Focused Care of Gilmer

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide normal transportation for residents to medical services outside of the facility for 1 of 6 residents (Resident #1) reviewed for transportation. The facility failed to provide transportation for Resident #1 to a doctor's appointment on 10/14/25. This failure could place residents at risk of possible adequate evaluation, hospitalization and unmet needs.Findings include: Record review of Resident #1's face sheet, dated 10/28/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: paraplegia (a condition characterized by the loss or impairment of motor sensory functions in both lower limbs), gastro-esophageal reflux disease (a condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms) and flatulence (the release of gas from the digestive tract through the anus). Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 was usually understood and usually understood by others. Resident #1's BIMs score was a 15, which indicated cognition was intact. Resident #1 required dependent assistance with all ADLs. Record review of Resident #1's care plan, dated 8/4/25, reflected Resident #1 had alteration in bowel elimination related to the history of constipation. The interventions included administer medications as ordered by the MD and monitor effectiveness, notify MD if not effective, encourage fluid intake if not contraindicated by diet or fluid restriction, encourage participation in activities, monitor bowel movements every shift and record and check for impaction as needed, monitor for abdominal distention, bowel sounds, or complaint of abdominal pain or pressure as needed resident complaint and provide adequate time and privacy for elimination. Record review of Resident #1's nurses' notes reflected LVN B documented on 10/02/25 at 11:41 A.M. Resident #1 had an Appointment with on October 14th at 10:00 A.M. Record review of Resident #1's nurses' notes reflected LVN C documented on 10/28/23 at 12:52 P.M. Nurse Practitioner here and talked with resident about consult on 14th with the doctor for colostomy bag for diagnosis of sweal bowel ischemia (a condition where the bile ducts do not get enough blood flow). During an interview on 10/28/25 at 9:32 A.M., a Family Friend said the facility knew about the doctor's appointment for Resident #1 on 10/14/25, at 10:00 A.M. two weeks prior to the day. She said there was no reason why the facility should have let Resident #1 miss her appointment, because the van was at the facility. She said Resident #1 needed to go to her appointment because her physicians' office referred her to the colon surgeon for a colonoscopy (a medical procedure to examine the inside of the large intestine [colon] and rectum using a flexible tube with a camera called a colonoscope.) due to a swollen colon. She said on 10/14/25 during the morning hours, she spoke with the office staff and reminded them about the appointment for Resident #1, then the staff told her they did not have a van driver to take Resident #1 to her appointment. During an interview on 10/28/25 at 11:57 A.M., with Family Member #1, he said Resident #1 had an issue last week when the facility did not take her to her doctor's appointment. He said Resident #1 was very upset she missed her doctor's appointment on 10/14/25. He said he did not know the reason why the facility did not take her to her appointment, but it was concerning, because Resident #1 was so upset. During an interview on 10/28/25 at 1:51 P.M., with Resident #1, she said on 10/14/25, she had an appointment at 10:00 A.M. to go see a surgeon about getting a colostomy. She said the facility knew about her appointment two weeks before the date and that morning they told her they did not have a driver to take her to her appointment. She said that made her so angry, because they knew she needed to go to that appointment and they waited to the last minute to tell her they did not have a driver to take her. During an interview on 10/28/25 at 3:18 P.M., with EDOO, she said the incident happened on 10/14/25 with Resident #1, she wanted to say she had an appointment, and it was an issue with a transportation service, and they canceled . During an interview on 10/28/25 at 3:54 P.M., with EDOO, she said Maintenance Man A was going to drive the facility van the day of Resident #1's appointment, but he called in sick; then the backup driver came in a little later and took another resident to their doctor's appointment. At that point MRC had already rescheduled Resident#1's appointment, because her MD charged a $50.00 fee if appointments were not canceled. She said the backup transportation driver came in after Resident #1's appointment. She said Maintenance Man A notified MRC early that morning he was not going to be able to come in to take Resident #1 to her appointment, but they could not get the backup driver to come in soon enough to get Resident #1 to her appointment. During an interview on 10/28/25 at 4:05 P.M. with MRC, she said she was not sure what happened when Resident #1 missed her appointment on 10/14/25. She said she thought maybe the transportation service was cancelled, due to their van not working. During an interview on 10/28/25 at 5:00 P.M., with MRC she said the facility did have a transportation aide who took the residents to their appointments, but she quit without notice. She said on 10/14/25 they had one person available to drive and he called in. She said Maintenance Man A was the van driver currently. He was currently the only driver they had. She said he contacted her at 7:08 A.M. that morning on 10/14/25 to let her know he was not coming to work, and he was not going to be able to do the transport. She said Resident #1's appointment was scheduled for 10:00 A.M. that morning, so they should have left the facility about 9:15 A.M., but she canceled the appointment. She said prior to canceling Resident #1's appointment, she called a local emergency medical service and local transportation service to see if she could get them to take Resident #1 to her appointment. She said the facility currently did not have a backup driver; they were talking about cross training her to be the backup driver. She said the appointment Resident #1 missed was a consultation for a colostomy (a surgical procedure creating an opening [stoma] in the abdomen to divert waste out of the body and into a collection pouch.) She said she was not sure what Resident #1's previous health was or the reason for getting the colostomy (a surgical procedure creating an opening [stoma] in the abdomen to divert waste out of the body and into a collection pouch. During an interview on 10/28/25 at 5:23 P.M., with RDOCS she said the facility would do whatever was needed to meet the residents' needs. She said she understood things that came up. She said she did not know when the resident was going to the doctor, and she did not know Resident #1's medical history to know what the appointment was for exactly. She said she agreed to a colostomy (a surgical procedure creating an opening (stoma) in the abdomen to divert waste out of the body and into a collection pouch.) consultation was probably a very important appointment. She said she was not sure where LVN C got that diagnosis from in Resident #1's progress notes of sweal bowel ischemia. She said the risk of Resident #1 missing her appointment was if a resident had bile ischemia (damage to the bile ducts caused by insufficient blood supply) it could lead to bile blockage. During an interview on 10/28/25 at 5:33 P.M. with the EDOO she said her expectations were the facility would schedule the appointments and got our residents to their appointments. She said Maintenance Man A was the driver, and he was the only driver they had right now. She said she had an aide who was a PRN driver, and she resigned last week. She said they did not currently have a backup driver. She said the MRC would be trained this week to be the backup driver. She said the risk of Resident #1 missing her appointment was a delay in care. She said the facility was currently running an ad for transportation aid. Record review of the facility's Transportation, Diagnostic Services Policy, revised December 2008, reflected Our facility will assist residents in arranging transportation to/from diagnostic appointments when necessary.Should it become necessary for the facility to provide transportation, the Social Service Designee will be responsible for arranging the transportation through the business office. Record review of the facility's Resident Rights Policy, revised December 2016, Resident Rights reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. f. communication with and access to people and services, both inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 3 of 39 resident rooms (Resident #12, Resident #19 and Resident #30) reviewed for environment.<BR/>The facility did not repair the corner of bedroom wall with metal exposed under the sheetrock or a large hole in the bathroom door for Resident #12.<BR/>The facility did not repair a large hole in the bathroom door or jagged areas noted to the fireproof shield attached to the bedroom door of Resident #19.<BR/>The facility did not repair the wood on the bottom of bedroom window that was broken in half or the broken headboard for Resident #30.<BR/>These failures could place the residents at risk for an unsafe environment.<BR/>Findings include:<BR/>1.Record Review of Resident #12 admission record (no date) indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease), peripheral vascular disease (circulation disorder) and hypertension (high blood pressure). <BR/>Record Review of Resident #12 MDS dated [DATE] indicated that he had a BIMS score of 8 indicating he was mildly impaired. <BR/>During an observation on 09/12/22 at 12:21 p.m., Resident #12 had a large hole in the bathroom door and 1 large amount of metal exposed under the sheetrock of the wall corner in room. Resident #12 was not interviewable. <BR/>2.Record Review of Resident #19 admission record (no date) indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of dementia, muscle weakness and hypertension (high blood pressure). <BR/>Record Review of Resident #19 MDS dated [DATE] indicated a BIMS of 12 for mildly impaired. <BR/>During an observation/interview on 09/12/2022 at 12:08 p.m., Resident #19 had a large hole in the bathroom door and Resident #19 did not know how it got there. The bedroom door had broken/jagged areas noted to the fire-proof shield. Resident #19 stated that he has never gotten hurt on the jagged areas and denied having any issues. <BR/>3.Record Review of Resident #30 admission record (no date) indicated she was a [AGE] year-old female admitted on [DATE] with a diagnosis of chronic kidney disease, seizures, and hypertension (high blood pressure). <BR/>Record Review of Resident #30 MDS dated [DATE] indicated a BIMS score of 6 indicating severely impaired cognition. <BR/>During observation/interview on 09/15/22 at 9:39 a.m. of Resident #30, Resident #30 had broken wood at the bottom of her window in the bedroom. The wood was broken in half and her headboard was broken on the bed. Resident #30 stated her bed catches the window frame and it pulls it off. Resident #30 stated when she is sleeping at night the sound of it cracking wakes her up. Resident #30 stated she reported the broken window frame and broken headboard to the maintenance man 2 weeks ago. Resident #30 stated the broken items do not bother her anymore because it is not her home.<BR/>During interview with Maintenance supervisor on 9/15/22 at 12:38 p.m., Maintenance supervisor stated he checks all the rooms daily. Maintenance supervisor stated, He needs to take care of Resident #19's door and just has not gotten around to it yet. Maintenance supervisor stated he must order the material for the door first and it takes it a while to come in. Maintenance supervisor could not provide proof of order and stated he could not print it out. Maintenance supervisor stated they just recently started keeping a log and most people just tell him when something needs to be fixed and he does it. Maintenance supervisor would not respond to how long the headboard and window frame had been broken in Resident #30's room and would not respond to questions regarding resident harm because of the broken items. Maintenance supervisor stated the broken headboard and window frame could not result in any harm to resident. <BR/>During an interview on 9/15/22 at 9:11 a.m. with LVN A, LVN A stated it is everyone's responsibility to report environmental issues and there is a maintenance log at the nursing station to write down issues. LVN A stated the door shield should have been reported, because the resident could have cut his foot on the jagged areas. LVN A reported she did not know about the door shield or the broken bed frame and window frame. LVN A stated she did not know if the broken window or headboard were recent, but the window is a hazard and can cause splinters and lead to infection.<BR/>During an interview on 9/15/22 at 2:59 p.m. with LVN B (2-10 shift), LVN B stated that she never puts anything in the maintenance log, instead she just tells the Maintenance Supervisor when she sees him down the hall. <BR/>During an interview with the Administrator on 9/15/22 at 2:34 p.m., the Administrator stated she expects the rooms to be in good repair. The Administrator reported it is her responsibility to make sure the Maintenance Supervisor is doing his job. Administrator reported she placed the Maintenance Supervisor on a Performance improvement plan 2 months ago when she started and now a log is kept at the nursing station to report any issues with completion dates. Administrator stated the broken items in resident rooms could cause injury to the residents and stated it is part of the residents right to have a nice environment to live in. <BR/>Record Review of the Maintenance Repair Request dated 8/31/22 to 9/15/22 did not indicate any reports of the broken items in for Resident #12, Resident #19 and Resident #30.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infects for 1 of 6 residents (Resident #28) reviewed for incontinence care. <BR/>The facility did not ensure Resident #28 foley catheter (connection between the urinary bladder and the urethra to drain urine from the bladder) was secured to facilitate urine flow and prevent kinking for four days.<BR/>These failures could place residents at risk for injury and urinary tract infections.<BR/>Findings include:<BR/>Record review of the of the order summary report, dated 9/15/2022, indicated Resident #28 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements), cognitive communication deficit, and pressure ulcer of sacral region, Stage 4. <BR/>Record review of the order summary report dated 9/15/2022, indicated check foley catheter placement, ensure foley was secured via stabilization device to reduce friction/pulling with a start date 4/05/2022. <BR/>Record review of the annual MDS dated [DATE], indicated Resident #28 sometimes understood others and sometimes made herself understood. The assessment did not address Resident #28 BIMS score. The assessment indicated Resident #28 required extensive assistance with bed mobility, dressing and: total dependence with transfers, eating, toileting, personal hygiene, and bathing. The assessment indicated Resident #28 had an indwelling catheter/external catheter for bladder elimination.<BR/>Record review of the undated care plan indicated Resident #28 was incontinent and had a foley catheter due to dx: neuromuscular dysfunction of the bladder and Parkinson's disease. The care plan interventions included, check foley catheter placement, and ensure foley was secured via Velcro strap to reduce friction/pulling every shift. <BR/>During an observation on 9/12/2022 at 11:12 a.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/12/2022 at 4:01 p.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/13/2022 at 8:59 a.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an attempted interview and observation on 9/13/2022 at 11:25 a.m., indicated she was non-interview able. Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/13/2022 at 4:20 p.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/14/2022 at 9:15 a.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/14/2022 at 2:28 p.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an interview and observation on 9/15/2022 at 10:42 a.m., LVN A stated she was Resident #28's 6a-2p charge nurse. LVN A stated the charge nurses were responsible for ensuring Resident #28 catheter was secured. LVN A verbalized she should have ensured the catheter was secured but overlooked it. LVN A stated the aides were also responsible for reporting if there was no catheter securement during repositioning and incontinent care. LVN A stated no one had reported to her that there was no catheter securement. LVN A said the failure of not having the catheter secured cause potential damage, pain, and infection to the site. <BR/>During an interview on 9/15/2022 at 1:19 p.m., CNA G stated she was Resident #28's 6a-2p aide, CNA G stated nurses were responsible for ensuring Resident #28 catheter tubing was secured. CNA G said she noticed Resident #28 catheter tubing not secured when she provided care to Resident #28 on 9/12/2022. CNA G said she reported to the nurse when she noticed the catheter was not secured but could not remember what nurse she told. CNA G said having the catheter secured would prevent the catheter from being pulled out. <BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been at the facility for three days. The Interim DON stated she expected the charge nurses to ensure Resident #28 catheter tubing was secured. The DON stated she expected the CNAs to notify the nurses about the catheter not being secured. The Interim DON stated it would be her responsibility for ensuring foley catheter compliance. The Interim DON stated the failure of not having the catheter tubing secured would be skin irritation and potential damage. The Interim DON stated she would be monitoring through education, visual spots checks, and random questioning. <BR/>Record review of the facility's policy Catheters-Insertion and Care: Indwelling, Straight, Supra-Public, and external, dated 4/2021, indicated . Procedure-Indwelling Catheter-Insertion 7. Attach catheter strap to be leg to assist in securing tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 for 5 residents (Resident #3) reviewed for infection control during medication pass. <BR/>The facility failed to ensure MA A did not touch medications with her bare hand on 11/13/23 at 9:50 a.m. <BR/>This failure could place residents at risk for the spread of infection and cross contamination. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 11/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease in which immune system damages protective covering of the nerves), fibromyalgia (widespread muscle pain and tenderness), and chronic migraine (moderate to severe and intense headache which happens more than half of a month for 3 months). <BR/>Record review of Resident #3's annual MDS assessment, dated 10/12/23, indicated a BIMS score of 15 out of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #3's, undated, care plan indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to a fracture of his arm and terminal multiple sclerosis.<BR/>Record review of the physician order summary for November 2023 indicated Resident #3's received 20 pills or capsules at 9:00 a.m. medication pass. <BR/>During an observation of medication pass on 11/13/23 at 9:50 a.m., MA A performed hygiene then MA A and placed Resident #3's medications into medication cup from touching the blister packets and bottles. MA A placed the medications on a clean tissue,without hand hygiene and started counting them, touching the pills with her bare hands as she placed them back into the medication cup. <BR/>During an interview on 11/14/23 at 11:00 a.m., MA A said she got nervous and touched Resident #3's pills, but she should have used gloves to prevent possible cross-contamination. <BR/>During an interview on 11/14/23 at 2:45 p.m., the DON said a resident's medication/pills should not be touched with a bare hand. She said gloves were to be used to prevent cross contamination. <BR/>During an interview on 11/14/23 at 4:45 p.m., the Administrator said she expected her staff to follow policy and procedures to use gloves to prevent spreading germs or not having medications available. <BR/>Record review of the facility's policy dated 10/25/22 titled Infection Control indicated This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.<BR/>Record review of the facility's policy dated 08/2020 titled Administration Procedures for All Medications indicated . 3. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 2 of 15 residents reviewed for ADLs (Residents #15 and Resident #10 )<BR/>The facility failed to provide assistance with facial hair removal for Resident #15.<BR/>The facility failed to ensure Resident #15's fingernails were clean.<BR/>The facility failed to ensure Resident #10 was routinely showered.<BR/>These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self esteem<BR/>Findings Included<BR/>1. Record review of consolidated physician orders dated 9/15/22 indicated Resident #15 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses COPD, diabetes type 2, dementia, heart failure, lack of coordination, muscle weakness, and tremor.<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #15 usually understood others and was usually understood by others. The MDS indicated Resident #15 had a BIMS score of 11 indicating she was moderatelty cognitive impairment. The MDS indicated Resident #15 was not resistive to evaluation or care. The MDS indicated Resident #15 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. <BR/>Record review of the undated care plan indicated Resident #15 had an impaired cognitive function or impaired thought process and required assistance with decision making. The care plan indicated Resident #15 was not always understood or able to understand verbal and non-verbal expressions. The care plan indicated Resident #15 had an ADL self-care performance deficit with interventions including resident required extensive assistance with personal hygiene. <BR/>Record review of the documentation survey report dated 9/14/22 indicated Resident #15 had only missed 3 of her scheduled showers for August 2022 and September 2022. <BR/>During an observation on 9/12/22 at 1:34 p.m. Resident #15 was observed with chin hair approximately 1cm in length.<BR/>During an observation and interview on 9/12/22 at 3:08 p.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails. Resident #15 said the facility staff had helped her clean out from under her fingernails a couple days ago. <BR/>During an observation on 9/13/22 at 8:22 a.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails.<BR/>During an observation and attempted interview 9/14/22 at 9:08 a.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails. Resident #15 was more confused and unable to answer questions coherently.<BR/>During an observation on 9/14/22 at 1:22 p.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails.<BR/>During an interview on 9/15/22 at 2:12 p.m. RN K said facial hair removal and nail cleaning should be completed on the resident's shower days and as needed. RN K said the importance of facial hair removal on female residents was for self-esteem and dignity. RN K said the importance of cleaning under a resident's fingernails was to decrease infections, sanitary purposes, and irritation to skin and peri-area. RNK said Resident #15 had refused one shower the nurse is aware of. <BR/>During an interview on 9/15/22 at 2:23 p.m. CNA C said facial hair removal and nail cleaning should be done on shower days and as needed. CNA C said facial hair removal was important for female resident's dignity. CNA C said clean nails help prevent the spread of germs and bacteria. CNA C said Resident #15 occasionally refused care.<BR/>During an interview on 9/15/22 at 2:31 p.m. LVN E said facial hair removal and nail cleaning should be performed weekly. LVN F said it was the nurse's responsibility to ensure the CNAs performed facial hair removal and nail cleaning. LVN E said the importance of facial hair removal was for dignity. LVN E said the importance of cleaning nails was to prevent contamination and infections. LVN E said Resident #15 did not refuse nail cleaning or facial hair removal. <BR/>During an interview on 9/15/22 at 3:04 p.m. the interim DON said she started at the facility on 9/13/22. The interim DON said she expected facial hair removal and nail cleaning to be performed as needed. The interim DON said the importance of facial hair removal was to increase self-esteem. The interim DON said the importance of clean nails was for sanitary purposes. <BR/>During an interview on 9/15/22 at 4:12 p.m. the Administrator said she expected residents to have facial hair removal and nail cleaning as needed and on shower days. The Administrator said importance of clean nails was for infection control, resident rights, and personal hygiene. The Administrator said the importance of facial hair removal was for dignity. The Administrator said it was responsibility of CNAs and nurses. <BR/>2. Record review of the order summary report, dated 9/15/2022, indicated Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included absence of right leg below knee, generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), osteoarthritis (degeneration of joint cartilage and the underlying bone), and need for assistance with personal care.<BR/>Record review of the annual MDS dated [DATE], indicated Resident #10 understood others and made herself understood. The assessment indicated Resident #10 was cognitively intact with a BIMS of 15. The assessment indicated Resident #10 did not reject care. The assessment indicated she required extensive assistance with bed mobility, dressing, toileting, personal hygiene, bathing: supervision with eating and: total dependence with transfers. <BR/>Record review of the undated care plan indicated Resident #10 had a self-care deficit and required assistance with ADLs related to disease processes (R BKA). There were inventions that Resident #10 required assistance by staff with showering. Provide a sponge bath when a full bath or shower could not be tolerated. <BR/>Record review of the shower schedule indicated Resident #10 would receive her showers on Tuesdays, Thursdays, and Saturdays. <BR/>Record review of the documentation survey report dated 8/1/2022-8/31/2022 indicated Resident #10 had not received a shower or sponge bath on 8/2, 8/4, 8/9 and 8/13. <BR/>Record review of the documentation survey report dated 9/1/2022-9/30/2022 indicated Resident #10 had not received a shower or sponge bath on 9/1 and 9/6. <BR/>During an interview and observation on 9/13/2022 at 10:11 a.m., Resident #10 stated she did not receive her showers three times a week. Resident #10 stated her last shower was Saturday 9/10/2022. Resident #10 was observed hair disheveled and uncombed. Resident #10 stated not receiving her showers three times a week makes me feel nasty. <BR/>During an interview on 9/15/2022 at 1:31 p.m., CNA F stated she was Resident #10's 6a-2p aide. CNA F stated CNAs were responsible for providing showers. CNA F stated Resident #10 should get a shower on Tuesdays, Thursdays, and Saturdays. CNA F stated Resident #10 had complained to her about not getting her showers three times a week. CNA F stated she had not reported Resident #10 not getting her showers as scheduled to anyone. CNA F stated, It slipped my mind. CNA F stated it had been an issue with providing residents their scheduled showers due to staffing. CNA F stated she had told the administrator and the DON that she could not give scheduled showers due to short staff. CNA F stated she was told by the administrator that she was trying to hire extra help. CNA F stated it was important for residents to get a shower so they could feel clean and prevent a skin infection. <BR/>During an interview on 9/15/2022 at 1:53 p.m., LVN E stated she was Resident #10's 6a-2p charge nurse. LVN E stated CNAs were responsible for providing showers. LVN E stated Resident #10 should get a shower on Tuesdays, Thursdays, and Saturdays. LVN E stated Resident #10 had not complained to her about not received her showers. LVN E stated she had never been told by the aides that they were not able to provide residents their showers. LVN E stated there had been issues with residents especially new admissions not receiving their showers because the shower schedule was not updated when they arrived at the facility. LVN E stated the previous DON created a shower communication sheet for the aide and nurse to sign to ensure showers have been given. LVN E stated she could not remember if there had been any shower communication sheets missing for Resident #10. LVN E stated, I had not personally reported this issue to anyone. LVN E stated it was important for residents to get receive a shower to prevent skin breakdown, UTI and it was also a dignity issue. <BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been at the facility for three days. She stated she expected Resident #10 showers to be completed as scheduled. The Interim DON stated CNAs were responsible for providing showers to residents and the nurses were responsible for monitoring to ensure there been done. The Interim DON stated it would be her responsibility for ensuring ADL compliance. The Interim DON said the importance of providing showers were to make the resident feel clean and prevent skin infections. The Interim DON stated she would be monitoring through education, visual spots checks, and random questioning. <BR/>During an interview on 9/15/2022 at 3:51 p.m., the Administrator stated she had only been here for two weeks, but she expected the residents to be bathed at least three times weekly. The Administrator stated it had not been reported to her that showers were not giving due to staff. The Administrator stated she was in the process of hiring more CNAs to help with residents' care. The Administrator stated the Interim DON would be monitoring by education, in-services, and spot checks to ensure those tasks were being completed. <BR/>During an interview on 9/15/2022 at 3:18 p.m., Resident #10's shower communication sheet for the month of August and September was requested from the Interim DON but was provided upon exit. <BR/>During an interview on 9/15/2022 at 5:39 p.m., the Administrator stated there was no policy related to ADLs.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of each resident for one of six of residents (Resident #1) reviewed for medications.<BR/>LVN A failed to ensure all medications were administered according to facility procedure when she left a cup of medication with Resident #1 and failed to observe Resident #1 take the medication.<BR/>This failure could place residents at risk for not receiving the therapeutic benefits from medications. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 07/30/23 showed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses of Multiple Sclerosis, Displace Spinal Fracture, Muscle Weakness, Difficulty Walking, Morbid obesity, Asthma, Neuromuscular Dysfunction of Bladder, Chronic Atrial fibrillation, and Fibromyalgia.