spots approximately 5 spots were observed on the fall mat.<BR/>Review of Resident #49's electronic health record on 06/16/22 at 3:16 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia, Moderate Protein-Calorie Malnutrition, Myelodysplastic Syndrome, Gastrostomy Malfunction, Cognitive Communication Deficit, Gastro-Esophageal Reflux Disease, Adult Failure to Thrive, Chronic Gout, Anorexia, Alzheimer's Disease, Anemia, Dyspnea, Dysphagia, Oral Phase, Hypothyroidism, Major Depressive Disorder, Mild Cognitive Impairment, Hypertension, and Osteoarthritis. Review of resident's annual MDS dated [DATE] revealed a BIM's score of 4. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 55ml/hr with water flush 35 ml/hr x 22 hours.<BR/>Review of Resident #77's electronic health record on 06/16/22 at 3:35 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Occlusion and Stenosis of Unspecified Cerebral Artery, Anemia, Unspecified Protein-Calorie Malnutrition, Dementia without Behavioral Disturbance, Hypertension, Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis, and Aphasia. Review of resident's quarterly MDS dated [DATE] revealed a BIM's score of 00. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 55ml/hr with water flush 25 ml/hr x 22 hours.<BR/>Review of Resident #209's electronic health record on 06/16/22 at 3:50 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Malignant Neoplasm Unspecified Ovary, Anemia, Hyperlipidemia, Polyneuropathy, Metabolic Encephalopathy, Hypertension, Atrial Fibrillation, Peripheral Vascular Disease, Pneumonia, Acute Respiratory Failure with Hypoxia, Gastro-Esophageal Refluz Disease, Chronic Hepatitis, Pressure Ulcer of Sacral Region, Stage 3, Chronic Kidney Disease, and Unspecified Fracture of Right Femur. Review of resident's admission MDS dated [DATE] revealed a BIM's score of 10 . Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 50cc/hr with water flush 35 cc/hr x 23 hours.<BR/>Review of Resident #7's electronic health record on 06/16/22 at 4:15 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Acute and Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes, Pneumonia, Abnormal Weight Loss, Dementia In Other Diseases Classified Elsewhere with Behavioral Disturbance, Esophageal Obstruction, Dysphagia, Oral Phase, Other Reduced Mobility, Osteoporosis, Adult Failure to Thrive, Gastrostomy Status, Hypothyroidism, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder, Gastro-Esophageal Reflux Disease, Insomnia, Unspecified Mononeuropathy of Unspecified Lower Limb, and Hypertension. Review of resident's quarerly MDS dated [DATE] revealed a BIM's score of 01. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump give glucernia 1.2 @ 55ml/hr cc/hr per GT x 22 hours water flush at 40 ml/hr x 22 hours every shift.<BR/>During an interview and observation on 06/16/22 at 8:58 AM with LVN A, of the condition of the enteral feeding pumps and pole of residents #49 and #77, LVN A stated, no one has ever told me who is responsible for cleaning them. She stated residents #49 and #77's peg tube pumps and poles looked really bad and I will clean them. LVN A also stated dirty feeding pumps and poles can affect residents by having infection control issues and it is a dignity issue.<BR/>During an interview and observation on 06/16/22 at 9:12 AM with LVN B, of the condition of the enteral feeding pumps and pole of resident #209, LVN B stated, there was no specific person assigned to cleaning them but anyone that notices it should clean them, either way it falls back on the nurse at some point. LVN B stated regarding dirty feeding pumps and poles, there is always a risk of infection, with anything that is dirty, and it doesn't look good nor reflective of good care. LVN B also stated it is a dignity issue for residents. <BR/>During an interview and observation on 06/16/22 at 9:27 AM with LVN C, of the condition of the enteral feeding pumps and pole of resident #7, LVN C stated, everyone was responsible for keeping peg tube poles and pumps clean, saying if you see it you should clean it. LVN C stated regarding dirty feeding pumps and poles, there is always a risk of cross-contamination and the residents have a right to have their medical equipment clean. <BR/>During an interview on 06/17/22 at 11:30 AM with the DON, of the condition of the enteral feeding pumps and pole of four residents, the DON stated anyone can clean the poles and the pumps and tubing nurses need to clean those. She stated there was no schedule for cleaning poles and pumps however, she expects poles and pumps to be cleaned as soon as it is noticed they are dirty. The DON stated the adverse effect on residents could be infection control, environmental, cleanliness, and dignity issues.