<BR/>Review of a MDS dated [DATE], showed Resident #1 was recently admitted on [DATE] with a BIMS score of 15 which indicated resident #1 was alert to person, place. and time.<BR/>Review of a care plan dated 06/22/23 did not show Resident #1had been assessed for self-medication<BR/>Review of consolidated Physician's orders for July 2023 showed Resident #1 was prescribed the following medications to be administered at 9:00 a.m.: <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. Give 2 capsule by mouth one time daily for depression. <BR/>*Fexofenadine HCI Tablet 180 mg. Give 1 tablet by mouth one time a day for allergies. <BR/>*Guaifenesin Tablet. Give 1200 mg y mouth one time a day for allergies. <BR/>*Hydrochlorothiazide Tablet 12.5 mg. Give 1 tablet by mouth one time a day for edema. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, give 2 tablets by mouth one time a say for supplement. DO NOT CRUSH. Administer with a snack or full glass of water.<BR/>*Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for difficulty breathing.<BR/>*Verapamil HCI Tablet 40 mg Give 1 tablet by mouth one time a day for Atrial fibrillation (Heart condition), hold for systolic (Blood Pressure) less than 100 no restrictions on DPB. (Diffuse pan-bronchiolitis (DPB) is a chronic inflammatory airway disease which was lethal in the past despite combined treatment with antibiotics)<BR/>*Buspirone HCI Tablet 5 mg Give 2 Tablets by mouth two time a day for anxiety.<BR/>*MiraLAX Oral Powder 17 GM/Scoop. Give one scoop by mouth two times a day for constipation.<BR/>*Pregabalin Capsule 200 mg. (A strong narcotic pain killer) Give 1 Capsule by mouth two time a day for pain. <BR/>*Prilosec OTC Tablet Delayed Release. Give two tables by mouth 2 times a day for reflux. Do not crush or chew. <BR/>*Senna Tablet 8.6 mg. Give 2 tablets by mouth 2 times a day to prevent constipation, and <BR/>*Valacyclovir HCI Tablet 1 GM Give 1 tablet by month two times a day for MS (Multiple Sclerosis). <BR/>Review of Medication Administration Records dated 07/30/23 at 9:00 a.m. showed the following medication had been administered by LVN A. <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. <BR/>*Fexofenadine HCI Tablet 180 mg. <BR/>*Guaifenesin Tablet. 1200 mg <BR/>*Hydrochlorothiazide Tablet 12.5 mg. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, <BR/>*Prednisone Oral Tablet 20 MG.<BR/>*Verapamil HCI Tablet 40 MG <BR/>*Buspirone HCI Tablet 5 MG <BR/>*MiraLAX Oral Powder 17 GM/Scoop. <BR/>*Pregabalin Capsule 200 MG. <BR/>*Prilosec OTC Tablet Delayed Release. <BR/>*Senna Tablet 8.6 MG, and <BR/>*Valacyclovir HCI Tablet 1 GM.<BR/>During an observation and interview on 07/30/23 at 10:05 a.m. Resident #1 was laying on her back in her bed. There was a plastic cup with multiple pills pouring out of the cup on to the blanket which was covering Resident #1's stomach. Resident # 1 said LVN A had left the cup of medication for her to take. Resident #1 said she asked LVN A to leave the medication and she would take it in a little while. <BR/>During an interview on 07/30/23 at 10:10 a.m. LVN A said she left the cup of medication with Resident #1 to take. LVN A said Resident #1 is in her right mind and she feels okay leaving the medications with Resident #1 to take. LVN said she documented Resident #1 was administered the medication in the electronic MAR, even though she did not witness Resident #1 take the medication. LVN said the medication is to be given at 9:00 a.m.<BR/>During an interview 07/31/23 at 10:35 a.m. the DON said LVN A should not have left the medication with Resident #1. The DON said it is the policy of the facility to watch a resident swallow their medication. The DON said there is a Medication Self-Administration Screening that could be completed to see if a resident is able to administer their own medication, but there had been no such screening for Resident #1. The DON stated LVN A should not have left the cup of pills with Resident #1, even though Resident #1 has a BIMS score of 15 and is totally alert and able to make her own decisions.<BR/>Review of a pharmacy policy dated 08-2018 showed Administer .remain with the resident while medication is swallowed. Exercise caution with residents who have difficulty with swallowing. Do not leave medications at the bedside, unless specifically order by the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate less than 5% during the medication pass, in which there were 5 errors out of 30 opportunities, resulting in a 16.67% error rate for 3 of 3 residents (Resident #27, Resident #7, and Resident #28) observed for medication administration.<BR/>LVN S did not administer Resident #27's Vitamin B12 (a medication used to treat Vitamin B12 deficiency, osteoporosis, and fatigue). <BR/>LVN E did not administer Resident #7's Vitamin B12 (a medication used to treat Vitamin B12 deficiency, osteoporosis, and fatigue) or Calcium Carbonate (a medication used to treat acid reflux, upset stomach, indigestion, and heartburn).<BR/>LVN E did not administer the correct dose of Resident #7's Vitamin D3 (a medication needed in the body for healthy bones, muscles, nerves, and to support the immune system).<BR/>LVN A did not administer Resident #28's Potassium (a medication used to treat low potassium or to prevent potassium levels from dropping to low due to certain medical conditions or medications).<BR/>These failures could place residents at risk for avoidable complications and symptoms of their disease process.<BR/>Finding Include:<BR/>Error #1 <BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #27 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including vitamin deficiency. The physician orders indicated Resident #27 had an order starting on 9/01/21 for Vitamin B12 1000 mcg (micrograms) to be given by mouth twice a day for vitamin deficiency.<BR/>During an observation and interview on 9/13/22 at 7:38 a.m. LVN S did not administer the prescribed Vitamin B12 to Resident #15. LVN S said she did not have any Vitamin B12 on her medication cart but was going to look in the medication room. LVN S said there was not any Vitamin B12 in the medication room to administer to Resident #15. <BR/>Error #2, #3, and #4<BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #7 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including Vitamin B12 deficiency, Vitamin D deficiency, and gastro-esophageal reflux (when the stomach acid repeatedly flows back into the tube connecting the mouth and stomach). The physician orders indicated Resident #7 had an order starting on 6/24/22 for Calcium Carbonate 600mg (milligrams) by mouth twice a day for health maintenance. The physician orders indicated Resident #7 had an order starting 6/25/22 for Vitamin B12 500mcg by mouth daily for health maintenance. The physician orders indicated Resident #7 had an order for Vitamin D3 3000 units by mouth daily for a supplement. <BR/>Record review of the care plan (revision dated unknown) indicated Resident #7 was at risk for altered nutritional status and altered labs related to diagnoses, medications, diet, and appetite with interventions including administer medication as ordered. <BR/>During an observation on 9/13/22 at 7:57 a.m. LVN E did not administer Resident #7's Calcium Carbonate or Vitamin B12. LVN E administered Resident #7 Vitamin D3 2000 units and not the prescribed Vitamin D3 3000 units. <BR/>During an interview on 9/13/22 at 12:38 p.m. LVN E said she did not have any Vitamin B12 500mcg to administer to Resident #7. LVN E she gives medications when they pop up on the medication administration record to be given. LVN E said she showed the surveyor all Resident #7's medications as she put them in the medication cup. LVN E said she was unsure as to whether she gave Resident #7 Calcium Carbonate this morning. <BR/>Error #5<BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #28 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including hypokalemia (decreased potassium level). The physician orders indicated Resident #28 had an order starting on 9/13/22 for Potassium Chloride 20 MEQ (milli-equivalents) via G-tube one time a day for hypokalemia. <BR/>During an observation on 9/15/22 at 8:53 a.m. LVN A did not administer Resident #28's Potassium Chloride as prescribed. <BR/>During an interview on 9/15/22 at 2:12 p.m. LVN K said medications should not be missed including vitamins. LVN K said the importance of not missing medication was due to physician orders and vitamins like B12 and D3 can affect bones, energy, and immune system. <BR/>During an interview on 9/15/22 at 2:31 p.m. LVN E said medications on the medication administration record should be given if available. LVN E said if a medication was not available the nurse should look in medication room and ask the other nurse if they have any of that medication. LVN E said the importance of not missing ordered vitamins was for bone health and immunity. LVN E said the facility was out of B12 500mcg. LVN E said she did not recall omitting Resident #7's Calcium Carbonate or administering the wrong dose of Vitamin D3. <BR/>During an interview on 9/15/22 at 03:04 p.m. the interim DON said she had started at the facility on 9/13/22. The interim DON said all medications including vitamin should be administered as ordered. The interim DON said the importance of vitamins was wound healing, anemia, and bone health. The interim DON said the importance of potassium was for heart health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 3 of 13 residents (Residents #10, #11 and #12) reviewed for personal food safety. <BR/>The facility did not implement their own food from outside sources policy by discarding foods that shows obvious signs of potential foodborne danger. <BR/>The facility did not implement their own food from outside sources policy related to personal refrigerators by managing appropriate temperatures. <BR/>This failure could place the residents at risk for food borne illnesses.<BR/>Findings include:<BR/>1. Record review of the of the order summary report, dated 9/15/2022, indicated Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included need for assistance with personal care.<BR/>Record review of the annual MDS dated [DATE], indicated Resident #10 understood others and made herself understood. The assessment indicated Resident #10 was cognitively intact with a BIMS of 15. The assessment indicated Resident #10 did not reject care. The assessment indicated she required supervision with eating, and total dependence with transfers. <BR/>During an observation on 9/12/2022 at 12:28 p.m., Resident #10's mini fridge was initialed that the temperature was checked on 9/1/22, 9/2/22 and 9/3/22. <BR/>During an interview and observation on 9/13/2022 at 10:15 a.m., Resident #10 stated she could not remember the last time staff cleaned or checked her refrigerator. Resident #10's personal refrigerator had a thermometer in place with a clear container labeled banana pudding dated 6/22/2022. The mini fridge was initialed that the temperature was checked on 9/1/22, 9/2/22 and 9/3/22. <BR/>During an observation on 9/14/2022 at 8:45 a.m., Resident #10's personal refrigerator had a thermometer in place with a clear container labeled banana pudding dated 6/22/2022. The mini fridge was initialed that the temperature was checked on 9/1/22, 9/2/2022 and 9/3/2022. <BR/>During an interview on 9/15/2022 at 1:41 p.m., the Food Service Supervisor stated dietary and housekeeping staff were responsible for checking the temperatures and discarding expired items. He stated, We had gotten slacked on that. The Food Service Supervisor was unable to verbalized how often the mini fridge should be checked for expired items but stated that staff should be checking the temperature log daily. He stated this failure could place residents at risk for food borne illness. <BR/>2. Record review of the face sheet dated 9/15/22 indicated Resident #11 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including fracture of the left femur, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), fracture of the left clavicle, fracture of the right femur, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and muscle weakness.<BR/>Record review of the comprehensive MDS dated [DATE] indicated Resident #11 was usually understood by others and usually understood others. The MDS indicated Resident #11 had a BIMS assessment had not been completed. <BR/>Record review of the temperature log date September 2022 for Resident #11's personal refrigerator indicated the temperatures had been monitored on September 1, 2, and 3, 2022. <BR/>During an observation and interview on 9/12/22 at 10:49 a.m. Resident #11's personal refrigerator was observed with and incomplete temperature log for his personal refrigerator. Observations indicated Resident #11's personal refrigerator had a thermometer in place and no expired foods were observed. Resident #11 said he did not know the temperature log was on the side of personal refrigerator. Resident #11 said he did not know if the facility had been checking the temperature on his personal refrigerator. <BR/>During an observation on 9/13/22 at 3:12 p.m. Resident #11's personal refrigerator was observed with and incomplete temperature log for his personal refrigerator.<BR/>During an observation on 9/14/22 at 9:12 a.m. Resident #11's personal refrigerator was observed with and incomplete temperature log for his personal refrigerator.<BR/>3. Record Review of Resident #12's admission record (no date) indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease), peripheral vascular disease (circulation disorder) and hypertension (high blood pressure). <BR/>Record Review of Resident #12's MDS dated [DATE] indicated that he had a BIMS score of 8 indicating he was mildly impaired. <BR/>During an observation on 9/12/22 at 12:21 p.m., Resident #12's mini fridge was initialed that the temperature was checked on 09/01/22, 09/02/22 and 09/03/22. <BR/>During an observation on 09/13/22 at 09:28 a.m., Resident #12's mini fridge was initialed that the temperature was checked on 09/01/22, 09/02/22 and 09/03/22. <BR/>During an observation on 9/14/22 at 1:42 p.m., Resident #12's mini fridge was initialed that the temperature was checked on 09/01/22, 09/02/22 and 09/03/22. Mini fridge had water, V8, and baby food inside.<BR/>During an interview on 9/15/22 at 9:11 a.m. with LVN A, LVN A stated that she does not know who is responsible for checking the mini fridge temperatures. LVN A stated she has worked night and day shift and does not check the mini fridge temperatures. LVN A stated that the mini fridge temperatures should be checked so the food does not spoil, or resident's do not get food poisoning.<BR/>During interview on 9/15/22 at 2:59 p.m. with LVN B, LVN B stated the night nurse is responsible for mini fridge temperature checks.<BR/>During an interview on 9/15/22 at 12:50 p.m. with the housekeeping supervisor, the housekeeping supervisor stated the DON and ADON were responsible for checking the temperatures in the mini fridges. Housekeeping Supervisor stated the DON recently left and the ADON has been out on leave. The Housekeeping Supervisor stated he is responsible for the temperature checks on the mini fridges now and, whatever staff checks the mini fridge temperatures should date and initial that the temperature check was done because it is a community effort. The Housekeeping Supervisor stated management makes daily rounds to check resident rooms, including the mini fridge temperatures. Housekeeping Supervisor stated that checking the mini fridge temperatures were important to make sure the resident's do not get bad food. <BR/>During an interview on 9/15/22 at 4:20 p.m. with the DON, the DON reported she does not know the process regarding mini fridges at the facility because she has only been at the facility for 2 days, but she thinks it is housekeeping. DON stated that she expects housekeeping to monitor the mini fridge temperatures and stated she is responsible for making sure housekeeping is checking them. <BR/>During an interview on 9/15/22 at 2:34 p.m. with ADM, the ADM stated housekeeping is responsible for monitoring the mini fridges daily and she expects them to be done. ADM stated the Housekeeping Supervisor keeps a binder in his office with the temperature checks on them. The ADM stated she is responsible for the Housekeeping Supervisor completing the temperature checks on the mini fridges. ADM stated that Department Mangers should have double checked the rooms and mini fridges during their rounds. ADM stated that if temperature checks are not complete, the food in the mini fridge can spoil or cause illness to residents.<BR/>Record Review of the policy on Food from Outside Sources last revised on 03/2021 indicated that #2. Community personnel will be responsible for the managing of appropriate temperatures and food stored in the resident's refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 for 5 residents (Resident #3) reviewed for infection control during medication pass. <BR/>The facility failed to ensure MA A did not touch medications with her bare hand on 11/13/23 at 9:50 a.m. <BR/>This failure could place residents at risk for the spread of infection and cross contamination. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 11/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease in which immune system damages protective covering of the nerves), fibromyalgia (widespread muscle pain and tenderness), and chronic migraine (moderate to severe and intense headache which happens more than half of a month for 3 months). <BR/>Record review of Resident #3's annual MDS assessment, dated 10/12/23, indicated a BIMS score of 15 out of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #3's, undated, care plan indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to a fracture of his arm and terminal multiple sclerosis.<BR/>Record review of the physician order summary for November 2023 indicated Resident #3's received 20 pills or capsules at 9:00 a.m. medication pass. <BR/>During an observation of medication pass on 11/13/23 at 9:50 a.m., MA A performed hygiene then MA A and placed Resident #3's medications into medication cup from touching the blister packets and bottles. MA A placed the medications on a clean tissue,without hand hygiene and started counting them, touching the pills with her bare hands as she placed them back into the medication cup. <BR/>During an interview on 11/14/23 at 11:00 a.m., MA A said she got nervous and touched Resident #3's pills, but she should have used gloves to prevent possible cross-contamination. <BR/>During an interview on 11/14/23 at 2:45 p.m., the DON said a resident's medication/pills should not be touched with a bare hand. She said gloves were to be used to prevent cross contamination. <BR/>During an interview on 11/14/23 at 4:45 p.m., the Administrator said she expected her staff to follow policy and procedures to use gloves to prevent spreading germs or not having medications available. <BR/>Record review of the facility's policy dated 10/25/22 titled Infection Control indicated This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.<BR/>Record review of the facility's policy dated 08/2020 titled Administration Procedures for All Medications indicated . 3. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 18 residents (Residents #107 and #110) reviewed for call lights .<BR/>The facility failed to ensure Residents #107 and #110's bathrooms had a call light pull cord on 12/02/2024 and 12/03/2024.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings include:<BR/>1. Record review of Resident #107's facility face sheet, dated 12/04/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #107 had a diagnosis which included hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness following a stroke).<BR/>Record review of Resident #107's comprehensive care plan, dated 11/25/2024, revealed Resident#107 was high risk for increased falls and fractures and ensure resident's call light was within reach and encourage the resident to use it for assistance as needed. <BR/>Record review of Resident #107's admission MDS assessment, dated 11/29/2024, revealed Resident #107 had a BIMS of 14, which indicated intact cognition. Resident #107 was continent of bowel and bladder and required moderate assistance with toileting.<BR/>2. Record review of Resident #110's facility face sheet, dated 12/04/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #110 had a diagnosis which included chronic obstructive pulmonary disease (lung disease that causes shortness of breath).<BR/>Record review of Resident #110's comprehensive care plan, dated 11/20/2024, revealed Resident #110 was a moderate risk for increased falls and ensure resident's call light was within reach and encourage the resident to use it for assistance as needed.<BR/>Record review of Resident #110's admission MDS assessment, dated 11/25/2024, revealed Resident #110 had a BIMS of 15, which indicated intact cognition. Resident #110 was continent of bowel and bladder and was dependent on toileting.<BR/>During an observation on 12/02/24 at 11:18 AM revealed Resident #107 and Resident #110 did not have a call light pull cord attached to their bathroom call system. <BR/>During an observation on 12/03/24 at 8:22 AM revealed Resident # 107's bathroom call light did not have a pull cord. <BR/>During an observation on 12/03/24 at 8:24 AM revealed Resident #110 was observed in her bathroom alone performing ADL care and there was no bathroom call light pull cord in place . <BR/>During an interview on 12/02/24 at 2:19 PM, Resident #107 said he used his bathroom and had to push the button for help but if he was to fall, he did not know how he would get help other than yell. <BR/>During an interview on 12/02/24 at 2:30 PM, Resident #110 said she used her bathroom and had not noticed there was no cord in the bathroom. She said if she were to fall, she would have to yell for help if there was no cord to pull.<BR/>During an interview on 12/03/24 at 9:18 AM, CNA B said she had been a CNA for 18 years and had worked at the facility for 3 years. She said call lights should be checked on all rounds by anyone who entered the residents room. She said she had not noticed there was no cord to the call light in Resident #107 and #110's bathrooms. She said both residents used their bathroom and if they were to fall, they would not be able to get help, delaying care. She said she thought the Maintenance Director was responsible for checking call lights and installing the pull cords. She said there was a work order book for maintenance, but she was not sure if anyone had notified him or the missing pull cords. <BR/>During an interview on 12/03/24 at 12:05 PM, the Maintenance Director said he was hired June 2023 and was responsible for ensuring all call lights in the bedrooms and bathrooms were in working order. He said he was not aware of the missing cords in the bathrooms for Residents #107 and #110 and no one had put in a work order. He said he checked the call lights in the facility at least monthly. He said not having a call light pull cord in the bathroom could delay care if the resident were to fall and could not call for help.<BR/>During an interview on 12/04/24 at 11:55 AM, the Administrator said the Maintenance Director was responsible for making rounds on call lights and the staff should also be completing work orders for any repairs and replacement of call light cords. She said call lights should be checked daily by all staff. She said if call lights were not able to be activated it could cause a delay in staff getting to the resident for care and expected all bathrooms had a call light cord, were monitored daily, and reported to maintenance if there was a problem. <BR/>Record review of the facility's policy titled Bedrooms, dated May 2017, indicated, .all resident rooms are equipped with a resident call system that allows residents to call for staff assistance

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were free from neglect 1 of 3 (Resident #1) residents reviewed for neglect.<BR/>The facility failed to have an effective system in place for referrals resulting in Resident #1 not receiving a referral to the vascular specialist as ordered by his primary care physician and having an above the knee amputation to his right leg.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>This failure could result in residents not being seen by physicians when needed and lead to further decline in health status, harm, or death.<BR/>Findings Include:<BR/>1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking.<BR/>Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. <BR/>Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities.<BR/>Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. <BR/>Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease.<BR/>Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis.<BR/>Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task.<BR/>Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1. The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back.<BR/>Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress note indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. <BR/>Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. <BR/>Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. <BR/>Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. <BR/>During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral.<BR/>During an interview on 3/31/23 at 2:29 pm, the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg.<BR/>During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said they were booked and short-handed.<BR/>During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously.<BR/>During an interview on 3/31/23 at 3:32 pm, the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month.<BR/>During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes.<BR/>During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist.<BR/>During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals.<BR/>During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals.<BR/>During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals, the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist, the facility would call to start the process of getting the appointment made. <BR/>The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m.<BR/>The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: <BR/>In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. <BR/>To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. <BR/>In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. <BR/>Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes:<BR/>Referral Policy: <BR/>1. <BR/>Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. <BR/>2. <BR/>The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral.<BR/>3. <BR/>Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation.<BR/>4. <BR/>Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. <BR/>5. <BR/>Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. <BR/>In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. <BR/>Validation/Monitoring Tools<BR/>Director of Clinical Operations or Designee will validate staff knowledge base through random questioning.<BR/>Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21.<BR/>Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. <BR/>On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted.<BR/>Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner.<BR/>Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. <BR/>Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy<BR/>Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LV C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy.<BR/>Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists.<BR/>On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #4) reviewed for MDS assessment accuracy. <BR/>The facility did not accurately document Resident #4's weight and inaccurately indicated weight loss on her MDSs dated 10/07/22, 12/16/22, 02/07/23, 05/05/23, and 08/05/23. <BR/>This failure could place residents at risk of not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Record review of a face sheet dated 09/27/23 indicated Resident #4 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), type 1 diabetes (chronic condition in which the pancreas produces little or no insulin) and obesity (overweight).<BR/>Record review of the physician orders for November 2023 indicated Resident #4 had an order dated 07/31/22 for a carbohydrate controlled no added salt diet. <BR/>Record review of an MDS dated [DATE] indicated Resident #4 had clear speech, was able to make herself understood, and could understand others. She was cognitively intact with a BIMS score of 15 out of 15. She required supervision with set up help only for eating. She had no swallowing issues, received a therapeutic diet. She had no denture issues, mouth or facial pain, or discomfort/difficulty chewing. <BR/>During an observation and interview on 11/13/23 beginning at 09:04 a.m., Resident #4 was lying in bed watching television. She was a large person. She said she was doing fine. She said she had no issues with eating. She said she would lose a few pounds here and there, but she had not lost a large amount of weight. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS section was signed by the MDS Nurse on 10/21/22.<BR/>Record review of the EMR indicated on 10/02/22 Resident #4 weighed 240.6 pounds. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS section was signed by the MDS Nurse on 12/22/22.<BR/>Record review of the EMR Weights/Vitals section indicated Resident #4 had no weight documented for December 2022. <BR/>Record review of an annual MDS dated [DATE] indicated Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS section was signed by the MDS Nurse on 02/09/23. <BR/>Record review of the EMR Weights/Vitals section indicated on 02/02/23 Resident #4 weighed 230 pounds. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS was signed by the MDS Nurse on 05/25/23. <BR/>Record review of the EMR Weights/Vitals section indicated on 05/08/23 Resident #4 weighed 223.5 pounds. <BR/>Record review of a quarterly MDS dated [DATE] Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS was signed by the MDS Nurse on 08/14/23.<BR/>Record review of the EMR Weights/Vitals section indicated on 08/04/23 Resident #4 weighed 221 pounds. <BR/>During an interview on 11/14/23 at 02:47 p.m., the MDS Nurse said she would look at the resident chart to obtain the weight for the month to place on the MDS. She said the weights would carry over from the previous MDS. She said she did not check the weights and change them for the MDSs on Resident #4. She said the incorrect documented weight would make the MDS inaccurate. <BR/>During an interview on 11/15/23 at 12:37 p.m., the Corporate Regional Director of Operations said MDSs carried over the previous weights so the MDS Nurse was supposed to change the weight according to the resident's current weight in the chart. She said the MDS nurse evidently did not change the weights for Resident #4 on the MDSs. <BR/>During an interview on 11/15/23 at 12:45 p.m., the DON said they did not have an MDS policy. She said they followed the guidance of the current RAI Manual for accuracy of the MDS. <BR/>Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled,K0200: Height and Weight indicated B. Weight (in pounds). Base weight or most recent measure in last 30 days; measure weight consistently; according to standard facility practice (e.g., in a.m., after voiding, before meal, with shoes off, etc.) Steps for Assessment for K0200B, Weight: 1. Base weight or most recent measure in last 30 days. 2. Measure weight consistently in accordance to facility policy and procedure, which should reflect current standards of practice (shoes off, etc). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days if the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were screened for 1 of 6 residents reviewed for PASRR (Resident #42) <BR/>The facility did not have an accurate PASRR level 1 screening for Resident #42 upon admission, therefore a PASRR Evaluation was not conducted. <BR/>This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. <BR/>Findings included: <BR/>Record review of a face sheet dated 11/14/23 indicated Resident #42 was a [AGE] year-old male admitted [DATE] and readmitted [DATE]. He had diagnoses of depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent and excessive worry that interferes with daily activities), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). There were no diagnoses of dementia or Alzheimer's disease. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #42 was cognitively intact with a BIMS score of 15 out of 15; he had no diagnoses of dementia or Alzheimer's disease; he had diagnoses of anxiety disorder, depression, and bipolar disorder; and he received and antidepressant medication. <BR/>Record review of a PASRR Level 1 Screening completed by the transferring facility dated 02/27/23 indicated Resident #42 was negative for mental illness. The sections for Exempted Hospital Discharge or Expedited admission were both marked no. <BR/>Record review of Resident #42's EMR from 02/28/23 through 11/15/23 concluded there was no PASRR Level II (PE) Evaluation or Form 1012 (Mental Illness/Dementia Resident Review) included. <BR/>During an interview on 11/13/23 at 03:20 p.m., the MDS Nurse said all resident referrals went through a corporate clinical team to determine if the resident met criteria for a P1 to be positive for MI, ID, or DD. She said she would usually check behind them to ensure the information was correct. She said Resident #42 was missed by the clinical team and herself. <BR/>During an interview on 11/14/23 at 03:17 p.m. the MDS Nurse said Resident #42 was missed as having a mental illness with no diagnoses of Alzheimer's disease or dementia and she was instructed to fill out form 1012 to correct the negative PASRR 1. She said Resident #42 would be seen by the LMHA to be evaluated for MI to determine if he met the criteria for PASRR positive She said the potential risk of a resident not being identified as having MI, ID, or DD was a resident might not receive services they deserved or needed.<BR/>During an interview on 11/15/23 at 2:30 p.m., the DON said they did not have a PASRR policy. She said they followed what PASRR and the RAI Manual regarding PASRR. <BR/>Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 10 residents reviewed for comprehensive care plans. (Residents #6 and #42) <BR/>The facility did not develop a care plan for Resident #6 addressing his smoking, behaviors, resistance to care, or his full code status upon readmission. <BR/>The facility did not develop a care plan for Resident #42 addressing his bipolar disorder diagnosis, Factor 5 Leiden mutation diagnosis, or anticoagulant medication upon admission.<BR/>This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 10/23/23 indicated Resident #6 was an [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), respiratory failure (a serious condition that makes it difficult to breathe on your own), hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff and unable to fill properly), history of tobacco abuse and dependence (smoker), and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe).<BR/>Record review of the admission MDS dated [DATE] indicated Resident #6 was marked yes for current tobacco use. <BR/>Record review of physician orders for November 2023 indicated Resident #6 had an order dated 11/09/23 for Full Code status and to monitor for behaviors due to diagnosis of paranoid schizophrenia (a mental illness that can cause severe disruptions in a person's life because it affects their connection to reality due to delusions and hallucinations).<BR/>Record review of Progress Notes with nursing documentation for Resident #6 indicated:<BR/>* on 10/22/23 at 11:45 a.m. he said another resident came by his motorized wheelchair and tried to hit him. He yelled and cussed at the other resident, grabbed the other resident's Foley catheter tubing, and threatened to kill the other resident. <BR/>* on 10/23/23 at 10:30 a.m. he was smiling and talking to himself.<BR/>* on 10/23/23 at 04:10 p.m. physician was notified of the resident talking to himself and diagnosis of paranoid schizophrenia. Physician said he would evaluate the resident at that time. <BR/>* on 10/24/23 at 03:54 p.m. an order was received to administer Trazadone (antidepressant) at bedtime for sleeplessness and an order to restart Geodon (antipsychotic) for paranoid schizophrenia. <BR/>* on 10/25/23 at 07:20 a.m. he went into another resident room and cussed the resident. He yelled and said he would kill the other resident. Staff intervened and removed him from the other resident room. NP was notified. <BR/>*on 10/25/23 at 08:15 a.m. an order was received to send him to the ER for evaluation. <BR/>*on 10/25/23 at 09:40 a.m. ER physician notified of resident diagnosis of paranoid schizophrenia and medications started. Also ER physician was made aware of the resident's increased in physical and verbally aggressive behaviors towards other resident in facility and threats to kill other resident. <BR/>*on 10/27/23 at 12:57 p.m. facility spoke with representative of behavioral health center where resident was admitted . <BR/>* on 11/10/23 at 01:38 p.m. he refused the Nicotine patch. He said he smoked and did not need the patch.<BR/>* on 11/12/23 at 09:04 p.m. he threatened multiple residents. He was seen yelling at the walls. He would go into his room yelling with no one in his room. He said people were going into his room but no one had been in the room. He refused his medications. An order was received to send him to the ER for readmission to the psychiatric hospital. EMS arrived to transport him and he slammed the door saying he was not leaving. The police were contacted and came. They spoke with him which he calmed down. He was heard yelling in his room but was not threatening anyone. <BR/>* on 11/13/23 at 03:14 p.m. he was heard arguing in his room with someone who was not present about money and paying them 100,000 dollars and killing someone. <BR/>* on 11/13/23 at 05:07 a.m. the nurse smelled smoke in the hallway. He had a pack of cigarettes lying on his bedside table. He said he was not smoking but nurse could smell smoke in his room. The nurse removed the cigarettes and lighter from his room telling him they would be in the cigarette box. He tried to get the cigarette box but the nurse blocked the drawer where it was located. He was told it was illegal to smoke in the building because it was a nursing home which he cussed at the nurse. <BR/>* on 11/14/23 at 12:00 a.m. resident became angry and did not want to go to his scheduled appointment. Resident attempted to use a wheelchair to barricade his door. The wheelchair was removed for safety.<BR/>* on 11/15/23 at 01:03 a.m. he had wheelchair, bed side table, and chair attempting to barricade his door. They were removed from the door for safety. <BR/>Record review of Resident #6's care plans dated 11/09/23 indicated there were no care plans addressing his full code status, his smoking, his behaviors, or his resistance to care. <BR/>During an interview on 11/13/23 at 01:30 p.m. MA A said Resident #6 was known to have behaviors. She said he was physically and verbally aggressive towards other residents and staff. She said he had been started on new medications because of his behaviors.<BR/>During an interview on 11/15/23 at 12:00 p.m. CNA D said Resident #6 was known to have behaviors of cussing at other residents and staff at times She said he was sent out to the psychiatric hospital for the behaviors. <BR/>During an interview on 11/15/23 at 11:45 a.m., the DON said she and the MDS Nurse were responsible for the care plans. She said she cancelled all of Resident #6's previous care plans because he was discharged to the psychiatric hospital. She said she did not realize he had to be discharged for 30 days or more before she was to start a new care plan. She said a new care plan was started on Resident #6 but it did not address his smoking, full code status, or behaviors. She said he still smoked, he was a full code, he was still having behaviors, and he still resisted care. <BR/>2. Record review of a face sheet dated 11/14/23 indicated Resident #42 was a [AGE] year-old male admitted [DATE] and readmitted [DATE]. He had diagnoses of bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and a hereditary deficiency of other clotting factor. <BR/>Record review of a hospital History and Physical dated 02/18/23 indicated Resident #42 had a diagnosis of Factor 5 Leiden mutation (hereditary deficiency of blood clotting factor). <BR/>Record review of the admission MDS dated [DATE] indicated Resident #42 had a diagnosis of bipolar disorder and a diagnosis of hereditary deficiency of other clotting factor (Factor 5 Leiden mutation). <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #42 had a diagnosis of bipolar disorder, a diagnosis of hereditary deficiency of other clotting factor, and received anticoagulant medication.<BR/>Record review of physician orders for November 2023 indicated Resident #42 had an order dated:<BR/>* 03/01/23 to monitor for signs and symptoms of adverse reaction every shift for warfarin (anti-coagulant) <BR/>* 10/23/23 for warfarin 3 mg daily every Monday, Wednesday, and Friday.<BR/>* 10/23/23 for warfarin 4 mg daily every Tuesday, Thursday, Saturday, and Sunday. <BR/>Record review of Resident #42's care plans dated 09/28/23 indicated there was no care plan addressing the bipolar diagnosis, Factor 5 Leiden mutation diagnosis, or the warfarin. <BR/>During an interview on 11/15/23 at 11:45 a.m. the DON said she and the MDS nurse were responsible for the care plans. She said they missed developing a care plan to address Resident #42's bipolar disorder, blood clotting disorder, and his anticoagulant medication use. <BR/>Record review of a Comprehensive Care Plan policy revised 04/25/21 indicated:<BR/>Policy: Every resident will have an individualized interdisciplinary plan of care in place. A baseline care plan to meet the resident's immediate needs shall be developed within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (DS 3.0) and CAAs, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual, or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 residents (Residents #38) reviewed for enteral feeding. <BR/>The facility failed to change Resident #38's enteral feeding set/bag every 24 hours on 11/12/23 and did not follow physician order to provide enteral feeding only 20 hours daily on 11/13/23. <BR/>These failures could place residents receiving enteral nutrition at increased risk of not receiving the proper nutrition and infection. <BR/>Findings included: <BR/>Record review of Resident #38's face sheet dated November 2023 indicated he was [AGE] years old and admitted to the facility 02/17/22. His diagnosis included dysphagia (difficulty or discomfort in swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). <BR/>Record review of physician orders indicated he was to receive enteral feeding (a way of delivering nutrition directly to your stomach) of Nutren (a ready-to-use liquid tube feeding formula) 1.5 at 60 Ml/Hr with 30 Ml/Hr water flush every hour for 20 hours daily. <BR/>Record review of care plans dated 10/09/23 indicated Resident #38 required enteral feeding related to aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and swallowing problem. <BR/>Record review of Resident #38's significant change MDS dated [DATE] indicated he had severely impaired cognition, had active diagnosis of dysphagia and gastrostomy, and received nutrition through a feeding tube. <BR/>Record review of Resident #38's MAR dated November 2023 indicated he was to receive enteral feeding of Nutren 1.5 60 Ml/Hr continuous with 30 Ml/Hr water hourly for 20 hours daily and feeding was to be started daily at 11:00 a.m. <BR/>During an observation on 11/13/23 at 08:37 a.m., Resident #38 was lying in bed with the head of bed up 45 degrees. His enteral feeding was running via a pump at Nutren 1.5 60 Ml/Hr and water 30 Ml/Hr. The bags were dated 11/11/23 at 11:00 a.m.<BR/>During an interview on 11/13/23 at 09:26 a.m., the ADON said she was the LVN caring for Resident #38. She said his feeding bag and tubing and the water bag and tubing should be changed every 24 hours, but it had not been changed since 11/11/23 at 11:00 a.m. She said the feeding was to run 20 hours daily and should be turned off daily at 7:00 a.m. and restarted at 11:00 a.m. but she had not turned it off this morning as ordered. She said possible negative outcome of not hanging a new feeding and water bag every 24 hours could be infection or dried/hardened feedings that could cause the G-tube to become blocked. <BR/>During an observation and interview on 11/13/23 at 09:48 a.m., the DON viewed Resident #38's enteral feeding and agreed the bags and tubing were last changed 11/11/23 at 11:00 a.m. as labeled. <BR/>During an interview on 11/13/23 at 03:45 p.m., the enteral feeding bags and tubing should be changed every 24 hours to prevent the chance of infection for the resident. She said Resident #38's feeding was not turned off at 7:00 a.m. as ordered. <BR/>During an interview on 11/15/23 at 10:15 a.m., the Administrator said she expected nurses to follow physician orders and standards of practice for enteral feeding administration. She said the DON was the direct supervisor of all nursing staff and she expected the DON to monitor to ensure enteral feedings were administered correctly. <BR/>Record review of facility policy titled Enteral Nutrition effective April 2020 indicated in part .Enteral nutrition will be ordered by the physician . The policy did not address how often tubing and enteral feeding bags should be changed. <BR/>Record review of National Library of Medicine article titled Safety of Enteral Nutrition Practices: Overcoming the Contamination Challenges indicated in part .Ready-to-hang liquid formulas can be used up to 24 hours once opened <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of each resident for one of six of residents (Resident #1) reviewed for medications.<BR/>LVN A failed to ensure all medications were administered according to facility procedure when she left a cup of medication with Resident #1 and failed to observe Resident #1 take the medication.<BR/>This failure could place residents at risk for not receiving the therapeutic benefits from medications. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 07/30/23 showed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses of Multiple Sclerosis, Displace Spinal Fracture, Muscle Weakness, Difficulty Walking, Morbid obesity, Asthma, Neuromuscular Dysfunction of Bladder, Chronic Atrial fibrillation, and Fibromyalgia.<BR/>Review of a MDS dated [DATE], showed Resident #1 was recently admitted on [DATE] with a BIMS score of 15 which indicated resident #1 was alert to person, place. and time.<BR/>Review of a care plan dated 06/22/23 did not show Resident #1had been assessed for self-medication<BR/>Review of consolidated Physician's orders for July 2023 showed Resident #1 was prescribed the following medications to be administered at 9:00 a.m.: <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. Give 2 capsule by mouth one time daily for depression. <BR/>*Fexofenadine HCI Tablet 180 mg. Give 1 tablet by mouth one time a day for allergies. <BR/>*Guaifenesin Tablet. Give 1200 mg y mouth one time a day for allergies. <BR/>*Hydrochlorothiazide Tablet 12.5 mg. Give 1 tablet by mouth one time a day for edema. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, give 2 tablets by mouth one time a say for supplement. DO NOT CRUSH. Administer with a snack or full glass of water.<BR/>*Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for difficulty breathing.<BR/>*Verapamil HCI Tablet 40 mg Give 1 tablet by mouth one time a day for Atrial fibrillation (Heart condition), hold for systolic (Blood Pressure) less than 100 no restrictions on DPB. (Diffuse pan-bronchiolitis (DPB) is a chronic inflammatory airway disease which was lethal in the past despite combined treatment with antibiotics)<BR/>*Buspirone HCI Tablet 5 mg Give 2 Tablets by mouth two time a day for anxiety.<BR/>*MiraLAX Oral Powder 17 GM/Scoop. Give one scoop by mouth two times a day for constipation.<BR/>*Pregabalin Capsule 200 mg. (A strong narcotic pain killer) Give 1 Capsule by mouth two time a day for pain. <BR/>*Prilosec OTC Tablet Delayed Release. Give two tables by mouth 2 times a day for reflux. Do not crush or chew. <BR/>*Senna Tablet 8.6 mg. Give 2 tablets by mouth 2 times a day to prevent constipation, and <BR/>*Valacyclovir HCI Tablet 1 GM Give 1 tablet by month two times a day for MS (Multiple Sclerosis). <BR/>Review of Medication Administration Records dated 07/30/23 at 9:00 a.m. showed the following medication had been administered by LVN A. <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. <BR/>*Fexofenadine HCI Tablet 180 mg. <BR/>*Guaifenesin Tablet. 1200 mg <BR/>*Hydrochlorothiazide Tablet 12.5 mg. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, <BR/>*Prednisone Oral Tablet 20 MG.<BR/>*Verapamil HCI Tablet 40 MG <BR/>*Buspirone HCI Tablet 5 MG <BR/>*MiraLAX Oral Powder 17 GM/Scoop. <BR/>*Pregabalin Capsule 200 MG. <BR/>*Prilosec OTC Tablet Delayed Release. <BR/>*Senna Tablet 8.6 MG, and <BR/>*Valacyclovir HCI Tablet 1 GM.<BR/>During an observation and interview on 07/30/23 at 10:05 a.m. Resident #1 was laying on her back in her bed. There was a plastic cup with multiple pills pouring out of the cup on to the blanket which was covering Resident #1's stomach. Resident # 1 said LVN A had left the cup of medication for her to take. Resident #1 said she asked LVN A to leave the medication and she would take it in a little while. <BR/>During an interview on 07/30/23 at 10:10 a.m. LVN A said she left the cup of medication with Resident #1 to take. LVN A said Resident #1 is in her right mind and she feels okay leaving the medications with Resident #1 to take. LVN said she documented Resident #1 was administered the medication in the electronic MAR, even though she did not witness Resident #1 take the medication. LVN said the medication is to be given at 9:00 a.m.<BR/>During an interview 07/31/23 at 10:35 a.m. the DON said LVN A should not have left the medication with Resident #1. The DON said it is the policy of the facility to watch a resident swallow their medication. The DON said there is a Medication Self-Administration Screening that could be completed to see if a resident is able to administer their own medication, but there had been no such screening for Resident #1. The DON stated LVN A should not have left the cup of pills with Resident #1, even though Resident #1 has a BIMS score of 15 and is totally alert and able to make her own decisions.<BR/>Review of a pharmacy policy dated 08-2018 showed Administer .remain with the resident while medication is swallowed. Exercise caution with residents who have difficulty with swallowing. Do not leave medications at the bedside, unless specifically order by the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #13) reviewed for unnecessary medication. <BR/>The facility failed to monitor Resident #13 for side effects from 11/01/23 to 11/15/23 of the anticoagulant medication Eliquis (a blood thinning medication).<BR/>This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication.<BR/>Findings included:<BR/>Record review of Resident #13's face sheet, dated 11/13/23, indicated an [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke).<BR/>Record review of physician orders dated November 2023, indicated Resident #13 was prescribed Eliquis 5 mg two times a day for atrial fibrillation with a start date of 09/13/23. The orders did not address monitoring the anticoagulant medication.<BR/>Record review of a care plan, initiated 09/13/23, indicated Resident #13 received an anticoagulant medication, called Eliquis with interventions which included monitor for side effects. <BR/>Record review of an admission MDS, dated [DATE], indicated Resident #13 had a BIMS score of 00, which indicated severely impaired cognition. Resident #13 had a diagnosis of atrial fibrillation and received an anticoagulant medication 6 of 7 days during the look back period.<BR/>Record review of a MAR, dated 11/14/23, indicated Resident #13 received Eliquis 5 mg two times a day from 11/01/23 to 11/04/23, 11/6/23 to 11/7/23 and 11/09/23 to 11/14/23 with a start date of 09/13/23. On 11/05/23 Eliquis 5 mg was received one time a day due to refusal and on 11/08/23 one time a day due to hospitalized .<BR/>Record review of the electronic record for Resident #13 from 11/1/12 to 11/15/23 indicated the nurses did not document monitoring of side effects of the anticoagulant medication daily with medication administration. <BR/>During an interview on 11/14/23 at 3:01 p.m., LVN B said she was assigned to provide care for Resident #13. She said all residents on anticoagulant medication should be monitored for side effects including bleeding and bruising. LVN B said the MA gave anticoagulants such as Eliquis and the nurse monitored for side effects. LVN B said she was the nurse who admitted Resident #13 and she must have forgotten to put the monitoring for the anticoagulant into the computer system. She said the admission nurse was responsible for putting the monitoring into the system, the ADON and DON were responsible for double checking the monitoring was put into the system for anticoagulants. She said she did not remember getting in-serviced on monitoring for anticoagulants but knew to monitoring for bleeding. LVN B said the risk of a resident on anticoagulants not being monitored for side effects was bleeding, bruising, and/or dialysis residents could possibly bleed out. <BR/>During an interview on 11/14/23 at 3:22 p.m., MA C said she was providing care for Resident #13 today. She said there was no monitoring on Resident #13's anticoagulant medication and there should be. MA C said she was responsible for giving Eliquis to Resident #13 and the nurse was responsible for monitoring Resident #13 for the side effects of the anticoagulant medication. She said she was not in-serviced on monitoring of anticoagulant medication for side effects but if a monitoring popped up in the computer, she would monitor for it. She said she knew to monitor for bleeding and bruising on residents on anticoagulant medication. She said the nurses were responsible for monitoring side effects and entering it into the computer system. MA C said the risk of a resident on anticoagulants who were not monitored was bleeding, bruising and blood clots.<BR/>During an interview on 11/14/23 at 3:45 p.m., the DON said the nurse admitting a resident was responsible for inputting the monitoring of anticoagulants into the computer system. She said the MA gave anticoagulants such as Eliquis to the residents and the nurse monitored the resident for side effects of the anticoagulants. The DON said she and the ADON were responsible for a double check for monitoring of anticoagulant medication. She said the staff had not been in-serviced on monitoring for side effects. She said Resident #13 was not monitored for side effects of his anticoagulant medication and should have been. The DON said when she started working at the facility on 08/23/23, she did not know to put the monitoring template into the computer system. She said she was in the process of auditing charts and had not started on anticoagulants yet. The DON said her expectation was when the admission nurse entered the order for an anticoagulant into the system to enter the monitoring template into the system so the medication would be monitored. She said the risk of a resident on anticoagulant medication not monitored was the risk of bleeding and bruising.<BR/>During an interview on 11/14/23 at 4:01 p.m., the Administrator said the nurses were responsible for inputting the monitoring for anticoagulant medication into the computer system. She said Resident #13's anticoagulant medication should have been monitored for side effects and was not. The Administrator said the risk of a resident not monitored for side effects of anticoagulant medication was bleeding, bruising and medical issues.<BR/>During an interview on 11/14/23 at 4:30 p.m., the DON said the facility did not have a specific policy for monitoring anticoagulant medication.<BR/>Record review of a policy revised 08/2020, titled, Administration Procedures for All Medication indicated, . Medication will be administered in a safe and effective manner.8. Monitor for side effects or adverse drug reactions immediately after administrator and throughout each shift.13. Notify the attending physician and /or prescriber of: . c. Suspected adverse drug reactions.<BR/>Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS&reg; (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop.<BR/>Call your doctor or get medical help right away if you have any of these signs or symptoms of<BR/> bleeding when taking ELIQUIS:<BR/>*unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the<BR/> gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier<BR/> than normal<BR/>*bleeding that is severe or you cannot control<BR/>*red, pink, or brown urine; red or black stools (looks like tar)<BR/>*coughing up or vomiting blood or vomit that looks like coffee grounds<BR/>*unexpected pain, swelling, or joint pain<BR/>*headaches, or feeling dizzy or weak <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate less than 5% during the medication pass, in which there were 5 errors out of 30 opportunities, resulting in a 16.67% error rate for 3 of 3 residents (Resident #27, Resident #7, and Resident #28) observed for medication administration.<BR/>LVN S did not administer Resident #27's Vitamin B12 (a medication used to treat Vitamin B12 deficiency, osteoporosis, and fatigue). <BR/>LVN E did not administer Resident #7's Vitamin B12 (a medication used to treat Vitamin B12 deficiency, osteoporosis, and fatigue) or Calcium Carbonate (a medication used to treat acid reflux, upset stomach, indigestion, and heartburn).<BR/>LVN E did not administer the correct dose of Resident #7's Vitamin D3 (a medication needed in the body for healthy bones, muscles, nerves, and to support the immune system).<BR/>LVN A did not administer Resident #28's Potassium (a medication used to treat low potassium or to prevent potassium levels from dropping to low due to certain medical conditions or medications).<BR/>These failures could place residents at risk for avoidable complications and symptoms of their disease process.<BR/>Finding Include:<BR/>Error #1 <BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #27 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including vitamin deficiency. The physician orders indicated Resident #27 had an order starting on 9/01/21 for Vitamin B12 1000 mcg (micrograms) to be given by mouth twice a day for vitamin deficiency.<BR/>During an observation and interview on 9/13/22 at 7:38 a.m. LVN S did not administer the prescribed Vitamin B12 to Resident #15. LVN S said she did not have any Vitamin B12 on her medication cart but was going to look in the medication room. LVN S said there was not any Vitamin B12 in the medication room to administer to Resident #15. <BR/>Error #2, #3, and #4<BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #7 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including Vitamin B12 deficiency, Vitamin D deficiency, and gastro-esophageal reflux (when the stomach acid repeatedly flows back into the tube connecting the mouth and stomach). The physician orders indicated Resident #7 had an order starting on 6/24/22 for Calcium Carbonate 600mg (milligrams) by mouth twice a day for health maintenance. The physician orders indicated Resident #7 had an order starting 6/25/22 for Vitamin B12 500mcg by mouth daily for health maintenance. The physician orders indicated Resident #7 had an order for Vitamin D3 3000 units by mouth daily for a supplement. <BR/>Record review of the care plan (revision dated unknown) indicated Resident #7 was at risk for altered nutritional status and altered labs related to diagnoses, medications, diet, and appetite with interventions including administer medication as ordered. <BR/>During an observation on 9/13/22 at 7:57 a.m. LVN E did not administer Resident #7's Calcium Carbonate or Vitamin B12. LVN E administered Resident #7 Vitamin D3 2000 units and not the prescribed Vitamin D3 3000 units. <BR/>During an interview on 9/13/22 at 12:38 p.m. LVN E said she did not have any Vitamin B12 500mcg to administer to Resident #7. LVN E she gives medications when they pop up on the medication administration record to be given. LVN E said she showed the surveyor all Resident #7's medications as she put them in the medication cup. LVN E said she was unsure as to whether she gave Resident #7 Calcium Carbonate this morning. <BR/>Error #5<BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #28 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including hypokalemia (decreased potassium level). The physician orders indicated Resident #28 had an order starting on 9/13/22 for Potassium Chloride 20 MEQ (milli-equivalents) via G-tube one time a day for hypokalemia. <BR/>During an observation on 9/15/22 at 8:53 a.m. LVN A did not administer Resident #28's Potassium Chloride as prescribed. <BR/>During an interview on 9/15/22 at 2:12 p.m. LVN K said medications should not be missed including vitamins. LVN K said the importance of not missing medication was due to physician orders and vitamins like B12 and D3 can affect bones, energy, and immune system. <BR/>During an interview on 9/15/22 at 2:31 p.m. LVN E said medications on the medication administration record should be given if available. LVN E said if a medication was not available the nurse should look in medication room and ask the other nurse if they have any of that medication. LVN E said the importance of not missing ordered vitamins was for bone health and immunity. LVN E said the facility was out of B12 500mcg. LVN E said she did not recall omitting Resident #7's Calcium Carbonate or administering the wrong dose of Vitamin D3. <BR/>During an interview on 9/15/22 at 03:04 p.m. the interim DON said she had started at the facility on 9/13/22. The interim DON said all medications including vitamin should be administered as ordered. The interim DON said the importance of vitamins was wound healing, anemia, and bone health. The interim DON said the importance of potassium was for heart health.