<BR/>A Review of Resident #5's Face sheet dated 06/16/2022 revealed he was a [AGE] year-old male that was admitted on [DATE] with a diagnosis of Malignant Neoplasm of Unspecified part of the Unspecified Bronchus or Lung (Cancerous Tumor, Acute Embolism and thrombosis of Unspecified Deep Veins of Lower Extremity Bilateral (Blood Clot).<BR/>Review of Resident #5 MDS dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment.<BR/>A review of Resident #5's Care plan dated 6/5/22 revealed the resident has behaviors of throwing items at staff and yelling obscenities, impaired mobility, non-compliance with care and therapy, difficulty adjusting to new environment.<BR/>In an interview with Resident #5 on 06/16/2022 at 12:32 PM revealed that he could not get up out of bed without assistance from staff. He stated that the facility had not cleaned his room today and leaves the room dirty often.<BR/>Interview on 06/16/2022 at 12:40 p.m., LVN C said housekeeping had been on the 500 hall a little before noon spraying the handrails, cleaning rooms, floors, and door handles. LVN C said she saw housekeeping removing trash and soil linen but did not see them cleaning the floors. <BR/>In an interview with CNA T on 06/16/22 at 3:00 PM, revealed that the resident #5 was throwing food earlier, and that this was common behaviors for Resident #5, so it was possible that the facility cleaned the room but during lunch he became angry and three through items on the floor.<BR/>Interview on 06/16/2022 at 1:00 PM, the Housekeeping Director revealed that she was assigned to this building 2 weeks ago and that a housekeeper was assigned to go every day to clean the resident rooms, floors, bathrooms, and mats. The Housekeeping Director said it was important to keep the rooms clean not only for appearance but for infection control. The Housekeeping Director said that she saw the housekeeping staff cleaning that room. The Housekeeping Director said the that the staff that cleaned Resident #5's room had left for the day, and that she has cleaned the room herself and will conduct an in-service with her staff. She reviewed the room chore task for residents and importance of cleaning and disinfecting. She stated that the facility staff were tenured, and the facility do not need a checklist as the facility know the expectations. She provided an Inservice on 06/17/202 at 9: 00 AM. She stated that it was her expectation for housekeeping staff to maintain a clean and sanitary environment for residents, to prevent self-determination and be free of infections and bacteria.<BR/>A review of the facility housekeeping list revealed that staff enter the rooms, disinfect bathrooms, clean and dust blinds, floors, toilets, high touch areas, bed rails, remotes control to bed and television , call lights.<BR/>Interview with Director of Maintenance, revealed he has worked at facility for almost a year. He stated he is was responsible for all the cosmetic issues and appearance/functionality of resident's rooms/furniture. He stated he gets most of his requests for these issues through feedback from residents, nursing and other staff. Director of Maintenance stated these types of issues affect residents by not providing them a happy, safe homelike environment.<BR/>Record review of the Job Description for Housekeeper/Floor Care Technician revealed in part:<BR/> .Heavy housekeepers/floor care technicians are generally responsible for the overall floor maintenance of hard surfaces and carpet (dusting and wet mopping, stripping, waxing, buffing, shampooing . <BR/>Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated August 2011, revealed Policy Interpretation and Implementation 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue or the vascular system are considered critical items and must be sterile.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received and the facility provided food prepared by methods that conserved nutritive value, flavor, and appearance; food and drink that is palatable, attractive and at a safe and appetizing temperature.<BR/>1.Facility staff failed to offer Resident #1 his meal tray on 06/15/2022.<BR/>2.Facility staff failed to provide Resident #2 with her choice of dinner her selection on dining meal ticket.<BR/>3.Facility staff failed to provide Resident #4 with food that was palatable despite requests to change the food. <BR/>This deficient practice could affect residents that are dependent on staff for activities, cognitive stimulation, social interaction, and right to choose, therefore affecting their self-determination with choices. And place them at risk for their rights to be violated. <BR/>Findings include: <BR/>Review of Resident #1's face sheet dated 06/14/22 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses unspecified injury at C3 Level of Cervical Spinal Cord, Subsequent encounter (spinal cord injury causing paralysis) and Depression (mood).<BR/>Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated that the resident's cognitive abilities are intact. <BR/>Review of physician orders for Resident #1's Care Plan dated 05/28/22 revealed that the resident has had weight loss due to changes in his appetite. Resident #1's at risk for pressure ulcers and infection. Interventions listed state that resident should be served diet as ordered, record intake as it was important for him to maintain adequate nutrition. The interventions implemented were to offer health shakes or equivalent two times a day and bedtime snacks. Resident #4's dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations. <BR/>Interview with Resident #1 on 06/14/22 at 9:30 AM, revealed that Resident #1 that he does not get to choose his meals. He stated that meal tickets are placed on the trays delivered to his room, however, he does not receive his preference of meals selected. He stated that currently he has to purchasing purchase his own food, due to the poor quality of taste and choices. He has verbalized his concerns to the administration and Dietary manager, and they provided him a private room and refrigerator as a solution. He stated that the Dietary Manager met with him after admissions and received a list of food items that he prefers, such as, chef salad, tacos, and chicken. <BR/>Interview with Resident #1 on 06/15/22 at 11:30 AM revealed that he did not receive any meat on his dinner tray. He stated that the had not received a lunch tray today. He stated that the staff asked Resident #1 what are we having for lunch, and he stated that he would have some crackers. He stated that she did not have a meal tray with her when she entered the room, so he asked for his food. He stated that he did not see what was on his lunch tray today, nor had he seen his meal ticket, because CNA R did not bring the tray in the room. He stated that he did not asked aide about his tray. He stated that depending on who was working, they would offer the tray or ask what he wanted from his refrigerator. Resident #1 stated that he refused lunch, dinner and most meals, as the food was not properly prepared, with taste, texture, and smell. <BR/>In an interview with CNA R, on 06/15/22 at 11:40 AM revealed that she was the aide passing meal trays for Resident #1 today. She stated that she did not offer Resident #1 todays meal tray, because he would not have wanted the choice of food that was served. She stated that he was a very picky eater and most of the time when she offered the meal he would state that he did not want the food. She stated that she did not take the tray in the room. She stated that she did not offer him the tray, by not taking it into the room. She stated that she left Resident #1s tray on the food cart located in the hall. She stated that she was aware that she should have offered him the tray, then when he refused seek alternate meal, and notify the charge nurse to document and communicate to ADON. The aide, nurse, and dietary managers are responsible for assuring that the resident was offered shakes. The nursing station has extra shakes/supplements and snacks available for residents. <BR/>In an observation on 06/15/2022 at 11:45 AM revealed that Resident #1's tray was observed on the second shelf of 5 at the back. The tray was stored on the cart with other resident trays that had been eaten therefore exposing his tray to other Resident's causing cross contamination. The tray could no longer be offered. The meal tray was observed with a side salad, lettuce, cheese, and tomatoes, black-eyed peas and green beans, mandarin oranges, and milk. The meal ticket lying on the tray stated indicated that resident lunch meal on 06/15/22 Large Portion Xtra Ham Turkey on salad. CNA R was observed pulling Resident #1's food cart from the back of the food cart after removing used resident's trays, therefore unable to offer the tray due to exposure to cross Contamination. A small carton of milk was observed on the tray, however there were no supplements.<BR/>Review of Resident #2's face sheet dated 06/16/22 revealed an admission date of 06/06/2022 with diagnoses disorder of the Kidney and history Chemotherapy. <BR/>Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated that the resident's cognitive abilities are intact. <BR/>Review of Resident #2's Care Plan dated 06/07/22 revealed that the resident has an indwelling and Suprapubic Catheter (a drainage tube is inserted into the bladder via the urethra and is either left in place (indwelling catheter) or removed after the bladder is emptied (intermittent catheter). 