Based on interview and record review, the facility failed to submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for 2 of 4 quarters reviewed for payroll data information. (Quarter 1 and Quarter 4)<BR/>The facility failed to submit accurate staffing information to CMS for the 1st and 4th quarter of the fiscal year 2023.<BR/>This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Record Review of the facility's Civil Rights form (3761) dated 11/13/23 indicated the following:<BR/>-6 RNs <BR/>-9 LVNs <BR/>-23 Direct Care Staff<BR/>-6 Dietary<BR/>-4 Housekeeping & Laundry <BR/>-8 All Others<BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 1 2023 (October 1- December 31), dated 11/08/2023, indicated the following entries: <BR/>1.Excessively Low Weekend Staffing Triggered .Triggered = Submitted Weekend Staffing data is excessively low. <BR/>2.Failed to have Licensed Nursing Coverage 24 Hours/Day . Triggered .Triggered = Four or More Days Within the Quarter &lt;24 Hours/Day Licensed Nursing Staff Coverage. Infraction dates included:<BR/>10/8 (Saturday), 10/12 (Wednesday), 10/15 (Saturday), 10/16 (Sunday), 10/19 (Wednesday), 10/22 (Saturday), 10/23 (Sunday), 10/28 (Friday), 10/30 (Sunday)<BR/>11/01 (Tuesday), 11/02 (Wednesday), 11/10 (Thursday), 11/12 (Saturday), 11/13 (Sunday), 11/19 (Saturday), 11/20 (Sunday), <BR/>11/25 (Friday), 11/26 (Saturday), 11/27 (Sunday), 11/28 (Monday), 11/30 Wednesday)<BR/>12/02 (Friday), 12/03 (Saturday), 12/04 (Sunday), 12/05 (Monday), 12/07 (Wednesday)<BR/>Record review of facility direct care time sheets and agency time sheets indicated the following staffing data during the first quarter:<BR/>-6:00 a.m. to 6:00 p.m. shift = 1 LVN and 4 CNAs<BR/>-6:00 p.m. to 6:00 a.m. shift = 1 LVN and 3 CNAs<BR/>-And 8 hours of RN coverage 8 hours/day.<BR/>During an interview on 11/15/23 at 10:15 a.m., the Administrator said the 1st Quarter PBJ reports were submitted by the accounting department at the corporate office and all hours were not accurately captured and reported due to an error with the payroll system. It failed to include agency staffing or salaried employees in the reported hours. <BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 4 2023 (July 1- September 30), dated 11/08/2023, indicated the following entry: No RN Hours . Triggered . Triggered = Four or More Days Within the Quarter with no RN hours. <BR/>Infraction dates included:<BR/>07/04 (Monday), 07/16 (Saturday)<BR/>09/09 (Friday), 09/16 (Friday).<BR/>Record review of the interim DON's electronic medical record logins for facility Interim DON indicated he worked 8 hours on 07/04/23, 07/16/23, 09/09/23, and 09/16/23.<BR/>During an interview on 11/15/23 at 10:15 a.m., the Administrator stated salary staff were mistakenly left off the PBJ hours reported by corporate. She said the facility followed the CMS Electronic Staffing Data Submission Payroll-Based Journal for Long-Term Care Facility Policy Manual as their policy for submitting PBJ data. <BR/>The CMS Electronic Staffing Data Submission Payroll-Based Journal for Long-Term Care Facility Policy Manual indicated in part .Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 for 5 residents (Resident #3) reviewed for infection control during medication pass. <BR/>The facility failed to ensure MA A did not touch medications with her bare hand on 11/13/23 at 9:50 a.m. <BR/>This failure could place residents at risk for the spread of infection and cross contamination. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 11/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease in which immune system damages protective covering of the nerves), fibromyalgia (widespread muscle pain and tenderness), and chronic migraine (moderate to severe and intense headache which happens more than half of a month for 3 months). <BR/>Record review of Resident #3's annual MDS assessment, dated 10/12/23, indicated a BIMS score of 15 out of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #3's, undated, care plan indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to a fracture of his arm and terminal multiple sclerosis.<BR/>Record review of the physician order summary for November 2023 indicated Resident #3's received 20 pills or capsules at 9:00 a.m. medication pass. <BR/>During an observation of medication pass on 11/13/23 at 9:50 a.m., MA A performed hygiene then MA A and placed Resident #3's medications into medication cup from touching the blister packets and bottles. MA A placed the medications on a clean tissue,without hand hygiene and started counting them, touching the pills with her bare hands as she placed them back into the medication cup. <BR/>During an interview on 11/14/23 at 11:00 a.m., MA A said she got nervous and touched Resident #3's pills, but she should have used gloves to prevent possible cross-contamination. <BR/>During an interview on 11/14/23 at 2:45 p.m., the DON said a resident's medication/pills should not be touched with a bare hand. She said gloves were to be used to prevent cross contamination. <BR/>During an interview on 11/14/23 at 4:45 p.m., the Administrator said she expected her staff to follow policy and procedures to use gloves to prevent spreading germs or not having medications available. <BR/>Record review of the facility's policy dated 10/25/22 titled Infection Control indicated This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.<BR/>Record review of the facility's policy dated 08/2020 titled Administration Procedures for All Medications indicated . 3. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 4 residents (Residents #1 and #2) reviewed for abuse.<BR/>The facility failed to implement their Abuse Policy and ensure all allegations of abuse were reported to HHSC within 2 hours of the allegation for Residents #1 and #2.<BR/>This failure could place residents at risk of further abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings include:<BR/>Record review of the facility's Abuse and Neglect policy, revision date 07/10/18, indicated .Procedure .Reporting/Investigation .All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown must be reported immediately or within two hours of alleged violation <BR/>Record review of Resident #1's face sheet, dated 10/23/23, indicated Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), respiratory failure (a serious condition that makes it difficult to breathe on your own), hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a condition in which the heart's main pumping chamber [left ventricle] is weak and becomes stiff and unable to fill properly) and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe).<BR/>Record review of a Provider Investigation Report, dated 10/28/23, indicated a Resident-to-Resident incident occurred on 10/22/23 which involved Resident #1 and another resident. The Investigation Summary section indicated: .An additional verbal altercation with another resident took place on 10/25. Resulting in [Resident #1] being sent to the ER. ER physician reports [Resident #1] being referred to Behavioral Unit.<BR/>Record review of Resident #2's face sheet, dated 11/07/23, indicated Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), cancer of the prostrate, cancer of the right upper lung, and seizures (neurological disorder that causes seizures or unusual sensations and behaviors).<BR/>During an interview on 11/07/23 at 01:20 p.m., the Administrator said she was the Abuse Coordinator and it was her responsibility to report incidents of abuse to the state survey agency. She said the verbal incident involving Resident #1 also involved Resident #2. She said Resident #1 had a physical altercation with another resident and she thought because the verbal incident was within the 5 days to do the report for the physical altercation that it could be included with the intake. She said she did not realize they would have to be treated as 2 separate incidents and the verbal incident needed to be called in separately. She said because of the verbal incident, Resident #1 was sent to the ER for evaluation, and they were informed he was being admitted to the Behavior Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator or the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2) reviewed for abuse.<BR/>The facility failed to report allegations of abuse immediately, but not later than 2 hours to HHSC when Resident #1 was in Resident #2's room yelling at him. <BR/>This failure could place residents at risk of verbal abuse, mental anguish, and emotional distress.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 10/23/23, indicated Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), respiratory failure (a serious condition that makes it difficult to breathe on your own), hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff and unable to fill properly) and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe).<BR/>Record review of a Provider Investigation Report, dated 10/28/23, indicated a Resident-to-Resident incident occurred on 10/22/23 which involved Resident #1 and another resident. The Investigation Summary section indicated: .An additional verbal altercation with another resident took place on 10/25. Resulting in [Resident #1] being sent to the ER. ER physician reports [Resident #1] being referred to Behavioral Unit.<BR/>Record review of Resident #2's face sheet, dated 11/07/23, indicated Resident #2 was a [AGE] year-old male who was admitted on [DATE]. His diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), cancer of the prostrate, cancer of the right upper lung, and seizures (neurological disorder that causes seizures or unusual sensations and behaviors).<BR/>During an interview on 11/07/23 at 01:20 p.m., the Administrator said she was the Abuse Coordinator and it was her responsibility to report incidents of abuse to the state survey agency. She said the verbal incident which involved Resident #1 also involved Resident #2. She said Resident #1 had a physical altercation with another resident and she thought because the verbal incident was within the 5 days to do the report for the physical altercation that it could be included with the intake. She said she thought because the verbal incident was within the 5 days to do the report for the physical altercation, it could be included with the intake. She said she did not realize they would have to be treated as 2 separate incidents and the verbal incident needed to be called in separately. She said because of the verbal incident, Resident #1 was sent to the ER for evaluation, and they were informed he was being admitted to the Behavior Unit. <BR/>Record review of the facility's Abuse and Neglect policy, revision date 07/10/18, indicated .Procedure .Reporting/Investigation .All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown must be reported immediately or within two hours of alleged violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of each resident for one of six of residents (Resident #1) reviewed for medications.<BR/>LVN A failed to ensure all medications were administered according to facility procedure when she left a cup of medication with Resident #1 and failed to observe Resident #1 take the medication.<BR/>This failure could place residents at risk for not receiving the therapeutic benefits from medications. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 07/30/23 showed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses of Multiple Sclerosis, Displace Spinal Fracture, Muscle Weakness, Difficulty Walking, Morbid obesity, Asthma, Neuromuscular Dysfunction of Bladder, Chronic Atrial fibrillation, and Fibromyalgia.<BR/>Review of a MDS dated [DATE], showed Resident #1 was recently admitted on [DATE] with a BIMS score of 15 which indicated resident #1 was alert to person, place. and time.<BR/>Review of a care plan dated 06/22/23 did not show Resident #1had been assessed for self-medication<BR/>Review of consolidated Physician's orders for July 2023 showed Resident #1 was prescribed the following medications to be administered at 9:00 a.m.: <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. Give 2 capsule by mouth one time daily for depression. <BR/>*Fexofenadine HCI Tablet 180 mg. Give 1 tablet by mouth one time a day for allergies. <BR/>*Guaifenesin Tablet. Give 1200 mg y mouth one time a day for allergies. <BR/>*Hydrochlorothiazide Tablet 12.5 mg. Give 1 tablet by mouth one time a day for edema. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, give 2 tablets by mouth one time a say for supplement. DO NOT CRUSH. Administer with a snack or full glass of water.<BR/>*Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for difficulty breathing.<BR/>*Verapamil HCI Tablet 40 mg Give 1 tablet by mouth one time a day for Atrial fibrillation (Heart condition), hold for systolic (Blood Pressure) less than 100 no restrictions on DPB. (Diffuse pan-bronchiolitis (DPB) is a chronic inflammatory airway disease which was lethal in the past despite combined treatment with antibiotics)<BR/>*Buspirone HCI Tablet 5 mg Give 2 Tablets by mouth two time a day for anxiety.<BR/>*MiraLAX Oral Powder 17 GM/Scoop. Give one scoop by mouth two times a day for constipation.<BR/>*Pregabalin Capsule 200 mg. (A strong narcotic pain killer) Give 1 Capsule by mouth two time a day for pain. <BR/>*Prilosec OTC Tablet Delayed Release. Give two tables by mouth 2 times a day for reflux. Do not crush or chew. <BR/>*Senna Tablet 8.6 mg. Give 2 tablets by mouth 2 times a day to prevent constipation, and <BR/>*Valacyclovir HCI Tablet 1 GM Give 1 tablet by month two times a day for MS (Multiple Sclerosis). <BR/>Review of Medication Administration Records dated 07/30/23 at 9:00 a.m. showed the following medication had been administered by LVN A. <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. <BR/>*Fexofenadine HCI Tablet 180 mg. <BR/>*Guaifenesin Tablet. 1200 mg <BR/>*Hydrochlorothiazide Tablet 12.5 mg. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, <BR/>*Prednisone Oral Tablet 20 MG.<BR/>*Verapamil HCI Tablet 40 MG <BR/>*Buspirone HCI Tablet 5 MG <BR/>*MiraLAX Oral Powder 17 GM/Scoop. <BR/>*Pregabalin Capsule 200 MG. <BR/>*Prilosec OTC Tablet Delayed Release. <BR/>*Senna Tablet 8.6 MG, and <BR/>*Valacyclovir HCI Tablet 1 GM.<BR/>During an observation and interview on 07/30/23 at 10:05 a.m. Resident #1 was laying on her back in her bed. There was a plastic cup with multiple pills pouring out of the cup on to the blanket which was covering Resident #1's stomach. Resident # 1 said LVN A had left the cup of medication for her to take. Resident #1 said she asked LVN A to leave the medication and she would take it in a little while. <BR/>During an interview on 07/30/23 at 10:10 a.m. LVN A said she left the cup of medication with Resident #1 to take. LVN A said Resident #1 is in her right mind and she feels okay leaving the medications with Resident #1 to take. LVN said she documented Resident #1 was administered the medication in the electronic MAR, even though she did not witness Resident #1 take the medication. LVN said the medication is to be given at 9:00 a.m.<BR/>During an interview 07/31/23 at 10:35 a.m. the DON said LVN A should not have left the medication with Resident #1. The DON said it is the policy of the facility to watch a resident swallow their medication. The DON said there is a Medication Self-Administration Screening that could be completed to see if a resident is able to administer their own medication, but there had been no such screening for Resident #1. The DON stated LVN A should not have left the cup of pills with Resident #1, even though Resident #1 has a BIMS score of 15 and is totally alert and able to make her own decisions.<BR/>Review of a pharmacy policy dated 08-2018 showed Administer .remain with the resident while medication is swallowed. Exercise caution with residents who have difficulty with swallowing. Do not leave medications at the bedside, unless specifically order by the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents with food and drink that was palatable, attractive, served at a safe and appetizing temperature, prepared by methods that conserve nutritive, flavor, taste, and appearance for six of seven residents (Residents #1, #2, #3, #4, #5 and #6) reviewed for palatable food.<BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 who complained the food was served cold and did not taste good. <BR/>These failures could place residents at risk of decreased food intake, weight loss, altered nutritional status and diminished quality of life.<BR/>Findings included:<BR/>Resident #2 <BR/>Review of a MDS dated [DATE], showed Resident #2 was admitted on [DATE] with a BIMS score of 07 which indicated resident #2 had moderate to severe cognitive impairment but was alert to person, place. and time.<BR/>During an interview on 07/30/23 at 7:00 a.m., Resident #2 said he normally does not like the food that is served so he always asked for a cheeseburger. Resident #2 said last night he was served a cold salad that he sent back to the kitchen because the lettuce was nasty, and he could not eat it. Resident #2 said he requested a cheeseburger instead, but he never got it.<BR/>During an interview on 07/30/23 at 5:25 a.m. CNA A said she had worked at the facility since January 2023. CNA A said she had heard residents complain about the food. CNA said Resident #2 complained a lot. CNA A said if a resident does not like what is was served they can could choose from the anytime menu, CNA A said residents can ask for a sandwich, grilled cheese, salad, or a hamburger. CNA A said breakfast alternatives are dry cereal, toast, or oatmeal. <BR/>Resident #3<BR/>Review of a MDS dated [DATE], showed Resident #3 was admitted on [DATE] with a BIMS score of 15 which indicated resident #3 was alert to person, place. and time. Resident #3 received a regular diet. <BR/>Resident #4 <BR/>Review of a MDS dated [DATE], showed Resident #4 was admitted on [DATE] with a BIMS score of 15 which indicated resident #4 was alert to person, place. and time. Resident #4 received a regular diet.<BR/>Resident #5 <BR/>Review of a MDS dated [DATE], showed Resident #5 was admitted on [DATE] with a BIMS score of 12 which indicated resident #5 was alert to person, place. and time. Resident #5 received a regular diet.<BR/>During a group interview on 07/30/23 at 7:25 a.m., Residents #3, #4, and #5 said the food is often served under seasoned. Residents said they are not provided with salt on the table. Resident #4 said she had asked for salt, but it was not provided. Residents said the night before, during the evening meal they were served a chef salad with a fried chicken strip on top. They said they could not eat the lettuce because it was too hard, and they could not chew it. They said all they ate was the chicken strip and left the rest on their plate because they could not eat it. Residents said the sausage severed for breakfast today was over-cooked, hard, and difficult to chew. Resident #3 said the biscuit was hard and had garlic and cheese on the inside which he did not like for breakfast. Residents said there is normally an alternative, but the air conditioning in the kitchen was out and they did not want the cook to have to heat up the kitchen to fix something else, so they did not request an alternative to the chef salad. <BR/>Resident #1<BR/>Review of a MDS dated [DATE], showed Resident #1 was most recently admitted on [DATE] with a BIMS score of 15 which indicated resident #1 was alert to person, place. and time. Resident #1 received a regular diet.<BR/>During an interview on 07/30/23 at 10:05 a.m. Resident #1 said the food at the facility is horrible and something needs to be done about it. Resident #1 said most of the time she could not eat the food, and something must be done about the food.<BR/>Resident #6<BR/>Review of a MDS dated [DATE], showed Resident #6 was admitted on [DATE] with a BIMS score of 14 which indicated resident #6 was alert to person, place. and time. Resident #6 was discharged home on [DATE]. Review of weight records showed Resident #6 was weighed at admission with a weight of 214.8 pounds. Resident #6 was discharged home on [DATE] before being weighed a second time.<BR/>Review of a grievance dated 04/26/23 Resident #6 complained she was served a cheeseburger with no meat and was supposed to get French fries but instead served Fritos. Resident #6 said the night before residents were not told that rather than chicken with a salad, the night meal was changed to Chile dogs. Resident #6 Resident also complained she was served one burnt sausage patty and oatmeal for breakfast.<BR/>During a telephone interview on 07/28/23 at 11:32 a.m. Resident #6 said the food at the facility was not eatable. She said she complained but nothing was done. She said they served a chili dog one night, and she does not want something spicy before she goes to bed. She said she ended up losing weight while she was there for just a couple weeks.<BR/>Review of a breakfast menu dated 07/30/23 showed orange juice, Oatmeal, Denver scrambled egg, toast, jelly, milk 2%, Coffee, water, margarine.<BR/>During an observation and interview on 07/30/23 at 8:25 a.m. A test tray was delivered to the conference room by the administrator. The test tray consisted of what looked like a bowl of thick gravy but was found to be a bowl of pureed oatmeal. There was a biscuit, sausage patty and a half glass of orange juice. The oatmeal was a thick consistency, gummy in texture, bland with no seasoning, and lukewarm. The sausage patty was overcooked and hard. The biscuit was hard and cold. Inside the biscuit was small chucks of what appeared to be cheese that had been cooked into the biscuit. The Biscuit had the flavor of garlic. The orange juice was a thick consistency and very sweet. The test tray was found to be unpalatable. The administrator said the food did not look palatable. The administrator said the biscuit was overcook and dry. The administrator said the pureed oatmeal looked like a bowl of gravy, was very thick and not something she would want to eat. The administrator said the orange juice looked very dark and had a thick consistency, was under concentrated and water needed to be added. The administrator said the air conditioning was out in the kitchen and cooks were serving items that required the least amount of cooking to avoid heating up the kitchen. <BR/>During an interview on 07/30/23 at 8:35 a.m. DA-A said the food on the test tray was Pureed oatmeal. DA-A said the orange juice was from concentrate and was dispensed from a machine in the kitchen. DA-A said the machine needed to be recalibrated to make the orange juice a better consistency.<BR/>Review of lunch menu dated 07/30/23 showed Roast beef with gravy, parsley noodles, peas with pimento, roll with margarine, Carrot cake with cream cheese icing. Milk 2%, iced tea, and water.<BR/>During an observation of meal service on 07/30/23 at 11:55 a.m. showed all items on the food warming table were under the recommended temperature for food service. DA-A was observed reheating all the food prior to starting meal service. <BR/>During an Observation and interview on 07/30/23 at 12:35 p.m. a test tray was delivered to the conference room by the Dietary Manager. The tray consisted of roast beef with gravy, parsley noodles, peas with pimento, and a Hawaiian roll. The roast beef with gravy although visually unappealing, because it looked more like a stew mixed together, was well seasoned and had a pleasant taste and texture. The peas with pimento were hard, bland with no flavor, seasoning or salt. The Parsley noodles had an unpleasant texture and appeared to be undercook, hard, dry with no seasoning or salt. The Dietary Manager said the only thing on the tray that was palatable was the roast beef and gravy. The Dietary Manager said the noodles was bland and had a funny texture. The Dietary Manager said the facility had stopped using angle hair spaghetti because it became unpalatable on the steamtable in about 10 minutes. DM said he had heard about the breakfast service and will in-service staff on the importance of serving food that is palatable and nutritious. Dietary Manager said the peas had not been cooked properly, were not tender and the cook did not follow the recipe for cooking the pea or the noodles.<BR/>Review of a recipe for peas and pimentos showed peas were to be boiled for 10 minutes or until tender. Drain and add margarine, pimentos and toss lightly. Maintain temperature above 140 degrees during entire service period. Take temperature of unserved product every 30 minutes. Maximum holding time 4 hours.<BR/>Review of a recipe for Parsley Noodles showed Add 1 tablespoon and 2 1/8 teaspoons of salt to water. Bring water to a boil. Place noodles in water. [NAME] 10-15 minutes until tender. Drain well, add margarine. Sprinkle parsley over noodles and toss. Maintain temperature above 140 degrees during entire service period. Take temperature of unserved product every 30 minutes. Maximum holding time 4 hours. <BR/>During an interview on 07/31/23 at 10:45 a.m. [NAME] A said she had worked at the facility as a cook for 2 years. She said she did not work on 07/30/23 and the cook working was new and was his first day working alone. [NAME] A said each menu item has a recipe that should be followed that had been approved by the facility's Dietician. [NAME] A said on 07/30/23 during the evening meal Resident #2 requested a cheeseburger because he did not like the chef salad that was served. [NAME] A said she prepared the cheeseburger and took it to Resident #2's room but he was not there. [NAME] A said she went to the smoking area to find Resident #2, and he was not there. [NAME] A said she took the cheeseburger back to the kitchen and left it in case Resident #2 asked for it and clocked out and went home. [NAME] A said she did not know if Resident #2 got the cheeseburger. <BR/>During an interview on 07/31/23 at 1:50 p.m. the Dietician said she comes to the facility twice a month to monitor and assess residents and nutritional needs. The Dietician said there are 4 residents who triggered for weight loss, but she had recommended supplements and there are currently no residents with significant weight loss. Dietician said all menu items have a recipe provided that should be followed to ensure the food is prepared so it will be palatable and nutritious. Dietician said she had heard residents complain about what kind of food was being served but not complaints about the taste or palatability of the food. Dietician said she did not provide the menus to the dietary staff, and the menus and recipes are provided by cooperate.<BR/>Review of a grievance dated 05/12/23 showed a complaint was made by the Resident Council regarding food not being warm, toast not being toasted, undercook sausage and never having condiments. The corrective action showed We no longer have the cook anymore; we have a process in place to prevent this from occurring.<BR/>A Policy dated 04/2022 showed, The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve a nutritional meal .1. Resident will be provided with nourishing, palatable, attractive meals that meet the resident's daily nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were free from neglect 1 of 3 (Resident #1) residents reviewed for neglect.<BR/>The facility failed to have an effective system in place for referrals resulting in Resident #1 not receiving a referral to the vascular specialist as ordered by his primary care physician and having an above the knee amputation to his right leg.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>This failure could result in residents not being seen by physicians when needed and lead to further decline in health status, harm, or death.<BR/>Findings Include:<BR/>1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking.<BR/>Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. <BR/>Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities.<BR/>Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. <BR/>Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease.<BR/>Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis.<BR/>Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task.<BR/>Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1. The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back.<BR/>Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress note indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. <BR/>Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. <BR/>Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. <BR/>Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. <BR/>During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral.<BR/>During an interview on 3/31/23 at 2:29 pm, the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg.<BR/>During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said they were booked and short-handed.<BR/>During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously.<BR/>During an interview on 3/31/23 at 3:32 pm, the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month.<BR/>During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes.<BR/>During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist.<BR/>During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals.<BR/>During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals.<BR/>During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals, the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist, the facility would call to start the process of getting the appointment made. <BR/>The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m.<BR/>The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: <BR/>In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. <BR/>To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. <BR/>In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. <BR/>Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes:<BR/>Referral Policy: <BR/>1. <BR/>Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. <BR/>2. <BR/>The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral.<BR/>3. <BR/>Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation.<BR/>4. <BR/>Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. <BR/>5. <BR/>Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. <BR/>In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. <BR/>Validation/Monitoring Tools<BR/>Director of Clinical Operations or Designee will validate staff knowledge base through random questioning.<BR/>Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21.<BR/>Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. <BR/>On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted.<BR/>Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner.<BR/>Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. <BR/>Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy<BR/>Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LV C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy.<BR/>Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists.<BR/>On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care.<BR/>1. The Facility Failed to follow-up with the physician regarding referral ordered 3/02/23 to the vascular specialist in a timely manner resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23.<BR/>2. The facility failed to send a referral to the vascular specialist resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23.<BR/>This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk of harm or death related to not receiving proper care or death by not being seen by a specialist or another physician as ordered by their primary physician.<BR/>Findings Include:<BR/>1. Record review of the face sheet dated 4/05/2023 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including COPD (a group of lungs diseases that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and difficulty walking.<BR/>Record review of the physician orders dated 4/05/2023 indicated Resident #1 had an order for wound care to the right toes to cleanse with normal saline, pat dry, apply betadine moistened gauze, apply calcium alginate (a dressing used on moderate to heavy draining wounds during the transition from debridement to repair phase of wound healing) daily and as needed for wound care and infection prevention starting on 3/22/2023. <BR/>Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, personal hygiene, and dressing. <BR/>Record review of an undated care plan indicated Resident #1 had impaired cognitive function or impaired thought process related to impaired decision-making abilities.<BR/>Record review of the nursing progress note dated 2/28/2023 written by LVN F indicated nursing staff was having difficulty locating Resident #1's pedal pulse (foot pulse) to the right lower extremity. The nursing progress note indicated Resident #1's capillary refill was less than 3 seconds to right foot, excluding the second toe. The nursing progress note indicated a new order was received for Resident #1 to have a venous and arterial doppler to the right lower extremity. <BR/>Record review of the right lower extremity arterial doppler (an ultrasound exam of the arteries on the legs that can help evaluate whether there are blockages caused by plaque in the arteries) report dated 3/01/2023 indicated Resident #1 had moderated atherosclerotic cardiovascular disease.<BR/>Record review of the right lower extremity venous doppler (an ultrasound exam that evaluates blood as it flows through a blood vessel including the body's major arteries and veins) report dated 3/01/2023 indicated Resident #1 had superficial thrombophlebitis (an inflammatory disorder of superficial veins with coexistent venous thrombosis (blood clot)) of the greater saphenous vein and no deep vein thrombosis<BR/>Record review of the nursing progress note dated 3/02/2023 written by the Wound Care Nurse indicated Resident #1's doppler results were sent to the primary care physician. The nursing progress note indicated the primary care physician said Resident #1 needed a referral to a vascular specialist. The nursing progress note indicated the nurse on the floor was aware of the referral and would complete the task.<BR/>Record review of the nursing progress note dated 3/03/2023 written by the Wound Care Nurse indicated the vascular specialist office was called to make an appointment for Resident #1, The nursing progress note indicated a voicemail was left at the vascular specialist's office and the facility was awaiting a phone call back.<BR/>Record review of the nursing progress note dated 3/07/2023 written by RN B indicated Resident #'1 family reported the dressing to Resident #1's right foot was dirty and leaking pus. The nursing progress note indicated upon inspection Resident #1's dressing to his right foot was clean, dry, and intact. The nursing progress note indicated Resident #1's dressing to his right foot was freshly changed by the treatment nurse. The nursing progress noted indicated Resident #1 did not have any pus noted. <BR/>Record review of the nursing progress note dated 3/10/2023 written by LVN A indicated a new order was received for the nurse practitioner for Resident #1 to start antibiotic therapy related to Resident #1's right foot being red and warm to the touch. <BR/>Record review of the nursing progress note dated 3/13/2023 written by the Wound Care Nurse indicated the facility had spoken with the vascular specialist's office on 3/09/23 regarding the previous voicemail left concerning Resident #1 getting an appointment. The nursing progress note indicated the vascular specialist's office would let the facility know by the end of the day or by the next day if a referral was received. The nursing progress noted indicated the vascular specialist's office did not call back. The nursing progress note indicated the referral was discussed with the nurse practitioner on 3/10/2023. The nursing progress note indicated the nurse practitioner said the primary care physician's office did not do the referrals, but that it should be the facility's social worker who sends the referral. The nursing progress note indicated the social worker was not aware of what was needed for the referral. The nursing progress note indicated the nurse practitioner and the DCO were notified due to Resident #1's right lower extremity. The nursing progress note indicated the facility talked with the vascular specialist's office and the vascular specialist's office said they had not received a referral for Resident #1. The nursing progress note indicated the DCO was notified and will take care of it. <BR/>Record review of the nursing progress note dated 3/18/2023 written by LVN G indicated Resident #1 was lying in bed, hanging his right leg off the bed. The nursing progress note indicated Resident #1 said he did not want his leg up. The nursing progress note indicated Resident #1 said his leg felt better hanging off the bed. The nursing progress note indicated Resident #1 was encouraged to elevate his right leg due to edema. The nursing progress note indicated Resident #1 chose not to elevate his leg. <BR/>Record review of the nursing progress note dated 3/28/2023 written by LVN F indicated Resident #1's right foot and toes were looking significantly worse. The nursing progress note indicated orders were received to transport Resident #1 to the emergency room for further evaluation and treatment. <BR/>Record review of the hospital records dated 3/28/23 indicated the chief complaint for Resident #1's emergency room visit was wound check. The hospital records indicated the toenail on the 4th right toe came off and the facility staff noted a hole in the toe. The hospital records indicated Resident #1 had dressed wounds to Lt foot. The hospital records indicated Resident #1 had erythema (reddening) and significant discoloration of all toes on right foot with foul smell. The hospital records indicated Resident #1 had ulcers on the 3rd and 4th toes on right foot. The hospital records indicated Resident #1 had decreased sensation to right foot. <BR/>Record review of the hospital records dated 3/30/23 indicated Resident #1 was admitted from the facility with necrotic right foot and toes. The hospital records indicated Resident #1 was scheduled for an above the knee amputation on 3/31/2023. <BR/>Record review of the hospital records last reviewed on 3/31/2023 indicated Resident #1's problem list included cellulitis and abscess of the toe on the right foot noted on 3/282023, peripheral vascular disease noted on 3/28/2023, skin ulcer of the bilateral feet noted on 3/28/2023, venous stasis (a condition in which veins have problems moving blood back to the heart) noted on 3/28/2023, and peripheral arterial disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) noted on 3/30/2023.<BR/>During an interview on 3/31/23 at 2:25 pm the receptionist at the venous specialist's office said they had never seen Resident #1. The receptionist at the vascular specialist's office said they did not have Resident #1 in their computer system and had no record of a referral.<BR/>During an interview on 3/31/23 at 2:29 pm the nurse practitioner said the referral for Resident #1 to see a vascular specialist was regarding vascular issues and arterial blockages. The nurse practitioner said she was unsure how advanced Resident #1's arterial/venous damage was at that time. The nurse practitioner said she would not be comfortable saying whether seeing the vascular specialist would have prevented Resident #1 from such an advanced amputation to right leg.<BR/>During an interview on 3/31/2023 at 2:50 p.m. LVN F said she did not see Resident #1's feet often due to them being wrapped in wound dressing. LVN F said Resident #1 had edema to his bilateral feet. LVN F said the right foot was bluish in color at the beginning of March 2023. LVN F said Resident #1's family had asked his feet approximately 2 weeks prior. LVN F said she performed a dressing change on Resident #1's feet when the family had asked about his feet. LVN F said Resident #1's feet were a reddish/blue color and more swollen when she did the dressing changes approximately 2 weeks ago.<BR/>During an interview on 3/31/2023 at 2:55 p.m. the SW said she had called the vascular specialist's office approximately 2 weeks ago. The SW said the vascular specialist's office said the were booked and short-handed.<BR/>During an interview on 3/31/2023 at 2:56 p.m. the ADCO said the facility had asked the primary care physician's office to send a referral for Resident #1 to the vascular specialist. The ADCO said the vascular specialist's office had said the referral had to come from the primary care physician's office. The ADCO said she had called the vascular specialist's office to find out what information they needed for a referral and had not received a call back. The ADCO said Resident #1's right lower extremity had worsened over the past 2 weeks. The ADCO said Resident #1 was sent to the emergency room so they would be taken seriously.<BR/>During an interview on 3/31/23 at 3:32 pm the Wound Care Nurse said she did not know if a referral was sent to the vascular specialist's office for Resident #1. The Wound Care Nurse said the DCO was supposed to talk to the SW regarding the referral for Resident #1 to the vascular specialist. The Wound care nurse said the nurse practitioner said the physician's office did not send referrals and that the facility's SW needed to send the referral to the vascular specialist for Resident #1. The Wound Care Nurse said Resident #1's right leg had significantly worsened over the past month. The Wound Care Nurse said Resident #1 was placed on antibiotics for the wounds to his right toes versus being sent out to the hospital. The Wound Care Nurse said Resident #1 was seen by the wound care nurse practitioner every Thursday at the facility. The Wound Care Nurse said Resident #1 did not have any discoloration to his legs but had pitting edema to both legs. The Wound Care Nurse said Resident #1's toes had worsened over the past month.<BR/>During an interview on 4/03/2023 at 3:47 p.m. the primary care physician said he was informed of the referral for Resident #1 not being sent to the vascular specialist on 3/28/2023. The primary care physician said there was no way to know if Resident #1 had gotten into the vascular specialist if it would have prevented such an advanced right leg amputation. The primary care physician said he was aware of the wounds on Resident #1's toes. The primary care physician said he felt Resident #1 needed a referral to the vascular specialist due to the wounds on his right toes.<BR/>During an interview on 4/03/2023 time unknown the wound care nurse practitioner said she had seen Resident #1 a week and half ago. The wound care nurse practitioner said she was not aware of any of the issues with Resident #1's right foot/toes at the time or the infections. The wound care nurse practitioner said she did not remember any redness or signs of infections to Resident #1's right toes. The wound care nurse practitioner said Resident #1's right foot did not have a pulse. The wound care nurse practitioner said she did not think Resident #1 needed to go to the hospital, but Resident #1 did need a vascular consult<BR/>During an interview on 4/04/2023 at 1:45 p.m. the SW said she handled referrals to mobile optometry, podiatry, hearing, and dental services. The SW said she had never done a referral to a physician or specialist. The SW said she was told by the nursing staff referrals to a physician or specialist was supposed to come from the primary care physician. The SW said she sometimes made appointments/referred residents for optometry, podiatry, hearing, and dental services in the community. The SW said she had never been trained on sending a referral to a physician or specialist.<BR/>During an interview on 4/04/23 at 1:52 p.m. the ADCO said the facility did not have a process for sending referral to physicians or specialists. The ADCO said the DCO had told her it was the primary care physician's responsibility to send referrals.<BR/>During an interview on 04/04/23 at 1:54 p.m. the DCO said the physician/Medical Director told the facility they did not send referrals. The DCO said the facility cannot make referrals. The DCO said there was not a process in place for making/sending referrals.<BR/>During an interview on 04/04/23 at 2:00 p.m. the EDO said for referrals the charge nurse or SW would make the appointments. The EDO said the facility did not have a policy regarding referrals to outside physicians or specialists. The EDO said if the physician/Medical Director wrote an order for a resident to see an outside physician/specialist the facility would call to start the process of getting the appointment made. <BR/>Record review of the facility's Change in Condition or Status policy last revised May 2017 indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital or treatment center .<BR/>The EDO was notified on 4/04/2023 at 3:20 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The EDO was provided the Immediate Jeopardy template on 4/04/2023 at 3:22 p.m.<BR/>The facility's Plan of Removal was accepted on 4/06/2023 at 8:28 a.m. and included: <BR/>In Response to the facility failure to have a referral system or policy in place, the Administrator immediately created and implemented a referral policy on 4-4-23 to ensure that no additional residents are affected by poor quality of care. <BR/>To ensure no other residents were affected by the facility failure of not having a referral system in place, the Director of Clinical Operations or Assistant Director of Clinical Operations has completed a review all orders on 4-4-23, for any orders requiring physician and or specialist referrals to ensure referrals are handled in a timely manner. No additional missed referrals were found. <BR/>In Response to the facility failure to follow up with physician, the Medical Director, Licensed Nurses, Social Worker and wound care specialist will be provided in-service education related to the referral process policy. <BR/>Inservice: Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on 4-4-23 to be completed by 04-4-23, by the Administrator or Assistant Director of Nurse's which includes:<BR/>Referral Policy: <BR/>1. <BR/>Upon receiving directions or recommendations from a provider or nurse practitioner, whether a physician or nurse practitioner, the charge nurse is to contact the Medical Director immediately and enter an order in PCC. <BR/>2. <BR/>The charge Nurse to notify the Director of Nurses and/or the Assistant Director of Nurses and the Social Worker of the referral.<BR/>3. <BR/>Social Worker to call in referral order, confirm insurance, obtain doctor signature on forms if needed and make appointment with Specialist and arrange for appropriate transportation.<BR/>4. <BR/>Administrator to be notified if referrals are refused or denied by physician or Medical Director immediately with the reason for the denial to determine if the resident needs to be sent out to hospital for further evaluation. If it has been found the resident does not need immediate referral, the Director of Nurses will continue to monitor during daily clinical meetings with charge nurses and treatment nurses for change of condition. If a change of condition is found the physician is to be immediately notified. <BR/>5. <BR/>Newly hired nurses will receive in-service from the Assist Director of Nurses regarding physician referral during orientation process, and to be included in the nurse's information book or Brain Book at nurse's station. <BR/>In response to the facility failure to send a referral to the vascular specialist, the Director of Nurses, Assistant Director of Nurses and Social Worker will be provided in service to obtain the necessary information from the specialist's office, including vascular specialist, for the referral requirements needed from the physician and obtain the required signature's or orders to accommodate the requirements for the specialist to ensure there are no delays in resident's delay in care. In-service provided to Director of Nurses, Assistant Director of Nurses, and Social Worker 04/04/23 by Administrator to be completed by 04/04/23. <BR/>Validation/Monitoring Tools<BR/>Director of Clinical Operations or Designee will validate staff knowledge base through random questioning.<BR/>Director of Clinical Operations or designee will review any referral orders documented by reviewing orders in daily stand up meeting and clinical meetings to ensure appointments are being made, beginning 4-4-21.<BR/>Director of Clinical Operations or designee has called to follow up with Resident affected by the Failure of Quality of Care 4-4-23. Information obtained was that the resident received an above knee amputation and is being discharged to another skilled nursing facility for rehab. <BR/>On 4/06/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the chart audits for residents who had been referred to outside providers in March 2023 was performed with no other issues noted.<BR/>Record review of the facility's undated Referral Policy was performed. The Referral Policy indicated the facility's newly implemented steps in ensuring referrals were made to outside providers in a timely manner.<BR/>Record review of the facility's Brain Book located at the nurse's station indicated the referral policy had been added into the book and was available to the nursing staff at all times for reference. <BR/>Record review and signature verification was performed on in-services dated 3/30/23 through 4/13/23 regarding the facility's Referral Policy<BR/>Interviews of staff on 4/04/2023 between 11:03 a.m. and 11:48 a.m. (LVN A, RN B, LVN C, RN D, RN E, ADCO, LVN F, SW, MDS nurse, Wound Care Nurse, and DON) were performed. During the interviews staff were able to correctly identify the process for referrals per the facility's Referral Policy.<BR/>Interview with the Medical Director and nurse practitioner on 4/04/23 between 11:38 a.m. and 11:41 a.m. regarding the facility's referral policy indicated they had received and agreed with facility's Referral Policy. Both the Medical Director and nurse practitioner said this policy would help ensure residents received appointments and were seen by outside providers and specialists <BR/>On 4/06/2023 at 11:51 a.m., the EDO was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 foyer and 3 (Room #'s 101, 108, and 113) of 15 resident rooms on hall 100 reviewed.<BR/>The facility did not repair the leak or the water damage on the ceiling of the foyer. <BR/>The facility did not repair or replace the damaged ceiling in Room #'s 101, 108, and 113). <BR/>These failures could place the census of 42 residents at risk of living and working in an unsafe, unsanitary and uncomfortable environment. <BR/>Findings included: <BR/>During an observation on 7/10/23 at 7:45 a.m., the foyer had a large trash can placed in the middle of the floor with 3 bath towels around it. No leaking from the roof was observed at that time. The ceiling had significant water damage, approximately 6-7 feet long with open areas. It was not raining outside but there had been a recent rain and the outdoor pavement was wet. There were water puddles in the parking lot. <BR/>During an observation on 7/10/23 at 9:10 a.m., the trash can and the 3 bath towels had been moved out of the foyer floor. The floor was not wet. <BR/>During an interview on 7/10/23 at 9:40 a.m., the Administrator said they had been patching the roof but it still leaked. She said there were 3 rooms they had to move residents out of because of water damage. She said they leased the building and the owner refused to fix the leaks or water damage. She said the facility needed a new roof. She said someone from Corporate assessed the damage at some point and said it was not dangerous. <BR/>During an interview on 7/10/23 at 10:04 a.m., the Administrator said the leak in the foyer had been there before she got to the facility in August of 2022. She said the foyer ceiling leaked with heavy rain. The DON said the leak in the foyer ceiling had been there before he got there in November of 2022. She said if the rain outside was really heavy the trash can may have up to 1 inch of water in it. The Administrator said different companies had tried to repair the foyer leak but it was not able to be fixed by patching it. The Administrator said the crack in the foyer ceiling was approximately 7 feet long but only a small portion of it was open. She said there used to be tape on the seam but it came off last month. <BR/>During an interview on 7/10/23 at 10:06 a.m., the SW said she had been at the facility since November of 2022 and the leak in the foyer had been here that long at least. <BR/>During an observation and interview on 7/10/23 at 10:08 a.m., with the Administrator took this surveyor down hall 100. We walked into room [ROOM NUMBER]. There was no resident residing in the room. She observed the ceiling and said there was three 6-foot-long stains on the ceiling and the ceiling was flaking. She said there were also other water spots on the ceiling. The stains did not look wet. She said water did not leak into the room floor when it rained. The Administrator observed room [ROOM NUMBER]. There was no resident residing in the room. She observed the ceiling and said there were water stains around the light on the ceiling along with other 3-4-foot linear areas of water stains. She said water did not leak into the room from the ceiling when it rained. She walked into room [ROOM NUMBER]. There was no resident residing in the room. She said the ceiling was flaking from water damage. She said some of the ceiling had been repaired. The Administrator said there was a 2-foot circular area of the ceiling (popcorn texture type) missing and the sheet rock was showing. She said there was also a 2-foot water damaged area, linear area along the ceiling that went into the outside wall. She said there were also several other water spots/damage on the ceiling in room [ROOM NUMBER]. She said the ceiling in room [ROOM NUMBER] did not leak into the room when it rained. She said they had moved the residents out of rooms [ROOM NUMBER] due to the water damage. She said residents would not go into those rooms until the water damage was repaired. <BR/>During an interview on 7/10/23 at 10:16 a.m., CNA A said she had worked at the facility for approximately 7 years. She said the leak in the foyer had been there about a year. She said the ceiling in the foyer leaks when it rains hard. She said rooms [ROOM NUMBER] have water damage but they do not leak. CNA A said the water damage in those rooms had been there about a year. She said there were no residents in those rooms. She said maintenance had repaired the foyer ceiling a few times and it would quit leaking but it always started leaking again. She said staff put a trash can under the leak and towels around it. She said she did not know how much it leaked or how much water was usually in the trash can after a rain. <BR/>During an interview on 7/10/23 at 10:18 a.m., the Director of Resident Accounts said she had worked at the facility over 2.5 years. She said the ceiling in the foyer had leaked off and on the whole time she had worked at the facility She said people had tried to fix it but could not. She said staff put a trash can under the foyer ceiling when it was raining. She said depending on how hard it rained the trash can could have up to 1 inch of water in it. She said with light rain there would be no accumulation in the trash can. The Director of Resident Accounts said when it rained heavily you could see the ceiling was wet in the foyer. She said some rooms on 100 hall, rooms [ROOM NUMBER] had water damage but no residents were in them. She said the ceilings in those rooms did not leak into the floor. She said companies had come in to fix those too but were not able to fix them. <BR/>During an observation on 7/10/23 at 10:23 a.m., it was raining heavy outside. Water was leaking from the foyer ceiling into the floor. The water leaking was a steady drip and made a circular wet area in the floor about 10 inches in diameter. Staff went to get the trash can and the bath towels. <BR/>During an interview on 7/10/23 at 10:26 a.m., the Maintenance Supervisor said he was new and was just beginning his third week at the facility. He said fixing the roof or ceiling was out of his scope. He said Corporate handled the roof and repairs. He said no one had tried to fix the roof since he had worked at the facility. The Maintenance Supervisor said there was usually not that much water in the trash can. He said the accumulation might be &frac12; to 1 inch with heavy rain. <BR/>During an interview and record review on 7/10/23 at 10:34 a.m., the Administrator provided an email from the [NAME] President of Plant Operations that indicated: <BR/> .I am writing to address the recent concern regarding the leaky roof at [facility name]. While it is imperative to address any building maintenance issues, I would like to assure you that the current leak does not pose any immediate danger to residents, staff, or the overall structure of the building. I assessed the situation and there are no indications of compromised structural integrity. The building's frame work remains stable and secure.<BR/>During an interview on 7/10/23 at 10:36 a.m., Resident #1 said as much as they charge them to stay there, they should fix the leak. He said he was not upset; it was just the principle of the thing. <BR/>During an interview on 7/10/23 at 10:38 a.m., CNA B said the foyer had leaked since November of 2022 when she started to work at the facility. She said no residents had complained about it. She said a couple of rooms had water damage on 100 hall but water did not leak into the rooms. She said she thought they had tried to fix the water damage and leak in the foyer but she did not really remember. <BR/>During an interview on 7/10/23 at 10:40 a.m., Resident #3 said she had been at the facility for 2 years and the foyer had always leaked. Resident #2 said she did not understand why they did not get it fixed. Resident #2 and Resident #3 were not upset but did not understand why it had not been repaired since it had been going on for so long. <BR/>Record review of A Quality of Life - Homelike Environment Policy dated May 2017 provided by the Administrator indicated: <BR/>Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .<BR/>2.The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 3 of 39 resident rooms (Resident #12, Resident #19 and Resident #30) reviewed for environment.<BR/>The facility did not repair the corner of bedroom wall with metal exposed under the sheetrock or a large hole in the bathroom door for Resident #12.<BR/>The facility did not repair a large hole in the bathroom door or jagged areas noted to the fireproof shield attached to the bedroom door of Resident #19.<BR/>The facility did not repair the wood on the bottom of bedroom window that was broken in half or the broken headboard for Resident #30.<BR/>These failures could place the residents at risk for an unsafe environment.<BR/>Findings include:<BR/>1.Record Review of Resident #12 admission record (no date) indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease), peripheral vascular disease (circulation disorder) and hypertension (high blood pressure). <BR/>Record Review of Resident #12 MDS dated [DATE] indicated that he had a BIMS score of 8 indicating he was mildly impaired. <BR/>During an observation on 09/12/22 at 12:21 p.m., Resident #12 had a large hole in the bathroom door and 1 large amount of metal exposed under the sheetrock of the wall corner in room. Resident #12 was not interviewable. <BR/>2.Record Review of Resident #19 admission record (no date) indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of dementia, muscle weakness and hypertension (high blood pressure). <BR/>Record Review of Resident #19 MDS dated [DATE] indicated a BIMS of 12 for mildly impaired. <BR/>During an observation/interview on 09/12/2022 at 12:08 p.m., Resident #19 had a large hole in the bathroom door and Resident #19 did not know how it got there. The bedroom door had broken/jagged areas noted to the fire-proof shield. Resident #19 stated that he has never gotten hurt on the jagged areas and denied having any issues. <BR/>3.Record Review of Resident #30 admission record (no date) indicated she was a [AGE] year-old female admitted on [DATE] with a diagnosis of chronic kidney disease, seizures, and hypertension (high blood pressure). <BR/>Record Review of Resident #30 MDS dated [DATE] indicated a BIMS score of 6 indicating severely impaired cognition. <BR/>During observation/interview on 09/15/22 at 9:39 a.m. of Resident #30, Resident #30 had broken wood at the bottom of her window in the bedroom. The wood was broken in half and her headboard was broken on the bed. Resident #30 stated her bed catches the window frame and it pulls it off. Resident #30 stated when she is sleeping at night the sound of it cracking wakes her up. Resident #30 stated she reported the broken window frame and broken headboard to the maintenance man 2 weeks ago. Resident #30 stated the broken items do not bother her anymore because it is not her home.<BR/>During interview with Maintenance supervisor on 9/15/22 at 12:38 p.m., Maintenance supervisor stated he checks all the rooms daily. Maintenance supervisor stated, He needs to take care of Resident #19's door and just has not gotten around to it yet. Maintenance supervisor stated he must order the material for the door first and it takes it a while to come in. Maintenance supervisor could not provide proof of order and stated he could not print it out. Maintenance supervisor stated they just recently started keeping a log and most people just tell him when something needs to be fixed and he does it. Maintenance supervisor would not respond to how long the headboard and window frame had been broken in Resident #30's room and would not respond to questions regarding resident harm because of the broken items. Maintenance supervisor stated the broken headboard and window frame could not result in any harm to resident. <BR/>During an interview on 9/15/22 at 9:11 a.m. with LVN A, LVN A stated it is everyone's responsibility to report environmental issues and there is a maintenance log at the nursing station to write down issues. LVN A stated the door shield should have been reported, because the resident could have cut his foot on the jagged areas. LVN A reported she did not know about the door shield or the broken bed frame and window frame. LVN A stated she did not know if the broken window or headboard were recent, but the window is a hazard and can cause splinters and lead to infection.<BR/>During an interview on 9/15/22 at 2:59 p.m. with LVN B (2-10 shift), LVN B stated that she never puts anything in the maintenance log, instead she just tells the Maintenance Supervisor when she sees him down the hall. <BR/>During an interview with the Administrator on 9/15/22 at 2:34 p.m., the Administrator stated she expects the rooms to be in good repair. The Administrator reported it is her responsibility to make sure the Maintenance Supervisor is doing his job. Administrator reported she placed the Maintenance Supervisor on a Performance improvement plan 2 months ago when she started and now a log is kept at the nursing station to report any issues with completion dates. Administrator stated the broken items in resident rooms could cause injury to the residents and stated it is part of the residents right to have a nice environment to live in. <BR/>Record Review of the Maintenance Repair Request dated 8/31/22 to 9/15/22 did not indicate any reports of the broken items in for Resident #12, Resident #19 and Resident #30.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 5 residents (Resident #138 and Resident #135) reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #138 and Resident #135 had a baseline care plan completed within 48 hours of admission.<BR/>This failure could place newly admitted residents at risk of receiving inadequate care and services.<BR/>Findings included: <BR/>1. Record review of the consolidated Physician Orders dated 9/15/22 indicated Resident #138 was a [AGE] year-old male, admitted the to the facility on 9/09/22 with diagnoses including cerebral infarction (ischemic stroke due to disruption of blood flow to the brain, diabetes type 1, hemiplegia and hemiparesis following cerebral infarction affecting an unspecified side (paralysis and weakness to one side of the body following a stroke), bipolar disorder, seizures, hypertension (high blood pressure), lack of coordination, and history of falling. The Physician Orders indicated Resident #138 required crushed medication, was receiving hospice services, and required encouragement from staff for fluids and keeping fluids in reach all initiated on 9/09/22.<BR/>Record review of the Comprehensive MDS dated [DATE] indicated Resident #138 was usually understood by others and usually understood others. The MDS indicated Resident #138 had a BIMS score of 08 indicating he was moderately cognitively impaired. The MDS indicated Resident #138 required limited assistance with bed mobility, and dressing. The MDS indicated Resident #138 required extensive assistance with transfers, toileting, and personal hygiene.<BR/>Record review of Resident #138's electronic and physical chart from 9/09/22 through 9/15/22 revealed no baseline care plan was completed. <BR/>During an interview on 9/14/22 at 2:41 p.m. the Administrator said Resident #138 did not have a baseline care plan completed. <BR/>2. Record review of the consolidated Physician Orders dated 9/15/22 indicated Resident #135 was a [AGE] year-old male, admitted the to the facility on 9/05/22 with diagnoses including prostate cancer, bone cancer, hypertension (high blood pressure), cachexia (weakness and wasting of the body due to severe chronic illness) and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). The Physician Orders indicated Resident #135 was receiving hospice services and had a diet order for mechanical soft with ground meat texture all initiated on 9/5/22.<BR/>Record review of the Comprehensive MDS dated [DATE] indicated Resident #135 was understood by others and understood others. The MDS indicated Resident #135 had a BIMS score of 12 indicating he was moderately cognitively impaired. The MDS indicated Resident #135 required limited assistance with personal hygiene. The MDS indicated Resident #135 required extensive assistance with bed mobility, transfers, dressing, and toileting <BR/>Record review of Resident #135's electronic and physical chart from 9/05/22 through 9/15/22 revealed no baseline care plan was completed. <BR/>During an interview on 9/14/22 at 3:26 p.m. the Director of Clinical Education said the facility did not have a baseline care plan completed for Resident #135.<BR/>During an interview on 9/15/22 at 2:12 p.m. RN K said a baseline care plan should be completed within 12 hours of a resident entering the building. RN K said the admitting nurse was responsible for completing the baseline care plan. RN K said if the baseline care plan not completed there would be no goal for the resident or guide to the how the resident would improve.<BR/>During an interview on 9/15/22 at 2:31 p.m. LVN E said the baseline care plan should be completed the 1st day of admission. LVN E it was the responsibility of the admitting nurse to complete the baseline care plan. LVN E said the importance of the baseline care plan was to indicate the resident's needs and what ADL's they were capable of performing. LVN E said if the baseline care plan was not completed it would affect the care the residents received.<BR/>During an interview on 9/15/22 at 3:04 p.m. the Interim DON said baseline care plans should be completed as soon as possible after a resident admitted to the facility. The Interim DON said the importance of a baseline care plan was so staff would know how to give care to the resident. <BR/>During an interview on 9/15/22 at 4:12 p.m. the Administrator said she expected baseline care plans to be completed on admission. The Administrator said it was the responsibility of the nurse managers and MDS coordinator to complete baseline care plans.<BR/>Record review of the facility's policy Baseline Care Plan dated 11/1/19 indicated, A baseline care plan is required to be completed within 49 hours of admission. The baseline care plan must include Initial goal based on admission orders, Physician orders, Dietary Orders, Therapy Services, Social Services, and PASARR (if applicable).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 2 of 15 residents reviewed for ADLs (Residents #15 and Resident #10 )<BR/>The facility failed to provide assistance with facial hair removal for Resident #15.<BR/>The facility failed to ensure Resident #15's fingernails were clean.<BR/>The facility failed to ensure Resident #10 was routinely showered.<BR/>These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self esteem<BR/>Findings Included<BR/>1. Record review of consolidated physician orders dated 9/15/22 indicated Resident #15 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses COPD, diabetes type 2, dementia, heart failure, lack of coordination, muscle weakness, and tremor.<BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #15 usually understood others and was usually understood by others. The MDS indicated Resident #15 had a BIMS score of 11 indicating she was moderatelty cognitive impairment. The MDS indicated Resident #15 was not resistive to evaluation or care. The MDS indicated Resident #15 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. <BR/>Record review of the undated care plan indicated Resident #15 had an impaired cognitive function or impaired thought process and required assistance with decision making. The care plan indicated Resident #15 was not always understood or able to understand verbal and non-verbal expressions. The care plan indicated Resident #15 had an ADL self-care performance deficit with interventions including resident required extensive assistance with personal hygiene. <BR/>Record review of the documentation survey report dated 9/14/22 indicated Resident #15 had only missed 3 of her scheduled showers for August 2022 and September 2022. <BR/>During an observation on 9/12/22 at 1:34 p.m. Resident #15 was observed with chin hair approximately 1cm in length.<BR/>During an observation and interview on 9/12/22 at 3:08 p.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails. Resident #15 said the facility staff had helped her clean out from under her fingernails a couple days ago. <BR/>During an observation on 9/13/22 at 8:22 a.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails.<BR/>During an observation and attempted interview 9/14/22 at 9:08 a.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails. Resident #15 was more confused and unable to answer questions coherently.<BR/>During an observation on 9/14/22 at 1:22 p.m. Resident #15 was observed with chin hair approximately 1cm in length and a dark brown substance under her fingernails.<BR/>During an interview on 9/15/22 at 2:12 p.m. RN K said facial hair removal and nail cleaning should be completed on the resident's shower days and as needed. RN K said the importance of facial hair removal on female residents was for self-esteem and dignity. RN K said the importance of cleaning under a resident's fingernails was to decrease infections, sanitary purposes, and irritation to skin and peri-area. RNK said Resident #15 had refused one shower the nurse is aware of. <BR/>During an interview on 9/15/22 at 2:23 p.m. CNA C said facial hair removal and nail cleaning should be done on shower days and as needed. CNA C said facial hair removal was important for female resident's dignity. CNA C said clean nails help prevent the spread of germs and bacteria. CNA C said Resident #15 occasionally refused care.<BR/>During an interview on 9/15/22 at 2:31 p.m. LVN E said facial hair removal and nail cleaning should be performed weekly. LVN F said it was the nurse's responsibility to ensure the CNAs performed facial hair removal and nail cleaning. LVN E said the importance of facial hair removal was for dignity. LVN E said the importance of cleaning nails was to prevent contamination and infections. LVN E said Resident #15 did not refuse nail cleaning or facial hair removal. <BR/>During an interview on 9/15/22 at 3:04 p.m. the interim DON said she started at the facility on 9/13/22. The interim DON said she expected facial hair removal and nail cleaning to be performed as needed. The interim DON said the importance of facial hair removal was to increase self-esteem. The interim DON said the importance of clean nails was for sanitary purposes. <BR/>During an interview on 9/15/22 at 4:12 p.m. the Administrator said she expected residents to have facial hair removal and nail cleaning as needed and on shower days. The Administrator said importance of clean nails was for infection control, resident rights, and personal hygiene. The Administrator said the importance of facial hair removal was for dignity. The Administrator said it was responsibility of CNAs and nurses. <BR/>2. Record review of the order summary report, dated 9/15/2022, indicated Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included absence of right leg below knee, generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), osteoarthritis (degeneration of joint cartilage and the underlying bone), and need for assistance with personal care.<BR/>Record review of the annual MDS dated [DATE], indicated Resident #10 understood others and made herself understood. The assessment indicated Resident #10 was cognitively intact with a BIMS of 15. The assessment indicated Resident #10 did not reject care. The assessment indicated she required extensive assistance with bed mobility, dressing, toileting, personal hygiene, bathing: supervision with eating and: total dependence with transfers. <BR/>Record review of the undated care plan indicated Resident #10 had a self-care deficit and required assistance with ADLs related to disease processes (R BKA). There were inventions that Resident #10 required assistance by staff with showering. Provide a sponge bath when a full bath or shower could not be tolerated. <BR/>Record review of the shower schedule indicated Resident #10 would receive her showers on Tuesdays, Thursdays, and Saturdays. <BR/>Record review of the documentation survey report dated 8/1/2022-8/31/2022 indicated Resident #10 had not received a shower or sponge bath on 8/2, 8/4, 8/9 and 8/13. <BR/>Record review of the documentation survey report dated 9/1/2022-9/30/2022 indicated Resident #10 had not received a shower or sponge bath on 9/1 and 9/6. <BR/>During an interview and observation on 9/13/2022 at 10:11 a.m., Resident #10 stated she did not receive her showers three times a week. Resident #10 stated her last shower was Saturday 9/10/2022. Resident #10 was observed hair disheveled and uncombed. Resident #10 stated not receiving her showers three times a week makes me feel nasty. <BR/>During an interview on 9/15/2022 at 1:31 p.m., CNA F stated she was Resident #10's 6a-2p aide. CNA F stated CNAs were responsible for providing showers. CNA F stated Resident #10 should get a shower on Tuesdays, Thursdays, and Saturdays. CNA F stated Resident #10 had complained to her about not getting her showers three times a week. CNA F stated she had not reported Resident #10 not getting her showers as scheduled to anyone. CNA F stated, It slipped my mind. CNA F stated it had been an issue with providing residents their scheduled showers due to staffing. CNA F stated she had told the administrator and the DON that she could not give scheduled showers due to short staff. CNA F stated she was told by the administrator that she was trying to hire extra help. CNA F stated it was important for residents to get a shower so they could feel clean and prevent a skin infection. <BR/>During an interview on 9/15/2022 at 1:53 p.m., LVN E stated she was Resident #10's 6a-2p charge nurse. LVN E stated CNAs were responsible for providing showers. LVN E stated Resident #10 should get a shower on Tuesdays, Thursdays, and Saturdays. LVN E stated Resident #10 had not complained to her about not received her showers. LVN E stated she had never been told by the aides that they were not able to provide residents their showers. LVN E stated there had been issues with residents especially new admissions not receiving their showers because the shower schedule was not updated when they arrived at the facility. LVN E stated the previous DON created a shower communication sheet for the aide and nurse to sign to ensure showers have been given. LVN E stated she could not remember if there had been any shower communication sheets missing for Resident #10. LVN E stated, I had not personally reported this issue to anyone. LVN E stated it was important for residents to get receive a shower to prevent skin breakdown, UTI and it was also a dignity issue. <BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been at the facility for three days. She stated she expected Resident #10 showers to be completed as scheduled. The Interim DON stated CNAs were responsible for providing showers to residents and the nurses were responsible for monitoring to ensure there been done. The Interim DON stated it would be her responsibility for ensuring ADL compliance. The Interim DON said the importance of providing showers were to make the resident feel clean and prevent skin infections. The Interim DON stated she would be monitoring through education, visual spots checks, and random questioning. <BR/>During an interview on 9/15/2022 at 3:51 p.m., the Administrator stated she had only been here for two weeks, but she expected the residents to be bathed at least three times weekly. The Administrator stated it had not been reported to her that showers were not giving due to staff. The Administrator stated she was in the process of hiring more CNAs to help with residents' care. The Administrator stated the Interim DON would be monitoring by education, in-services, and spot checks to ensure those tasks were being completed. <BR/>During an interview on 9/15/2022 at 3:18 p.m., Resident #10's shower communication sheet for the month of August and September was requested from the Interim DON but was provided upon exit. <BR/>During an interview on 9/15/2022 at 5:39 p.m., the Administrator stated there was no policy related to ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 15 residents (Resident #11) reviewed for accidents<BR/>The facility failed to ensure Resident #11 was properly secured in his wheelchair during transport resulting in the Resident #11 coming out of his wheelchair and having bilateral femur fractures and a clavicle fracture.<BR/>This was determined to be past a non-compliance Immediate Jeopardy (IJ) with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The Administrator was notified of the past non-compliance Immediate Jeopardy (IJ) on 9/13/22 at 4:22 p.m.<BR/>This failure could place residents at risk for injury/death from a vehicle accident and decreased quality of life.<BR/>Findings Include:<BR/>1. Record review of the face sheet dated 9/15/22 indicated Resident #11 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including fracture of the left femur, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), fracture of the left clavicle, fracture of the right femur, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and muscle weakness.<BR/>Record review of the comprehensive MDS dated [DATE] indicated Resident #11 was usually understood by others and usually understood others. The MDS indicated Resident #11 had a BIMS assessment had not been completed. The MDS indicated Resident #11 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #11 required limited assistance with eating.<BR/>Record review of the care plan last revised on 5/31/22 indicated Resident #11 was at risk for falls related to diagnoses of cerebral palsy, Parkinson's disease, paraplegia, and unspecified convulsions. The care plan indicated Resident #11 had limited physical mobility related to cerebral palsy, Parkinson's disease, and paraplegia with interventions including resident had a manual wheelchair and a motorized wheelchair special made for his body/contractures. The care plan indicated Resident #11 had alteration in mobility related to sustained multiple fractures (bilateral femurs (upper leg bone) and left clavicle (collar bone)).<BR/>Record review of the provider investigation report dated 5/31/22 indicated Resident #11 and Resident #15 were being transported by the facility van and accompanied by facility staff when Resident #11 fell out of his wheelchair when the vehicle stopped. The provider investigation report indicted Resident #11 was transferred from the scene of the incident to the emergency department by ambulance for assessment. The provider investigation report indicated the facility was notified by the hospital on 5/31/22 Resident #11 had a fracture to both lower extremities that would require surgery and may have had additional injuries as some results were still pending. The provider investigation report indicated CNA R and the former SW were found negligent in their actions when failing to properly secure Resident #11 and his wheelchair after performing a demonstration of how the Resident #11 and his wheelchair were secured prior to the accident. The provider investigation report indicated CNA R and the former SW were both terminated following the investigation by the facility. <BR/>Record review of an in-service dated 5/31/22 indicated staff had been in-serviced on driver and vehicle safety, driver and vehicle safety policy, and hands on demonstration.<BR/>Record review of Resident #15's witness statement dated 6/01/22 indicated Resident #15 said she and Resident #11 were not buckled in securely during the transport on 5/31/22. Resident #15 said in her witness statement the driver was reckless and hit the brakes hard. Resident #15 said in her witness statement she had to brace herself when the van came to a stop and Resident #11 came out of his wheelchair. Resident #15 said on the trip from the facility to her appointment her wheelchair had not been strapped down and that only the wheelchair break had been applied.<BR/>Record review of an action plan agenda dated 6/1/22 indicated the facility recognized an issue/concern of securing and transporting residents. The action plan agenda had a measurable goal of no resident would be injured during transport related to loading or securing mechanisms. The action plan agenda included the following interventions:<BR/>All staff that would be allowed to operate the facility van had performed a return demonstration on loading residents who use wheelchairs and securing residents in wheelchairs.<BR/>All new employees who would operate the facility van, on the skill check off, including loading riders who use wheelchairs, power chairs vs wheelchair, and procedures for securing wheelchairs.<BR/>Director of Maintenance and/or any trained administrative designee will in-service and train all staff that would provide transportation.<BR/>Record review of CNA R employee file indicated she was terminated from the facility on 6/8/22.<BR/>Record review of the former SW's employee file indicated she was terminated from the facility on 6/8/22.<BR/>Record review of CNA C's employee file it indicated had a New Driver Form including DL number signed by the administrator on 8/04/22, had signed acknowledgement and consent agreement company or rental vehicle policy on 8/04/22, had Vehicle Safety Acknowledgement signed 8/04/22, and a Securing Resident in Van Competency signed by the Administrator.<BR/>Record review of the Maintenance Supervisor's employee file indicated New Driver Form including DL number signed by the administrator on 8/04/22, had signed acknowledgement and consent agreement company or rental vehicle policy on 8/04/22, had Vehicle Safety Acknowledgement signed 8/04/22, and a Securing Resident in Van Competency signed by the Administrator.<BR/>During an interview on 9/12/22 at 10:49 a.m. Resident #11 said on 5/31/22 he had gone to the surgical center and was transported by the facility van. Resident #11 said he went to the surgical center for pain management. Resident #11 said he was picked up by the facility van. Resident #11 said the driver of the facility van was a transportation aide in training. Resident #11 said there was stuff on the floor of facility van. Resident #11 said the transportation aides had to move things around to put him on the facility van. Resident #11 said the transportation aides only secured his wheelchair with two straps on the left-hand side. Resident #11 said he did not have a strap across his body (shoulder harness or lap belt). Resident #11 said the transportation aide came to abrupt stop and resident flipped out of his WC. Resident #11 said he was lying in the floor of the bus. Resident #11 said he insisted the facility staff call the for transport to the emergency department. Resident #11 said he was transferred to the emergency department and test results revealed he had bilateral femur fractures and a clavicle fracture.<BR/>During an interview on 9/12/22 at 12:19 pm the BOM said the former SW had transported residents in the facility van prior to the accident involving Resident #11. She said the former SW was training new transportation drivers at the time of the accident involving Resident #11.<BR/>During an interview on 9/12/22 at 3:08 p.m. Resident #15 said she remembered the incident on 5/31/22 involving Resident #11 getting injured on the facility van. Resident #15 said they were being transported in the facility van and the transportation aide stopped too fast. Resident #15 said Resident #11's wheelchair was not locked down properly and he came out of the wheelchair. Resident #15 said she was pulled forward by the sudden stop, but her wheelchair did not move and she did not come out of her wheelchair. <BR/>During an interview and observation on 9/13/22 at 9:00 a.m. CNA, C demonstrated securing a wheelchair in the facility van. CNA C secured the wheelchair with 5 straps attached to the floor and a shoulder strap and lap belt over where the resident would be sitting in the wheelchair. CNA C said she had been working at the facility for about 1 month. CNA C said she was trained on facility transport by the Maintenance Supervisor. The van was observed to have accommodations for one wheelchair to be secured in the facility van. CNA C said she had been trained to only transport one resident in a wheelchair at a time. <BR/>During an interview on 9/13/22 at 9:46 am the Administrator said she expected only one resident in a wheelchair to be transported at a time. The Administrator said only one resident in a wheelchair should be transported due to the van only being equipped to safely secure one wheelchair. <BR/>During an interview on 9/13/22 at 9:49 a.m. the former SW said she was not training the transport person. The former SW said she was in the van with the transport person when she picked up the Resident #11. The former SW said she had assisted in transporting residents. The former SW said she had not been trained on transporting residents. The former SW said she had transported residents on her own and with CNA's. The former SW said there were 2 residents in the van both were in wheelchairs at the time of the accident. The former SW said she did not know how many wheelchairs the van could safely secure. The former SW said that was the first time 2 residents in wheelchairs had been transported at the same time. <BR/>During an interview on 9/13/22 at 10:50 a.m. the Maintenance Supervisor said he trained the new certified transportation aide. The Maintenance Supervisor said he was trained by the Administrator. The Maintenance Supervisor said he watched videos and performed demonstrations to become trained. The Maintenance Supervisor said when he trains a new transportation aide they watched the required videos and then performed safety demonstrations on securing residents who were in wheelchairs and who ambulate, using the lift, securing loose items, and driving the facility van.