2. Suprapubic catheterization: a drainage tube is inserted into the bladder through a small cut in the abdominal wall.) due to a terminal Cancer Diagnosis. Resident #2's at risk for pressure ulcers and infection due to ADL Self-Care Performance Deficit. Interventions listed state indicated that resident should be served diet as ordered, provide supplements as ordered, and record intake as it's important for her to maintain adequate nutrition. The interventions implemented were to offer health shakes or equivalent two times a day and bedtime snacks. Resident #1's dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations. <BR/>Interview with Resident #2 on 06/14/22 at 12:30 PM revealed that she did not receive the dinner ordered on 06/13/22. She stated that on 06/13/22 when she was served her meal at dinner time in her room, she received a sandwich with turkey no cheese, lettuce, tomatoes, dressing and macaroni salad that was dry and not as described on the menu. She stated that she did not eat the food. Resident #2 did not ask anyone for a meal replacement or substitute, as she stated this happens very often, and nothing changes. Resident #2 stated that she refused meal due to it not being what she asked for and this occurs often. <BR/>An observation and Record review of Resident #2's dinner meal from 06/13/22 at 12:00PM revealed white bread with turkey lunch meat, tea, and macaroni with consistency of scrambled eggs. A review Resident #2's meal ticket revealed that she was served Turkey Sandwich with lettuce and tomato plate, 1 packet of mayonnaise, &frac12; cup of broccoli salad, &frac12; cup of creamy dill macaroni salad, and chocolate cake with peanut butter frosting 1 square, milk 8oz, and tea of choice, 6 oz. <BR/>A review of Resident #4's face sheet dated 06/16/2022 revealed that he was a [AGE] year-old male that was admitted on [DATE] with a diagnosis of Atherosclerotic heart disease of Native Coronary Artery with unstable Angina Pectoris (artery disease related to blood flow deficiencies.)<BR/>A review of Resident #4's MDS revealed a BIMS score of 12 indicating the resident's cognitive abilities are intact.<BR/>Review of Resident #4's Care Plan dated 03/29/22 revealed that the Resident #4 was at risk of weight fluctuation as he has snacks in his room due to changes in appetite. Resident #4's at risk for pressure ulcers and infection due to ADL self-care deficit due to limited mobility. Resident #4's interventions states stated that he's dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations. <BR/>In an interview with Resident #4 on 06/14/2022 at 1:00 PM revealed that he does not like the food at the facility as it does not taste or smell like food. He stated that he has communicated to Resident Council and leadership his concerns with the food, and there have been no changes. He stated that his family member brings him food and snacks to eat to prevent weight loss. He stated that he's very frustrated with the dining services and food provided to the residents as there are very limited choices at mealtime and the variety for alternates. Resident #4 stated that he refused lunch, because the food smells bad and looks like slop<BR/>In an interview with Resident #4's family member on revealed that her sibling Resident #4 does not like the food at the facility and he's capable of communicating his dislikes to facility staff, yet there have been no changes. RS stated that she brings her brother Resident #4 snacks and food to eat as he will refuse to eat the food that could lead to weight loss.<BR/>An observation on 06/14/22 at 1:00 PM Resident #4 was observed in his room with his family visiting eating fried chicken, biscuit and mask potatoes that was purchased from Kentucky Fried Chicken. A local fast-food establishment <BR/>In an interview with the DM on 06/14/2022 at 1:30 PM revealed that she relies relied on the meal tracker to select each resident's diet selection based on the menu. She stated that they do not have a shortage of food at the facility, and that she could not understand why Resident #1 did not receive a salad on 6/15/22 as requested. She stated as for Resident #2 she requested a turkey sandwich and that's what was provided. She stated that she does not know why the resident did not get the additional items of broccoli salad, milk, lettuce, tomatoes, mayonnaise, and chocolate cake. Dietary manager stated that she has supplement shakes in the kitchen and they are supplied at the nursing station. It