<BR/>During an interview on 9/13/22 at 10:52 a.m. the former DON said it was her first week working in the facility when the accident occurred on 5/31/22. The former DON said she was notified of the accident by the former Administrator. The former DON said Resident #11 was sent to the ER after the accident. The former DON said Resident #11 suffered a clavicle fracture and bilateral femur fractures. The former DON said there had been 2 residents on the van in wheelchairs when the accident occurred. The former DON said she thought the van was equipped to transport 2 residents in a wheelchair at the same time. The former DON said the former SW and CNA R were not trained on transporting residents. The former DON said after the incident the former Administrator, the former SW, CNA R, and she were trained regarding transporting residents by the corporate nurses. <BR/>During an interview on 9/13/22 at 11:30 a.m. the former Administrator said the former SW was training CNA R on transporting. The former Administrator said he had been led to believe the former SW had been trained on transports. The former Administrator said on 5/30/22 CNA R shadowed the former SW during resident transports. The former Administrator said on 5/31/22 CNA R return demonstrated back to the former SW the proper way to transport residents. The former Administrator said 2 residents in wheelchairs had been transported together at the time of the accident. The former Administrator said the van was equipped to secure 2 residents in wheelchairs at the same time. The former Administrator said there was adequate equipment to secure both residents when the accident occurred. The former Administrator said Resident #11 sustained injuries including 2 broken femurs and a broken clavicle. The former Administrator said the Maintenance Supervisor was trained along with other staff members a day or two after the incident. The former Administrator said the training was performed by corporate nurses. <BR/>During an observation on 9/13/22 at 3:15 p.m. the surveyor watched the following training videos provided by the facility:<BR/>SURE-LOK Wheelchair Restraints by NW Bus Sales<BR/>Commercial Wheelchair Operators Video<BR/>Wheelchair Lift Overview Video<BR/>All videos observed by the survey gave instruction for properly loading and unloading residents via the lift on the facility van and properly securing a resident in a wheelchair for transport. <BR/>Record review of the facility's undated Driver and Vehicle Safety Manual indicated, .The objective of this policy is to implement safe driving policies and practices so that the following goals are met .No employee or resident injuries in or around a vehicle .Residents are properly secured at all times .Employees droving the company vehicle shall also: Know how to safely load and unload residents/passengers and properly secure wheelchairs and other equipment if responsible for transporting residents .Team members who drive the company vehicle for residents must watch the following videos: SURE-LOK Wheelchair Restraints by NW Bus Sales, Commercial Wheelchair Operators Video, and Wheelchair Lift Overview Video .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infects for 1 of 6 residents (Resident #28) reviewed for incontinence care. <BR/>The facility did not ensure Resident #28 foley catheter (connection between the urinary bladder and the urethra to drain urine from the bladder) was secured to facilitate urine flow and prevent kinking for four days.<BR/>These failures could place residents at risk for injury and urinary tract infections.<BR/>Findings include:<BR/>Record review of the of the order summary report, dated 9/15/2022, indicated Resident #28 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements), cognitive communication deficit, and pressure ulcer of sacral region, Stage 4. <BR/>Record review of the order summary report dated 9/15/2022, indicated check foley catheter placement, ensure foley was secured via stabilization device to reduce friction/pulling with a start date 4/05/2022. <BR/>Record review of the annual MDS dated [DATE], indicated Resident #28 sometimes understood others and sometimes made herself understood. The assessment did not address Resident #28 BIMS score. The assessment indicated Resident #28 required extensive assistance with bed mobility, dressing and: total dependence with transfers, eating, toileting, personal hygiene, and bathing. The assessment indicated Resident #28 had an indwelling catheter/external catheter for bladder elimination.<BR/>Record review of the undated care plan indicated Resident #28 was incontinent and had a foley catheter due to dx: neuromuscular dysfunction of the bladder and Parkinson's disease. The care plan interventions included, check foley catheter placement, and ensure foley was secured via Velcro strap to reduce friction/pulling every shift. <BR/>During an observation on 9/12/2022 at 11:12 a.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/12/2022 at 4:01 p.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/13/2022 at 8:59 a.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an attempted interview and observation on 9/13/2022 at 11:25 a.m., indicated she was non-interview able. Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/13/2022 at 4:20 p.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/14/2022 at 9:15 a.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an observation on 9/14/2022 at 2:28 p.m., Resident #28 had a foley catheter and the tubing was not secured. <BR/>During an interview and observation on 9/15/2022 at 10:42 a.m., LVN A stated she was Resident #28's 6a-2p charge nurse. LVN A stated the charge nurses were responsible for ensuring Resident #28 catheter was secured. LVN A verbalized she should have ensured the catheter was secured but overlooked it. LVN A stated the aides were also responsible for reporting if there was no catheter securement during repositioning and incontinent care. LVN A stated no one had reported to her that there was no catheter securement. LVN A said the failure of not having the catheter secured cause potential damage, pain, and infection to the site. <BR/>During an interview on 9/15/2022 at 1:19 p.m., CNA G stated she was Resident #28's 6a-2p aide, CNA G stated nurses were responsible for ensuring Resident #28 catheter tubing was secured. CNA G said she noticed Resident #28 catheter tubing not secured when she provided care to Resident #28 on 9/12/2022. CNA G said she reported to the nurse when she noticed the catheter was not secured but could not remember what nurse she told. CNA G said having the catheter secured would prevent the catheter from being pulled out. <BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been at the facility for three days. The Interim DON stated she expected the charge nurses to ensure Resident #28 catheter tubing was secured. The DON stated she expected the CNAs to notify the nurses about the catheter not being secured. The Interim DON stated it would be her responsibility for ensuring foley catheter compliance. The Interim DON stated the failure of not having the catheter tubing secured would be skin irritation and potential damage. The Interim DON stated she would be monitoring through education, visual spots checks, and random questioning. <BR/>Record review of the facility's policy Catheters-Insertion and Care: Indwelling, Straight, Supra-Public, and external, dated 4/2021, indicated . Procedure-Indwelling Catheter-Insertion 7. Attach catheter strap to be leg to assist in securing tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who require respiratory care are provided such care, consistent with professional standards of practices for 1 of 6 residents (Resident #5) reviewed for respiratory care. <BR/>The facility failed to store a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask in a plastic bag when it was not in use for Resident #5.<BR/>This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings include: <BR/>Record review of the of the order summary report, dated 9/15/2022, indicated Resident #5 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue), asthma (chronic condition that affects the airways in the lungs), wheezing (whistling sound you make when your airway is partially blocked, and atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of the order summary report dated 9/15/2022 indicated Resident #5 received Ipratropium-Albuterol Solution (medication which opens the airways in the lungs) 0.5-2.5 (3) mg/ml via inhalation orally every 4 hours as needed for wheezing, shortness of breath with a start date 5/3/2022. <BR/>Record review of the annual MDS, dated [DATE], indicated Resident #5 usually understood others and made herself understood. The assessment indicated Resident #5 was cognitively intact with a BIMS of 15. The assessment indicated she required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene: supervision with eating, and: total dependence with bathing. The assessment indicated Resident #5 did not became short of breath or trouble breathing with/without activity.<BR/>Record review of the undated care plan indicated Resident #5 had shortness of breath related to asthma. There were interventions to administer Ipratropium-Albuterol Solution (medication which opens the airways in the lungs) 0.5-2.5 (3) mg/ml via inhalation orally every 4 hours as needed for wheezing, shortness of breath via inhalation, maintain a clear airway by encouraging resident to clear own secretions with effective coughing and monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. <BR/>Record review of the treatment administration record dated 9/01/2022-9/30/22 revealed there was not any documentation related to administration of Ipratropium-Albuterol Solution. <BR/>During an observation and interview on 9/12/2022 at 2:48 p.m., Resident #5's nebulizer mask was on the bedside table and was not covered. Resident #5 stated the last time she wore her nebulizer mask was last week due to shortness of breath. <BR/>During an observation on 9/13/2022 at 8:58 a.m., Resident #5's nebulizer mask was on the bedside table and was not covered.<BR/>During an observation on 9/14/2022 at 8:41 a.m., Resident #5's nebulizer mask was on the bedside table and was not covered.<BR/>During an observation on 9/15/2022 at 2:00 p.m., Resident #5's nebulizer mask was on the bedside table and was not covered.<BR/>During an interview on 9/15/2022 at 2:14 p.m., LVN A stated she was Resident #5's 6a-2p charge nurse. LVN A stated the charge nurses were responsible for ensuring the mask was placed in a plastic bag after each nebulizer treatment. LVN stated she had not given Resident #5 a nebulizer treatment in the past few weeks. LVN stated I really did not notice the mask lying on her bedside table. LVN stated this failure could potentially put Resident #5 at risk for a respiratory infection. <BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been in the facility for three days, but she expected Resident #5's nebulizer mask be stored in a plastic bag when not in use. The Interim DON stated the nurses were responsible for ensuring the mask was placed in a bag after each nebulizer treatment. The Interim DON stated it would be her responsibility to make sure the nursing staff were properly storing respiratory equipment. The Interim DON stated she would be monitoring through education, visual spots checks, and random questioning. <BR/>Record review of the facility's policy Nebulizer Treatments, dated 04/2021, indicated . 13. Keep tubing and nebulizer mask in plastic bag when not in use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate less than 5% during the medication pass, in which there were 5 errors out of 30 opportunities, resulting in a 16.67% error rate for 3 of 3 residents (Resident #27, Resident #7, and Resident #28) observed for medication administration.<BR/>LVN S did not administer Resident #27's Vitamin B12 (a medication used to treat Vitamin B12 deficiency, osteoporosis, and fatigue). <BR/>LVN E did not administer Resident #7's Vitamin B12 (a medication used to treat Vitamin B12 deficiency, osteoporosis, and fatigue) or Calcium Carbonate (a medication used to treat acid reflux, upset stomach, indigestion, and heartburn).<BR/>LVN E did not administer the correct dose of Resident #7's Vitamin D3 (a medication needed in the body for healthy bones, muscles, nerves, and to support the immune system).<BR/>LVN A did not administer Resident #28's Potassium (a medication used to treat low potassium or to prevent potassium levels from dropping to low due to certain medical conditions or medications).<BR/>These failures could place residents at risk for avoidable complications and symptoms of their disease process.<BR/>Finding Include:<BR/>Error #1 <BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #27 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including vitamin deficiency. The physician orders indicated Resident #27 had an order starting on 9/01/21 for Vitamin B12 1000 mcg (micrograms) to be given by mouth twice a day for vitamin deficiency.<BR/>During an observation and interview on 9/13/22 at 7:38 a.m. LVN S did not administer the prescribed Vitamin B12 to Resident #15. LVN S said she did not have any Vitamin B12 on her medication cart but was going to look in the medication room. LVN S said there was not any Vitamin B12 in the medication room to administer to Resident #15. <BR/>Error #2, #3, and #4<BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #7 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including Vitamin B12 deficiency, Vitamin D deficiency, and gastro-esophageal reflux (when the stomach acid repeatedly flows back into the tube connecting the mouth and stomach). The physician orders indicated Resident #7 had an order starting on 6/24/22 for Calcium Carbonate 600mg (milligrams) by mouth twice a day for health maintenance. The physician orders indicated Resident #7 had an order starting 6/25/22 for Vitamin B12 500mcg by mouth daily for health maintenance. The physician orders indicated Resident #7 had an order for Vitamin D3 3000 units by mouth daily for a supplement. <BR/>Record review of the care plan (revision dated unknown) indicated Resident #7 was at risk for altered nutritional status and altered labs related to diagnoses, medications, diet, and appetite with interventions including administer medication as ordered. <BR/>During an observation on 9/13/22 at 7:57 a.m. LVN E did not administer Resident #7's Calcium Carbonate or Vitamin B12. LVN E administered Resident #7 Vitamin D3 2000 units and not the prescribed Vitamin D3 3000 units. <BR/>During an interview on 9/13/22 at 12:38 p.m. LVN E said she did not have any Vitamin B12 500mcg to administer to Resident #7. LVN E she gives medications when they pop up on the medication administration record to be given. LVN E said she showed the surveyor all Resident #7's medications as she put them in the medication cup. LVN E said she was unsure as to whether she gave Resident #7 Calcium Carbonate this morning. <BR/>Error #5<BR/>Record review of consolidated physician orders dated 9/15/22 indicated Resident #28 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including hypokalemia (decreased potassium level). The physician orders indicated Resident #28 had an order starting on 9/13/22 for Potassium Chloride 20 MEQ (milli-equivalents) via G-tube one time a day for hypokalemia. <BR/>During an observation on 9/15/22 at 8:53 a.m. LVN A did not administer Resident #28's Potassium Chloride as prescribed. <BR/>During an interview on 9/15/22 at 2:12 p.m. LVN K said medications should not be missed including vitamins. LVN K said the importance of not missing medication was due to physician orders and vitamins like B12 and D3 can affect bones, energy, and immune system. <BR/>During an interview on 9/15/22 at 2:31 p.m. LVN E said medications on the medication administration record should be given if available. LVN E said if a medication was not available the nurse should look in medication room and ask the other nurse if they have any of that medication. LVN E said the importance of not missing ordered vitamins was for bone health and immunity. LVN E said the facility was out of B12 500mcg. LVN E said she did not recall omitting Resident #7's Calcium Carbonate or administering the wrong dose of Vitamin D3. <BR/>During an interview on 9/15/22 at 03:04 p.m. the interim DON said she had started at the facility on 9/13/22. The interim DON said all medications including vitamin should be administered as ordered. The interim DON said the importance of vitamins was wound healing, anemia, and bone health. The interim DON said the importance of potassium was for heart health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents with food and drink that was palatable, attractive, served at a safe and appetizing temperature, prepared by methods that conserve nutritive, flavor, taste, and appearance for six of seven residents (Residents #1, #2, #3, #4, #5 and #6) reviewed for palatable food.<BR/>The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 who complained the food was served cold and did not taste good. <BR/>These failures could place residents at risk of decreased food intake, weight loss, altered nutritional status and diminished quality of life.<BR/>Findings included:<BR/>Resident #2 <BR/>Review of a MDS dated [DATE], showed Resident #2 was admitted on [DATE] with a BIMS score of 07 which indicated resident #2 had moderate to severe cognitive impairment but was alert to person, place. and time.<BR/>During an interview on 07/30/23 at 7:00 a.m., Resident #2 said he normally does not like the food that is served so he always asked for a cheeseburger. Resident #2 said last night he was served a cold salad that he sent back to the kitchen because the lettuce was nasty, and he could not eat it. Resident #2 said he requested a cheeseburger instead, but he never got it.<BR/>During an interview on 07/30/23 at 5:25 a.m. CNA A said she had worked at the facility since January 2023. CNA A said she had heard residents complain about the food. CNA said Resident #2 complained a lot. CNA A said if a resident does not like what is was served they can could choose from the anytime menu, CNA A said residents can ask for a sandwich, grilled cheese, salad, or a hamburger. CNA A said breakfast alternatives are dry cereal, toast, or oatmeal. <BR/>Resident #3<BR/>Review of a MDS dated [DATE], showed Resident #3 was admitted on [DATE] with a BIMS score of 15 which indicated resident #3 was alert to person, place. and time. Resident #3 received a regular diet. <BR/>Resident #4 <BR/>Review of a MDS dated [DATE], showed Resident #4 was admitted on [DATE] with a BIMS score of 15 which indicated resident #4 was alert to person, place. and time. Resident #4 received a regular diet.<BR/>Resident #5 <BR/>Review of a MDS dated [DATE], showed Resident #5 was admitted on [DATE] with a BIMS score of 12 which indicated resident #5 was alert to person, place. and time. Resident #5 received a regular diet.<BR/>During a group interview on 07/30/23 at 7:25 a.m., Residents #3, #4, and #5 said the food is often served under seasoned. Residents said they are not provided with salt on the table. Resident #4 said she had asked for salt, but it was not provided. Residents said the night before, during the evening meal they were served a chef salad with a fried chicken strip on top. They said they could not eat the lettuce because it was too hard, and they could not chew it. They said all they ate was the chicken strip and left the rest on their plate because they could not eat it. Residents said the sausage severed for breakfast today was over-cooked, hard, and difficult to chew. Resident #3 said the biscuit was hard and had garlic and cheese on the inside which he did not like for breakfast. Residents said there is normally an alternative, but the air conditioning in the kitchen was out and they did not want the cook to have to heat up the kitchen to fix something else, so they did not request an alternative to the chef salad. <BR/>Resident #1<BR/>Review of a MDS dated [DATE], showed Resident #1 was most recently admitted on [DATE] with a BIMS score of 15 which indicated resident #1 was alert to person, place. and time. Resident #1 received a regular diet.<BR/>During an interview on 07/30/23 at 10:05 a.m. Resident #1 said the food at the facility is horrible and something needs to be done about it. Resident #1 said most of the time she could not eat the food, and something must be done about the food.<BR/>Resident #6<BR/>Review of a MDS dated [DATE], showed Resident #6 was admitted on [DATE] with a BIMS score of 14 which indicated resident #6 was alert to person, place. and time. Resident #6 was discharged home on [DATE]. Review of weight records showed Resident #6 was weighed at admission with a weight of 214.8 pounds. Resident #6 was discharged home on [DATE] before being weighed a second time.<BR/>Review of a grievance dated 04/26/23 Resident #6 complained she was served a cheeseburger with no meat and was supposed to get French fries but instead served Fritos. Resident #6 said the night before residents were not told that rather than chicken with a salad, the night meal was changed to Chile dogs. Resident #6 Resident also complained she was served one burnt sausage patty and oatmeal for breakfast.<BR/>During a telephone interview on 07/28/23 at 11:32 a.m. Resident #6 said the food at the facility was not eatable. She said she complained but nothing was done. She said they served a chili dog one night, and she does not want something spicy before she goes to bed. She said she ended up losing weight while she was there for just a couple weeks.<BR/>Review of a breakfast menu dated 07/30/23 showed orange juice, Oatmeal, Denver scrambled egg, toast, jelly, milk 2%, Coffee, water, margarine.<BR/>During an observation and interview on 07/30/23 at 8:25 a.m. A test tray was delivered to the conference room by the administrator. The test tray consisted of what looked like a bowl of thick gravy but was found to be a bowl of pureed oatmeal. There was a biscuit, sausage patty and a half glass of orange juice. The oatmeal was a thick consistency, gummy in texture, bland with no seasoning, and lukewarm. The sausage patty was overcooked and hard. The biscuit was hard and cold. Inside the biscuit was small chucks of what appeared to be cheese that had been cooked into the biscuit. The Biscuit had the flavor of garlic. The orange juice was a thick consistency and very sweet. The test tray was found to be unpalatable. The administrator said the food did not look palatable. The administrator said the biscuit was overcook and dry. The administrator said the pureed oatmeal looked like a bowl of gravy, was very thick and not something she would want to eat. The administrator said the orange juice looked very dark and had a thick consistency, was under concentrated and water needed to be added. The administrator said the air conditioning was out in the kitchen and cooks were serving items that required the least amount of cooking to avoid heating up the kitchen. <BR/>During an interview on 07/30/23 at 8:35 a.m. DA-A said the food on the test tray was Pureed oatmeal. DA-A said the orange juice was from concentrate and was dispensed from a machine in the kitchen. DA-A said the machine needed to be recalibrated to make the orange juice a better consistency.<BR/>Review of lunch menu dated 07/30/23 showed Roast beef with gravy, parsley noodles, peas with pimento, roll with margarine, Carrot cake with cream cheese icing. Milk 2%, iced tea, and water.<BR/>During an observation of meal service on 07/30/23 at 11:55 a.m. showed all items on the food warming table were under the recommended temperature for food service. DA-A was observed reheating all the food prior to starting meal service. <BR/>During an Observation and interview on 07/30/23 at 12:35 p.m. a test tray was delivered to the conference room by the Dietary Manager. The tray consisted of roast beef with gravy, parsley noodles, peas with pimento, and a Hawaiian roll. The roast beef with gravy although visually unappealing, because it looked more like a stew mixed together, was well seasoned and had a pleasant taste and texture. The peas with pimento were hard, bland with no flavor, seasoning or salt. The Parsley noodles had an unpleasant texture and appeared to be undercook, hard, dry with no seasoning or salt. The Dietary Manager said the only thing on the tray that was palatable was the roast beef and gravy. The Dietary Manager said the noodles was bland and had a funny texture. The Dietary Manager said the facility had stopped using angle hair spaghetti because it became unpalatable on the steamtable in about 10 minutes. DM said he had heard about the breakfast service and will in-service staff on the importance of serving food that is palatable and nutritious. Dietary Manager said the peas had not been cooked properly, were not tender and the cook did not follow the recipe for cooking the pea or the noodles.<BR/>Review of a recipe for peas and pimentos showed peas were to be boiled for 10 minutes or until tender. Drain and add margarine, pimentos and toss lightly. Maintain temperature above 140 degrees during entire service period. Take temperature of unserved product every 30 minutes. Maximum holding time 4 hours.<BR/>Review of a recipe for Parsley Noodles showed Add 1 tablespoon and 2 1/8 teaspoons of salt to water. Bring water to a boil. Place noodles in water. [NAME] 10-15 minutes until tender. Drain well, add margarine. Sprinkle parsley over noodles and toss. Maintain temperature above 140 degrees during entire service period. Take temperature of unserved product every 30 minutes. Maximum holding time 4 hours. <BR/>During an interview on 07/31/23 at 10:45 a.m. [NAME] A said she had worked at the facility as a cook for 2 years. She said she did not work on 07/30/23 and the cook working was new and was his first day working alone. [NAME] A said each menu item has a recipe that should be followed that had been approved by the facility's Dietician. [NAME] A said on 07/30/23 during the evening meal Resident #2 requested a cheeseburger because he did not like the chef salad that was served. [NAME] A said she prepared the cheeseburger and took it to Resident #2's room but he was not there. [NAME] A said she went to the smoking area to find Resident #2, and he was not there. [NAME] A said she took the cheeseburger back to the kitchen and left it in case Resident #2 asked for it and clocked out and went home. [NAME] A said she did not know if Resident #2 got the cheeseburger. <BR/>During an interview on 07/31/23 at 1:50 p.m. the Dietician said she comes to the facility twice a month to monitor and assess residents and nutritional needs. The Dietician said there are 4 residents who triggered for weight loss, but she had recommended supplements and there are currently no residents with significant weight loss. Dietician said all menu items have a recipe provided that should be followed to ensure the food is prepared so it will be palatable and nutritious. Dietician said she had heard residents complain about what kind of food was being served but not complaints about the taste or palatability of the food. Dietician said she did not provide the menus to the dietary staff, and the menus and recipes are provided by cooperate.<BR/>Review of a grievance dated 05/12/23 showed a complaint was made by the Resident Council regarding food not being warm, toast not being toasted, undercook sausage and never having condiments. The corrective action showed We no longer have the cook anymore; we have a process in place to prevent this from occurring.<BR/>A Policy dated 04/2022 showed, The dining experience will enhance the resident's quality of life and recognize the resident's needs during dining to achieve a nutritional meal .1. Resident will be provided with nourishing, palatable, attractive meals that meet the resident's daily nutritional needs.