is the health care staff's responsibility to offer the shakes. She stated that she meets with residents upon admission to gain knowledge of their meal preferences. She stated that she was not aware that many of the residents were not eating their food. She stated that the residents can chose their meals based on what is offered for the today. The facility does not have a select meal program, the facility offers a main choice and an alternate. She stated that when a resident does not like the selection nursing staff are expected to come to the kitchen and request an alternate choice. She stated that when the facility menu has changed, she does not visit the resident to communicate in advance. The dietary manager stated that she posts the menu's outside of the main dining hall in advance to allow the residents the opportunity to request a grill cheese sandwich or alternate listed on the menus.<BR/>During a resident council meeting with resident #4 verbalized that the food was not good and he does not believe that they will change the problem. <BR/>In an observation of lunch on 6/15/22 beginning at 12:00 PM on the 400 hall, 500 hall and 600 halls, approximately over 60% of the plates were refused by the residents without tasting the food. Menu black-eyed peas, green beans, carrots, mandarins and tea.<BR/>In an interview with CNA T on 06/17/2022 at 9:13 AM revealed that she has witnessed Resident #1 and #2 refuse meals due to the presentation and smell. She stated that she will offer the food trays first and allow the residents to choose to eat or request something else. She stated that she would not eat the food served at the facility nor would she purchase for her family, as it did not look or smell edible. She will document in point of contact fore aides if a resident receives a shake.<BR/>In an interview with DON on 06/17/22 at 10: 00 AM the DON revealed that communication with the dietary staff about the choices of food available to the residents have been ongoing. She stated that often the reports to the Dietary staff by nursing are met with resistance and delays to the residents. She stated that the residents are were complaining, and this has been addressed int eh in the team meetings on a weekly basis, with little to know change. <BR/>In an interview with the Registered Dietician on 06/17/22 a 10:00 am revealed that she was responsible for updated the meal select system notifying the kitchen staff to provide supplements to residents. <BR/>In an interview with Administrator on 06/17/22 at 11:00 AM revealed that it was her expectation for the dietary staff to provide a meal of choice for the residents that's consistent with the residents' desires and presents edible with taste to maintain nutrition. Administrator stated that she has eaten the food at the facility and does not have any complaints.<BR/>A review of facility policy on Resident Rights revealed that all employees shall treat all residents with respect and dignity, self-determination through choices, communication with and access to people and services at the facility, exercise his or her right as a resident at the facility, be informed about rights, voice grievances and be expected to receive response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 Resident (Resident #1) reviewed for tracheostomy care.<BR/>1. The facility failed to maintain sterile procedure during tracheostomy care for Resident #1. <BR/>2. The facility failed to provide disposable inner cannulas for daily cannula changes as physician ordered for Resident #1<BR/>These deficient practices could place residents with tracheostomies at risk of respiratory infection, complications, and hospitalization<BR/>Findings included:<BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included acute kidney failure, UTI, muscle weakness, diabetes (high sugar levels for prolonged periods), epilepsy (neurological disorder causing seizures), HTN, GERD, intracranial injury, tracheostomy status (opening into the windpipe allowing air to flow in and out) and gastrostomy status (feeding tube through hole in the stomach).<BR/>Record review of Resident #1's quarterly MDS (a resident assessment and care screening) dated 02/22/2023 revealed he had adequate ability to hear and had no speech. The staff assessment for mental status revealed Resident #1 had severely impaired cognitive skills for decision making (never/rarely made decisions). He required extensive to total assistance with all ADLs. The active diagnosis section revealed he had traumatic brain injury. He required oxygen, suctioning and tracheostomy care.<BR/>Record review of Resident #1's physician order dated 02/16/2023 at 11:23AM revealed an order to change the disposable inner cannula #8 daily and PRN. <BR/>Record review of Resident #1's April 2023 MAR/TAR, downloaded from the electronic health records on 04/23/2023 at 5:05PM, revealed the disposable inner cannula was documented as being changed daily on day shift between 6:00AM and 2:00PM.<BR/>During an observation and interview, on 04/23/2023 at 3:45PM, LVN A stated she began working at the facility in July of 2022. LVN A checked Resident #1's room for disposable inner cannulas. Observed that there were no replacement inner cannulas with the other respiratory supplies. She stated the cannulas were supplied by the RT and she was told they were on back order. She stated she was instructed by her supervisor to clean the existing cannula until replacements arrived. She stated she only worked weekends. She stated this was the first time she had not seen a supply of replacement cannulas and Resident #1 was the only resident with a tracheostomy. LVN A stated she did not know how long Resident #1's inner cannula was being reused. She stated she was uncomfortable cleaning a disposable cannula and therefore she did not do this when she did the trach care during the morning (04/23/2023). LVN A disinfected the bedside table and checked Resident #1's oxygen saturation rate which was 96% and his pulse was 79. The resident's eyes were open and was in no distress. LVN A raised the HOB higher and then washed her hands. LVN A opened three sterile trach kits. LVN A stated she will be using the gloves in the kits because she did not have a supply of clean gloves on hand. LVN A removed the sterile drape from one of the kits and draped it over the table then emptied contents of kit onto sterile drape. She then opened the sterile gloves package and put them on then moved the plastic container from the non-sterile area on the bedside table onto the sterile field. LVN A opened the NS plastic ampules that came with the kit and poured it into the plastic container. Resident #1's family was present and assisted LVN A by opening more NS plastic ampules and pouring the liquid into the sterile plastic container. LVN A reached over the sterile field for the suction catheter. LVN A connected the sterile suction catheter and used her left hand as dominant hand then tested the suction by drawing up normal saline. LVN A stated her left hand will be the dominant hand. Resident #1 coughed up thick, brown secretions which landed onto the split gauze. LVN A made three passes to suction secretions. The left sterile gloved hand used to suction, touched the mist mask each time. LVN A removed the inner cannula and then placed into normal saline to soak. The inner cannula had a thick clot of dark colored secretion stuck inside. LVN A removed the soiled gauze dressing, removed gloves, and tossed into the trash bin. LVN A reached over sterile field to get another pair of sterile gloves from another kit and put on the gloves then cleaned and dried the cannula with a sterile gauze. LVN A replaced the clean inner cannula into the resident's tracheostomy. LVN A cleaned the skin beneath the trach flange using cotton swabs dipped in normal saline then applied sterile split gauze. LVN A checked Resident #1's oxygen saturation rate and it was at 96%. LVN A cleaned up then washed her hands.<BR/>In an interview on 04/23/2023 at 4:30PM, LVN A stated her last in-service for tracheostomy care was last year with the RT. LVN A was asked why it was important to maintain sterility of the gloved dominant hand, she stated it was because bacteria could enter the resident's tracheostomy. She stated she was unaware that her hand touched the mask and that she reached over the sterile field. She stated it was important to not to reach over d/t cross contamination and infection control. She stated she did disinfect the table and that she did not know she had to hand hygiene between glove changes.<BR/>In an interview on 04/23/2023 at 5:15PM, the DON, who started working at the facility 3 weeks ago, stated usually the DON was supposed to set up the schedule and RT would conduct the staff inservices on Tracheostomy care. The DON stated the sterile field was to prevent infection and bacterial growth. The DON stated if the nurse was reaching over the sterile field, then anything on sterile field was no longer sterile. The DON stated the nurse should have sanitized her hands between glove changes for infection control. The DON stated the disposable cannulas cannot be cleaned and then reused but she was unsure and would look for the policy and procedure.<BR/>In a telephone conversation on 04/23/2023 at 5:20PM, the RT stated he just started working with the facility 3 months ago. The RT stated he did not realize how many cannulas Resident #1 would go through, and the family wanted it changed twice a day. RT stated the Portex inner cannulas were on back order and expected to arrive Monday 04/24/2023. The RT stated the inner cannulas were made from the same material as the permanent outer cannula and can be cleaned and reused. The RT stated most places keep the same disposable inner cannula and then toss in a week. RT stated there were no health risks to re-using the inner cannula. <BR/>In an interview on 04/23/2023 at 6:00PM, the DON stated she was unaware that Resident #1 did not have any more inner cannulas and that any nurse working with Resident #1 should have notified her.<BR/>In an interview on 04/23/2023 at 7:00PM, the DON stated, not having inner cannula replacements for Resident #1 probably happened because the staff were used to not having a DON and managing issues themselves even though an interim from Regional was at the facility. The DON stated she reached out to the MD and found some cannulas from another facility that they could have. The DON stated she expected that the nurses should not have check marked they were changing the cannula when there were no replacements available.<BR/> Record review of the facility policy for Suctioning the Lower Airway (Endotracheal (a tube inserted into the trachea through the nose or mouth), or Tracheostomy Tube), revised October 2010, read in part: .The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract General Guidelines .1.b Use sterile equipment to avid widespread pulmonary and systemic infection .Steps in the Procedure .14. Apply sterile gloves. The dominant hand will remain sterile <BR/>Record review of the facility policy for Handwashing/Hand hygiene, revised August 2015, read in part Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .f. before donning sterile gloves .m. After removing gloves

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that<BR/>4 Frozen rolls of 10 lb. ground beef in a pan being thawed in the sink.<BR/>This failure could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. <BR/>Findings Included:<BR/>Observation of the facility kitchen on 08/29/23 at 8:30 AM revealed 4- 10 lb. frozen ground beef in a pan being thawed in the sink faucet water running with a temperature of 91 degrees Fahrenheit. Ground beef had an internal temperature of 73.8 degrees Fahrenheit indicating that the temperature is in the Danger Zone (41 degrees Fahrenheit to 135 degrees Fahrenheit).<BR/>Interview with the Food Service Manager on 08/29/23 at 8:35 AM he stated that ground beef temperature of 73.8 degrees Fahrenheit indicates that the frozen beef was inappropriately being thawed. He also stated that he is responsible for training staff on thawing requirements ensuring dietary requirements are met. <BR/>Record review of facility's Food and Nutrition Services Policy and Procedure dated 9/2017 read in part. Proper food thawing methods are as follows :1. Under refrigeration to maintain the temperature at below 41 degrees Fahrenheit. 2. Submerge under cold running water that is no greater than 70 degrees Fahrenheit and creates enough agitation to float off loose ice particles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 6 residents whose care was reviewed in that:<BR/>1.Facility staff failed to allow Resident #3 the right to choose her location to have said meals.<BR/>This deficient practice could affect residents that are dependent on staff for activities, cognitive stimulation, social interaction, and right to choose, therefore affecting their self-determination with choices. And place them at risk for their rights to be violated. <BR/>The findings were:<BR/>A review of Resident #3's face sheet dated 06/16/2022 revealed that she was a [AGE] year-old female that was admitted on [DATE] with a diagnosis of Dysphagia (difficulty swallowing) following other cerebrovascular Disease (bleeding in the brain), Vascular Dementia without behavioral disturbances (difficulty wit with judgement related to high-risk stroke victims) and Dementia with behavioral disturbance (agitation and behaviors of verbal and physical aggression, wandering and hoarding.<BR/>A review of Resident #3's MDS dated [DATE] a BIMS Score of 2 indicating severe cognitive impairment.<BR/>An observation of Resident #3 on 06/14/22 at 10:00 AM, 12:00 PM, and 5:00 PM revealed resident sitting in her room lying in bed fully dressed. Resident would not respond to attempts to interview.<BR/>In an interview with Resident #3's Resident Representative on 06/15/2022 revealed that Resident #3 prefers to remain in her room away from everyone and refuses hygiene, food, and care often. She stated that she maintains contact with the facility, and when she visits Resident #3, she brings snacks. She stated that Resident #3 does eat the snacks. <BR/>Observation on 06/16/2022 at 5:00 PM revealed that Resident #3 had ambulated via walker to the dining room for dinner. Upon entering the dining room, she was confronted CNA S holding the handles of the walker of Resident #3 standing in front of her preventing movement telling her that she could not enter the dining room for dinner. Resident #3 was observed saying pushing her walker saying No! I want to stay! Please let me stay! over 3 times. CNA S stated to this Surveyor that the resident has behaviors of harking and spitting up items in the dining room on the floor and grabbing other resident's food while in the dining room, she can't enter to eat. Resident #3 had not been observed demonstrating any of the behaviors proclaimed by CNA S, therefore she was allowed to remain in the dining room. Resident was very upset and would not communicate other than stating to me that she wants to Stay.<BR/>A review of Resident #3's care plan dated 05/07/22 that Resident #3 was dependent on staff for activities, cognitive stimulation, social interaction related to Cognitive Deficits, and interventions include inviting resident to activities, caregivers provide opportunity for positive interactions, attention, and socialization, and when reasonable discuss the resident's behaviors. <BR/>In an interview with LVN G on 06/16/2022 at 5:15 PM revealed that she was the nurse for Resident #3. LVN G stated that Resident #3 was not prohibited from dining with other residents, and she does like to dine in the main dining room with other residents on occasions. LVN G stated that Resident #3 does have behaviors of spitting, however she should be allowed the opportunity to dine with others in her home with positive reinforcement, redirection of negative behaviors and encouragement.<BR/>A review of facility policy on Resident Rights revealed that all employees shall treat all residents with respect and dignity, self-determination through choices, communication with and access to people and services at the facility, exercise his or her right as a resident at the facility, be informed about rights, voice grievances and be expected to receive response.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal.<BR/>-The facility failed to ensure the dumpster lids and doors were secured.<BR/>This failure could place residents at risk of infection from improperly disposed garbage.<BR/>Findings include:<BR/>Observation on 08-29-23 at 8:50 am revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster &frac34; full of garbage and the top lid was missing<BR/>Interview on 08-29-23 at 8:50 am, the Food Service Director stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. <BR/>Record review of facility policy and procedure Dispose of Garbage and Refuse dated 8/2017 revealed all garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures read in part .that the Food Service Director will ensure that appropriate lids are closed and provided for the dumpster.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 3 residents reviewed for PASRR services.The facility failed to submit Resident #1's NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health. Record review of Resident #1's face sheet dated 09/03/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included- Profound intellectual disabilities, major depressive disorder, anxiety disorder, bilateral primary osteoarthritis of knee, (tissue wears down) prediabetes, gastric ulcer, anemia (Low Blood count), age-related osteoporosis, and end stage renal diseaseRecord review of Resident #1's PASRR evaluation dated 12/27/25 indicated Resident #1 was positive for Intellectual disability.Record review of PCSP dated 01/29/25 indicated there was a recommendation for Resident #1 to receive a customized manual wheelchair.Record review of Resident #1's clinical records revealed no evidence of the NFSS form. During an interview on 09/03/25 at 1:00PM, the Administrator said MDS Coordinator A was responsible for doing PASRR. She provided During an interview with MDS Coordinator A on 09/03/25 at 1:30PM, she said Resident #1's NFSS was not submitted because at the time of the meeting and recommendation, Resident #1 had no payer source and was not aware that she could submit the NFSS without being approved for Medicaid. She said failure to submit the NFSS, as required, may prevent residents from receiving services needed for their wellbeing. Policy on PASRR submission was requested on 09/04/25 from MDS Coordinator but not provided prior to exit on 09/04/25