Based on interview and record review, the facility failed to consistently serve a suitable, nourishing alternative meals and snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 7 of 9 resident's reviewed for snacks. <BR/>The facility failed to provide an evening nourishing snack routinely to all residents. <BR/>This failure could lead to residents' experiencing complications of diabetes such as low blood sugar or weight loss. <BR/>Findings include: <BR/>During a confidential resident group meeting on 9/13/2022 at 11:30 a.m., seven out of nine residents stated there was an ongoing issue with receiving snacks in the evenings and weekends. They said the issue had been reported to multiple staff members verbally but was unable to call names. <BR/>During an interview on 9/15/2022 at 8:39 a.m., LVN H stated the dietary staff were responsible for preparing snacks and the aides were responsible for passing them out. LVN H stated there has been issues with the dietary staff not providing snacks on the weekend. LVN H stated, It was a luck of draw that we had snacks. LVN H stated she had told the dietary staff on several occasions that snacks to be provided but they seemed to ignore it. LVN H stated she had reported it to the DON that was no longer here on several occasions, but she had not been an intervention put in place. LVN H stated it was important for residents to receive their evening snacks to prevent hypoglycemia and nourishment. <BR/>During an interview on 9/15/2022 at 1:10 p.m., the Activity Director stated residents had complained to her about not getting their snacks. The Activity Director stated she had reported this issue to the Food Service supervisor. The Activity Director stated dietary staff were responsible for preparing snacks and the aides were responsible for passing them out to residents. The Activity Director stated it was important for residents to be provided with snacks to prevent hypoglycemia, and for residents that was unable to purchase their own. <BR/>During an interview on 1:19 p.m., CNA G stated residents had complained to her about not getting their snacks. CNA G stated there were some nights that dietary staff had not provided the snacks for the aide to passed out. CNA G stated she had personally reported this issue to the Food Service Supervisor that snacks were not provided in the evening. CNA G stated the Food Service Supervisor told her he would take care of the issue. CNA G stated it was important for residents to be provided with snacks to prevent hypoglycemia, and for residents that could not afford snacks. <BR/>During an interview on 9/15/2022 at 1:41 p.m., the Food Service Supervisor stated it had been brought to his attention that snacks was not been provided. He stated the dietary staff were responsible for preparing the snacks and the aides were responsible for passing them out. The Food Service Supervisor stated he had noticed the issue and had tried to correct it by in servicing his staff. The Food Service Supervisor stated over the past few weeks he had only heard of one complaint about not getting snacks. The Food Service Supervisor stated he had instructed his staff to start dating the snack trays to ensure snacks had been prepared. The Food Service Supervisor stated he had not seen any issues with snacks been prepared but aides not passing them out. The Food Service Supervisor stated he did report this to the old DON and thought the issue was resolved. The Food Service Supervisor stated it was important for residents to be provided with snacks to prevent hypoglycemia, and for residents that could not afford their own snacks.<BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been at the facility for three days. The Interim DON stated she expected residents to have snacks in the evening and weekends. The Interim DON stated the dietary staff were responsible or preparing snacks and the nursing staff were responsible for passing them out. The Interim DON stated she had yet had the opportunity to evaluate residents needs and possible concerns. She stated as she got more acclimated to the residents and the facility any issues or concerns would be addressed through education, monitoring such as visual spot checks and random questioning. The Interim DON stated it was important for residents to be provided with snacks to prevent hypoglycemia and weight loss. <BR/>Record review of the facility's policy Frequency of Meals, revised 07/2021, indicated 6. Evening snacks will be offered routinely to all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 3 of 13 residents (Residents #10, #11 and #12) reviewed for personal food safety. <BR/>The facility did not implement their own food from outside sources policy by discarding foods that shows obvious signs of potential foodborne danger. <BR/>The facility did not implement their own food from outside sources policy related to personal refrigerators by managing appropriate temperatures. <BR/>This failure could place the residents at risk for food borne illnesses.<BR/>Findings include:<BR/>1. Record review of the of the order summary report, dated 9/15/2022, indicated Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included need for assistance with personal care.<BR/>Record review of the annual MDS dated [DATE], indicated Resident #10 understood others and made herself understood. The assessment indicated Resident #10 was cognitively intact with a BIMS of 15. The assessment indicated Resident #10 did not reject care. The assessment indicated she required supervision with eating, and total dependence with transfers. <BR/>During an observation on 9/12/2022 at 12:28 p.m., Resident #10's mini fridge was initialed that the temperature was checked on 9/1/22, 9/2/22 and 9/3/22. <BR/>During an interview and observation on 9/13/2022 at 10:15 a.m., Resident #10 stated she could not remember the last time staff cleaned or checked her refrigerator. Resident #10's personal refrigerator had a thermometer in place with a clear container labeled banana pudding dated 6/22/2022. The mini fridge was initialed that the temperature was checked on 9/1/22, 9/2/22 and 9/3/22. <BR/>During an observation on 9/14/2022 at 8:45 a.m., Resident #10's personal refrigerator had a thermometer in place with a clear container labeled banana pudding dated 6/22/2022. The mini fridge was initialed that the temperature was checked on 9/1/22, 9/2/2022 and 9/3/2022. <BR/>During an interview on 9/15/2022 at 1:41 p.m., the Food Service Supervisor stated dietary and housekeeping staff were responsible for checking the temperatures and discarding expired items. He stated, We had gotten slacked on that. The Food Service Supervisor was unable to verbalized how often the mini fridge should be checked for expired items but stated that staff should be checking the temperature log daily. He stated this failure could place residents at risk for food borne illness. <BR/>2. Record review of the face sheet dated 9/15/22 indicated Resident #11 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including fracture of the left femur, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), fracture of the left clavicle, fracture of the right femur, Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and muscle weakness.<BR/>Record review of the comprehensive MDS dated [DATE] indicated Resident #11 was usually understood by others and usually understood others. The MDS indicated Resident #11 had a BIMS assessment had not been completed. <BR/>Record review of the temperature log date September 2022 for Resident #11's personal refrigerator indicated the temperatures had been monitored on September 1, 2, and 3, 2022. <BR/>During an observation and interview on 9/12/22 at 10:49 a.m. Resident #11's personal refrigerator was observed with and incomplete temperature log for his personal refrigerator. Observations indicated Resident #11's personal refrigerator had a thermometer in place and no expired foods were observed. Resident #11 said he did not know the temperature log was on the side of personal refrigerator. Resident #11 said he did not know if the facility had been checking the temperature on his personal refrigerator. <BR/>During an observation on 9/13/22 at 3:12 p.m. Resident #11's personal refrigerator was observed with and incomplete temperature log for his personal refrigerator.<BR/>During an observation on 9/14/22 at 9:12 a.m. Resident #11's personal refrigerator was observed with and incomplete temperature log for his personal refrigerator.<BR/>3. Record Review of Resident #12's admission record (no date) indicated he was a [AGE] year-old male admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease), peripheral vascular disease (circulation disorder) and hypertension (high blood pressure). <BR/>Record Review of Resident #12's MDS dated [DATE] indicated that he had a BIMS score of 8 indicating he was mildly impaired. <BR/>During an observation on 9/12/22 at 12:21 p.m., Resident #12's mini fridge was initialed that the temperature was checked on 09/01/22, 09/02/22 and 09/03/22. <BR/>During an observation on 09/13/22 at 09:28 a.m., Resident #12's mini fridge was initialed that the temperature was checked on 09/01/22, 09/02/22 and 09/03/22. <BR/>During an observation on 9/14/22 at 1:42 p.m., Resident #12's mini fridge was initialed that the temperature was checked on 09/01/22, 09/02/22 and 09/03/22. Mini fridge had water, V8, and baby food inside.<BR/>During an interview on 9/15/22 at 9:11 a.m. with LVN A, LVN A stated that she does not know who is responsible for checking the mini fridge temperatures. LVN A stated she has worked night and day shift and does not check the mini fridge temperatures. LVN A stated that the mini fridge temperatures should be checked so the food does not spoil, or resident's do not get food poisoning.<BR/>During interview on 9/15/22 at 2:59 p.m. with LVN B, LVN B stated the night nurse is responsible for mini fridge temperature checks.<BR/>During an interview on 9/15/22 at 12:50 p.m. with the housekeeping supervisor, the housekeeping supervisor stated the DON and ADON were responsible for checking the temperatures in the mini fridges. Housekeeping Supervisor stated the DON recently left and the ADON has been out on leave. The Housekeeping Supervisor stated he is responsible for the temperature checks on the mini fridges now and, whatever staff checks the mini fridge temperatures should date and initial that the temperature check was done because it is a community effort. The Housekeeping Supervisor stated management makes daily rounds to check resident rooms, including the mini fridge temperatures. Housekeeping Supervisor stated that checking the mini fridge temperatures were important to make sure the resident's do not get bad food. <BR/>During an interview on 9/15/22 at 4:20 p.m. with the DON, the DON reported she does not know the process regarding mini fridges at the facility because she has only been at the facility for 2 days, but she thinks it is housekeeping. DON stated that she expects housekeeping to monitor the mini fridge temperatures and stated she is responsible for making sure housekeeping is checking them. <BR/>During an interview on 9/15/22 at 2:34 p.m. with ADM, the ADM stated housekeeping is responsible for monitoring the mini fridges daily and she expects them to be done. ADM stated the Housekeeping Supervisor keeps a binder in his office with the temperature checks on them. The ADM stated she is responsible for the Housekeeping Supervisor completing the temperature checks on the mini fridges. ADM stated that Department Mangers should have double checked the rooms and mini fridges during their rounds. ADM stated that if temperature checks are not complete, the food in the mini fridge can spoil or cause illness to residents.<BR/>Record Review of the policy on Food from Outside Sources last revised on 03/2021 indicated that #2. Community personnel will be responsible for the managing of appropriate temperatures and food stored in the resident's refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of each resident for one of six of residents (Resident #1) reviewed for medications.<BR/>LVN A failed to ensure all medications were administered according to facility procedure when she left a cup of medication with Resident #1 and failed to observe Resident #1 take the medication.<BR/>This failure could place residents at risk for not receiving the therapeutic benefits from medications. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 07/30/23 showed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses of Multiple Sclerosis, Displace Spinal Fracture, Muscle Weakness, Difficulty Walking, Morbid obesity, Asthma, Neuromuscular Dysfunction of Bladder, Chronic Atrial fibrillation, and Fibromyalgia.<BR/>Review of a MDS dated [DATE], showed Resident #1 was recently admitted on [DATE] with a BIMS score of 15 which indicated resident #1 was alert to person, place. and time.<BR/>Review of a care plan dated 06/22/23 did not show Resident #1had been assessed for self-medication<BR/>Review of consolidated Physician's orders for July 2023 showed Resident #1 was prescribed the following medications to be administered at 9:00 a.m.: <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. Give 2 capsule by mouth one time daily for depression. <BR/>*Fexofenadine HCI Tablet 180 mg. Give 1 tablet by mouth one time a day for allergies. <BR/>*Guaifenesin Tablet. Give 1200 mg y mouth one time a day for allergies. <BR/>*Hydrochlorothiazide Tablet 12.5 mg. Give 1 tablet by mouth one time a day for edema. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, give 2 tablets by mouth one time a say for supplement. DO NOT CRUSH. Administer with a snack or full glass of water.<BR/>*Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for difficulty breathing.<BR/>*Verapamil HCI Tablet 40 mg Give 1 tablet by mouth one time a day for Atrial fibrillation (Heart condition), hold for systolic (Blood Pressure) less than 100 no restrictions on DPB. (Diffuse pan-bronchiolitis (DPB) is a chronic inflammatory airway disease which was lethal in the past despite combined treatment with antibiotics)<BR/>*Buspirone HCI Tablet 5 mg Give 2 Tablets by mouth two time a day for anxiety.<BR/>*MiraLAX Oral Powder 17 GM/Scoop. Give one scoop by mouth two times a day for constipation.<BR/>*Pregabalin Capsule 200 mg. (A strong narcotic pain killer) Give 1 Capsule by mouth two time a day for pain. <BR/>*Prilosec OTC Tablet Delayed Release. Give two tables by mouth 2 times a day for reflux. Do not crush or chew. <BR/>*Senna Tablet 8.6 mg. Give 2 tablets by mouth 2 times a day to prevent constipation, and <BR/>*Valacyclovir HCI Tablet 1 GM Give 1 tablet by month two times a day for MS (Multiple Sclerosis). <BR/>Review of Medication Administration Records dated 07/30/23 at 9:00 a.m. showed the following medication had been administered by LVN A. <BR/>*Duloxetine HCI Capsule delayed release sprinkle 60 mg. <BR/>*Fexofenadine HCI Tablet 180 mg. <BR/>*Guaifenesin Tablet. 1200 mg <BR/>*Hydrochlorothiazide Tablet 12.5 mg. <BR/>*Potassium Chloride ER Tablet Extended Release 20 MG, <BR/>*Prednisone Oral Tablet 20 MG.<BR/>*Verapamil HCI Tablet 40 MG <BR/>*Buspirone HCI Tablet 5 MG <BR/>*MiraLAX Oral Powder 17 GM/Scoop. <BR/>*Pregabalin Capsule 200 MG. <BR/>*Prilosec OTC Tablet Delayed Release. <BR/>*Senna Tablet 8.6 MG, and <BR/>*Valacyclovir HCI Tablet 1 GM.<BR/>During an observation and interview on 07/30/23 at 10:05 a.m. Resident #1 was laying on her back in her bed. There was a plastic cup with multiple pills pouring out of the cup on to the blanket which was covering Resident #1's stomach. Resident # 1 said LVN A had left the cup of medication for her to take. Resident #1 said she asked LVN A to leave the medication and she would take it in a little while. <BR/>During an interview on 07/30/23 at 10:10 a.m. LVN A said she left the cup of medication with Resident #1 to take. LVN A said Resident #1 is in her right mind and she feels okay leaving the medications with Resident #1 to take. LVN said she documented Resident #1 was administered the medication in the electronic MAR, even though she did not witness Resident #1 take the medication. LVN said the medication is to be given at 9:00 a.m.<BR/>During an interview 07/31/23 at 10:35 a.m. the DON said LVN A should not have left the medication with Resident #1. The DON said it is the policy of the facility to watch a resident swallow their medication. The DON said there is a Medication Self-Administration Screening that could be completed to see if a resident is able to administer their own medication, but there had been no such screening for Resident #1. The DON stated LVN A should not have left the cup of pills with Resident #1, even though Resident #1 has a BIMS score of 15 and is totally alert and able to make her own decisions.<BR/>Review of a pharmacy policy dated 08-2018 showed Administer .remain with the resident while medication is swallowed. Exercise caution with residents who have difficulty with swallowing. Do not leave medications at the bedside, unless specifically order by the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 2 of 2 residents (Residents #1 and #30) reviewed for dialysis services.<BR/>The facility failed to keep ongoing communication with the dialysis facility for Resident #1 and Resident #30. <BR/>This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.<BR/>Findings include: <BR/>1.Record review of the order summary report, dated 9/15/2022, indicated Resident #1 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included amputation of left foot, chronic kidney disease (gradual loss of kidney function), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (force of the blood against the artery walls is too high). <BR/>Record review of the order summary report, dated 9/15/2022, indicated Resident #1 to attend hemodialysis on Mondays, Wednesdays, and Fridays with chair time at 11:00 a.m. with a start date 5/16/2022. <BR/>Record review of the admission MDS dated [DATE], indicated Resident #1usually understood others and made himself understood. The assessment indicated Resident #1 was moderately cognitively impaired with a BIMS score of 12. The assessment indicated Resident #1 did not reject care. The assessment indicated he required extensive assistance with bed mobility, dressing, toileting, personal hygiene: total dependence with transfers and: independent with eating. The assessment indicated the activity bathing did not occur or family and/or non-facility staff provided care 100% of the time that activity over the entire 7-day period. The assessment indicated did not received dialysis treatments during the 14-day look back period. <BR/>Record review of the undated care plan indicated Resident #1 had a Dx of unspecified kidney failure and needs hemodialysis related to renal failure (Stage 4 chronic kidney disease). There were inventions that Resident #1 received dialysis M-W-F at a local dialysis facility. Encourage resident to go for the scheduled dialysis appointments. Monitor/document/report PRN any s/sx of infection to access site: redness, swelling, warmth or drainage. Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. <BR/>Record review of the medical record for Resident #1 indicated there was no<BR/>documentation between the facility and dialysis for Resident #1 on the following dates:<BR/>*8/24/2022<BR/>*8/26/2022<BR/>*8/29/2022<BR/>*9/2/2022<BR/>*9/5/2022<BR/>*9/7/2022<BR/>*9/9/2022<BR/>*9/12/2022<BR/>*9/14/2022<BR/>During an interview on 9/13/2022 at 2:50 p.m., Resident #1 said he had dialysis on Mondays, Wednesdays, and Fridays at 10:30 a.m. Resident #1 said he had not missed any dialysis appointments on:<BR/>*8/24/2022<BR/>*8/26/2022<BR/>*8/29/2022<BR/>*9/2/2022<BR/>*9/5/2022<BR/>*9/7/2022<BR/>*9/9/2022<BR/>*9/12/2022<BR/>*9/14/2022<BR/>During an interview on 9/15/2022 at 1:53 p.m., LVN E stated charge nurses were responsible for ensuring the dialysis communication record was sent and received when a resident went to and came back from dialysis. LVN E stated the top portion of the form should be filled out prior to the resident leaving for dialysis, middle portion should be completed by dialysis and the bottom portion should be completed upon resident return. LVN E stated said if the dialysis facility did not send the communication sheet back with the resident the nurse should call dialysis to have them to fax over the communication form. LVN E stated it had been an issue with the facility and dialysis center not sending or returning the form when the resident return. LVN E said residents not assessed before or after dialysis could experience complications including hypotension, bleeding, and issues with the port access site. <BR/>During an interview on 9/15/2022 at 2:14 p.m., LVN A stated charge nurses were responsible for ensuring the dialysis communication record was sent and received when a resident went to and came back from dialysis. LVN A stated the top and bottom portion should be by the charge nurse and the middle portion to be completed by the dialysis center. LVN A stated the purpose of the form was communication between the facility and dialysis. LVN A said if the dialysis facility did not send the communication sheet back with the resident the nurse should call dialysis to obtain communication sheet. LVN A said residents could experience decrease blood pressure if they were not assessed before or after dialysis. <BR/>During an interview on 9/15/2022 at 3:18 p.m., the Interim DON stated she had only been at the facility for three days, but she expected residents receiving dialysis should be assessed pre and post dialysis and the assessment should be recorded on the dialysis communication report. The Interim DON stated the dialysis communication report was a communication between the facility and dialysis. The Interim DON stated if the dialysis facility did not send the communication report back with the resident it was the charge nurses' responsibility for calling the dialysis center and requesting the communication report. The Interim DON stated she would be responsible for monitoring dialysis residents to ensure communication was being maintained between the facility and the dialysis center through visual spots checks, and random questioning. The Interim DON stated residents not assessed before or after dialysis could experience complications including fluid depletion. <BR/>2. Record Review of Resident #30's admission record (no date) indicated she was a [AGE] year-old female admitted on [DATE] with a diagnosis of chronic kidney disease, seizures, and hypertension (high blood pressure). <BR/>Record Review of Resident #30's MDS dated [DATE] indicated a BIMS score of 6 indicating severely impaired cognition. <BR/>Record Review of Resident #30's orders dated 4/20/2022 indicated that she attends hemodialysis on Mondays, Wednesdays, and Fridays. <BR/>Record review of the medical record for Resident #30 indicated there was no communication report between the facility and dialysis for Resident #30 on the following dates:<BR/>*July 11, 2022<BR/>*July 13, 2022<BR/>*August 8, 2022<BR/>*August 10, 2022<BR/>*August 12, 2022<BR/>*August 15, 2022<BR/>*August 17, 2022<BR/>*August 19, 2022<BR/>*August 22, 2022<BR/>*August 24, 2022<BR/>*August 26, 2022<BR/>*August 29, 2022<BR/>*August 31, 2022<BR/>*September 2, 2022<BR/>During an interview with Resident #30 on 9/15/22 at 9:39 a.m., Resident #30 denied missing any dialysis visits.<BR/>During interview on 9/15/22 at 4:20 p.m. with DON, the DON stated the charge nurses are responsible for keeping up with the dialysis book and communication forms. DON reported she is responsible for making sure the nurses have kept up with the forms. DON reported that she started at facility 2 days ago and she would be responsible for making sure the nurses had the communication forms in the dialysis book. <BR/>During an interview on 9/15/22 at 2:34 p.m. with the Administrator, the Administrator stated the previous DON had the dialysis communication forms in her office and the office was empty when she resigned. Administrator reported that she called the dialysis center to retrieve a copy of the communication forms and the dialysis center did not keep copies. The Administrator stated it is the nurse managers responsibility to keep up with the communication forms and a binder should be kept at the nurse's station. Administrator reported she is responsible for the nurse manager and the communication forms are needed to determine the welfare/wellness of patients.<BR/>Record review of the facility's policy AV Fistula Shunt Examination and Maintenance, dated 11/1/2019, indicated . 4. Documentation: All physical findings. Report any abnormal findings to the physician .<BR/>Resident #30<BR/>Dialysis <BR/>09/13/22 04:23 PM monday, wed and fri at davita; missing communication reports; resident denied missing any days

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure food was provided that accommodated the preferences of 1 of 15 residents reviewed for preferences.<BR/>The facility did not ensure that Resident #10 received bananas<BR/>This failure could place resident at risk for poor intake, weight loss, and unmet nutritional needs.<BR/>Findings include:<BR/>Record Review of Resident #10's admission record (no date) indicated she was a [AGE] year-old female with a diagnosis of depression, absence of right leg below the knee and muscle weakness. <BR/>Record Review of Resident #10's MDS dated [DATE] indicated that she had a BIMS score of 15 indicating she was cognitively intact. The assessment did not indicate what diet was required for Resident #10. <BR/>Record Review of Resident #10's orders dated 9/2/2022 indicated that she was on a low cholesterol, low fat diet with regular texture. <BR/>Record Review of Resident #10's care plan (no date, but target date was 9/23/2022) indicated that she was on a regular diet. Interventions to monitor and document intake, offer snacks within diet, serve diet as ordered and offer substitute if less than 50% eaten and Dietary Manager to monitor/discuss food preferences.<BR/>During an interview on 9/12/22 at 12:28 p.m. with Resident #10, Resident #10 stated that she wants bananas every day and facility will not provide them to her . Resident #10 stated that she reported it to the DM and still does not receive them, so she must buy them herself. Resident #10 stated that she does not feel like having to buy the bananas herself because she believes the facility should pay for them.<BR/>During an interview on 9/15/22 at 12:50 p.m. with the DM, the DM stated that he ordered some bananas in the past for Resident #10, and they only lasted a couple of days and had to be thrown out. DM stated that the food supplier had been sending food that did not last long.<BR/>During an interview on 9/15/22 at 2:34 p.m. with the ADM, the ADM stated that dietary is responsible for getting snacks to the nurses and the charge nurses are responsible for checking the food. ADM stated some foods have been on back order and they cannot get them. ADM stated the facility can pick up some bananas from a local store. <BR/>Record Review of the policy on Therapeutic Diets (Revised October 2017) indicated that #1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure food items in the kitchen freezers were dated, labeled, and sealed appropriately.<BR/>The facility failed to ensure food items in the kitchen refrigerators were used by the best by date.<BR/>These failures could place the residents at risk for food-borne illness, and food contamination. <BR/>Findings include:<BR/>During an observation on 9/12/22 at 10:38 a.m., the following items were found with no date, no label and were not sealed:<BR/>1 bag of spinach with the use by date 9/5/22 in the freezer<BR/>1 large ham with an expiration date of 9/11/22 in the freezer<BR/>1 large jar of mustard potato salad with expiration date 9/09/22<BR/>1 large box of frozen cookies with open date of 7/7/22; bag inside of box is not sealed and several cookies had fallen out of the bag onto the freezer shelf<BR/>1 single box of frozen apple pie- box was opened and dated 8/11/22<BR/>1 clear plastic container with foil on the top labeled fried chicken use for pureed- no open date noted<BR/>During an interview/observation on 9/12/22 at 10:38 with the Kitchen Manager, the Kitchen Manager said food items past the expiration or best by date should not be used when preparing food and should have been thrown in the trash. Denied using any of the expired food for preparing any meals. The Kitchen Manager took the spinach, ham, mustard potato salad, apple pie out of the freezer and set them aside to throw away. The Kitchen Manage took the fried chicken that was in an unlabeled container that said for pureed meals out of the freezer and threw it away. The Kitchen Manager re-sealed the bag of cookies in the freezer.<BR/>During interview on 9/15/22 at 12:50 p.m. with the DM, the DM stated he is responsible for the kitchen staff, and he expects the kitchen staff to date and label everything they open in the kitchen. The DM stated he expects kitchen staff to throw away all the expired foods in the refrigerator because improper storage of foods can cause the residents to get sick.<BR/>During interview on 9/15/22 at 2:34 p.m. with the ADM, the ADM stated that she expects the expired food to be thrown away daily and food items should be labeled. The ADM stated not throwing away expired foods can lead to the food spoiling and cause illness.<BR/>Record Review of the Food Receiving and Storage policy (Revised October 2017) indicated on #8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). #11 The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. #14 e. other opened containers must be dated and sealed or covered during storage.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure food items in the kitchen freezers were dated, labeled, and sealed appropriately.<BR/>The facility failed to ensure food items in the kitchen refrigerators were used by the best by date.<BR/>These failures could place the residents at risk for food-borne illness, and food contamination. <BR/>Findings include:<BR/>During an observation on 9/12/22 at 10:38 a.m., the following items were found with no date, no label and were not sealed:<BR/>1 bag of spinach with the use by date 9/5/22 in the freezer<BR/>1 large ham with an expiration date of 9/11/22 in the freezer<BR/>1 large jar of mustard potato salad with expiration date 9/09/22<BR/>1 large box of frozen cookies with open date of 7/7/22; bag inside of box is not sealed and several cookies had fallen out of the bag onto the freezer shelf<BR/>1 single box of frozen apple pie- box was opened and dated 8/11/22<BR/>1 clear plastic container with foil on the top labeled fried chicken use for pureed- no open date noted<BR/>During an interview/observation on 9/12/22 at 10:38 with the Kitchen Manager, the Kitchen Manager said food items past the expiration or best by date should not be used when preparing food and should have been thrown in the trash. Denied using any of the expired food for preparing any meals. The Kitchen Manager took the spinach, ham, mustard potato salad, apple pie out of the freezer and set them aside to throw away. The Kitchen Manage took the fried chicken that was in an unlabeled container that said for pureed meals out of the freezer and threw it away. The Kitchen Manager re-sealed the bag of cookies in the freezer.<BR/>During interview on 9/15/22 at 12:50 p.m. with the DM, the DM stated he is responsible for the kitchen staff, and he expects the kitchen staff to date and label everything they open in the kitchen. The DM stated he expects kitchen staff to throw away all the expired foods in the refrigerator because improper storage of foods can cause the residents to get sick.<BR/>During interview on 9/15/22 at 2:34 p.m. with the ADM, the ADM stated that she expects the expired food to be thrown away daily and food items should be labeled. The ADM stated not throwing away expired foods can lead to the food spoiling and cause illness.<BR/>Record Review of the Food Receiving and Storage policy (Revised October 2017) indicated on #8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). #11 The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. #14 e. other opened containers must be dated and sealed or covered during storage.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure food items in the kitchen freezers were dated, labeled, and sealed appropriately.<BR/>The facility failed to ensure food items in the kitchen refrigerators were used by the best by date.<BR/>These failures could place the residents at risk for food-borne illness, and food contamination. <BR/>Findings include:<BR/>During an observation on 9/12/22 at 10:38 a.m., the following items were found with no date, no label and were not sealed:<BR/>1 bag of spinach with the use by date 9/5/22 in the freezer<BR/>1 large ham with an expiration date of 9/11/22 in the freezer<BR/>1 large jar of mustard potato salad with expiration date 9/09/22<BR/>1 large box of frozen cookies with open date of 7/7/22; bag inside of box is not sealed and several cookies had fallen out of the bag onto the freezer shelf<BR/>1 single box of frozen apple pie- box was opened and dated 8/11/22<BR/>1 clear plastic container with foil on the top labeled fried chicken use for pureed- no open date noted<BR/>During an interview/observation on 9/12/22 at 10:38 with the Kitchen Manager, the Kitchen Manager said food items past the expiration or best by date should not be used when preparing food and should have been thrown in the trash. Denied using any of the expired food for preparing any meals. The Kitchen Manager took the spinach, ham, mustard potato salad, apple pie out of the freezer and set them aside to throw away. The Kitchen Manage took the fried chicken that was in an unlabeled container that said for pureed meals out of the freezer and threw it away. The Kitchen Manager re-sealed the bag of cookies in the freezer.<BR/>During interview on 9/15/22 at 12:50 p.m. with the DM, the DM stated he is responsible for the kitchen staff, and he expects the kitchen staff to date and label everything they open in the kitchen. The DM stated he expects kitchen staff to throw away all the expired foods in the refrigerator because improper storage of foods can cause the residents to get sick.<BR/>During interview on 9/15/22 at 2:34 p.m. with the ADM, the ADM stated that she expects the expired food to be thrown away daily and food items should be labeled. The ADM stated not throwing away expired foods can lead to the food spoiling and cause illness.<BR/>Record Review of the Food Receiving and Storage policy (Revised October 2017) indicated on #8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). #11 The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. #14 e. other opened containers must be dated and sealed or covered during storage.

Based on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility.<BR/>The facility did not update their facility assessment when they discontinued the restorative nursing program. <BR/>This deficient practice could affect the resident by not having the necessary resources to ensure appropriate care is provided. <BR/>Findings included: <BR/>1. Record review of the facility assessment revealed it was dated 5/25/22. The Facility Assessment Part 2: Services and Care We Offer Based on Our Residents' Needs indicated the facility offered a Restorative Nursing Program to the residents. The Facility Assessment indicated the Restorative Nursing Program included morning exercises class with activities and Restorative Nurse Aides where residents were encouraged to participate to keep joint mobility function, range of motion, and increase circulation and Walk-to-Dine Restorative program. <BR/>Observation made 9/12/22 through 9/15/22 did not indicated residents observed had a decline in ADL's.<BR/>During an interview on 9/15/22 at 9:13 a.m. the Administrator said the facility did not offer a restorative program. The Administrator said the CNA's were responsible for applying braces and assisting residents. The Administrator said she was unaware why the facility assessment was not updated or when the restorative program was discontinued.<BR/>During an interview on 9/15/22 at 9:18 a.m. PTA P said the facility did not offer a restorative program for residents.<BR/>During an interview on 9/15/22 at 9:20 a.m. COTA O and Director of Rehabilitation said she had worked at the facility for 2 years. COTA said the facility did not offer a restorative program. COTA O said the facility had not offered a restorative program in the 2 years she had worked there.<BR/>During an interview on 09/15/22 04:12 PM the Administrator said it was the responsibility of the Administrator to ensure the Facility Assessment was up to date. The Administrator said the importance of an up-to-date facility assessment was to be able to provide for residents appropriately. The Administrator said the facility did not have a policy regarding facility assessment.

Based on interview and record review the facility failed to ensure as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 2 of 15 employees (CNA G and CNA L) reviewed for training.<BR/>The facility failed to ensure the quality assurance and performance improvement training was provided to CNA G and CNA L.<BR/>This failure could place residents at risk for not being aware of facility programs, implementation, and monitoring. <BR/>Findings include:<BR/>Record review of CNA G's personnel file revealed CNA G was hired on 7/13/2017 and had not completed annual QAPI training .<BR/>Record review of CNA L's personnel file revealed CNA L was hired on 2/06/2024 and had not completed QAPI training.<BR/>During an interview on 12/05/2024 at 2:30 PM, the ADON said she was responsible for overseeing the on hire and annual trainings and was not aware of the required annual QAPI training not being completed for CNA G and CNA L. She stated she used a binder to manually record and keep track of required training. She said if staff were not properly trained it could affect resident care .<BR/>During an interview on 12/05/2024 at 2:40 PM, the Administrator stated she was ultimately responsible for oversight of all trainings. She said trainings were assigned by the ADON and she generated a monthly report to monitor incomplete required trainings. She stated she was not aware that CNA G and CNA L had not completed required QAPI trainings but would work with the corporate education director to ensure every employee completed required training. She stated staff who were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire .