RUNNINGWATER DRAW CARE CENTER INC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #45) of 15 residents reviewed for resident rights.<BR/>The facility failed to prevent LVN B from referring to Resident #45's table in the dining room as the feeder table.<BR/>The facility failed to prevent labelling 10-12 residents at the center table in the dining room as Feed/Assist on a large whiteboard diagram on the wall of the dining room. <BR/>These failures could negatively impact the self-esteem, self-worth, and identity of residents who need assistance with eating.<BR/>Findings Included:<BR/>Record review of Resident #45's admission record dated 02/25/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinsonism (conditions that affect the ability to move and live independently), absolute glaucoma right eye (severe form of disease where eye has lost all vision and has uncontrolled pressure), and weakness. <BR/>Record review of Resident #45's quarterly MDS completed on 01/19/25 revealed the following:<BR/>Section B Hearing, Speech, and Vision: Resident #45's vision was impaired.<BR/>Section C Cognitive Patterns: Resident #45 had a BIMS of 9 which indicated moderately impaired cognition.<BR/>Section GG Functional Abilities: Resident #45 had impairment on both sides of his upper and lower extremities and utilized a wheelchair. He was dependent across all ADLs except for eating, upper body dressing, and rolling from side to side where he required substantial/maximal assistance. <BR/>Section I Swallowing/Nutritional Status: Resident #45 coughed and choked during meals or when swallowing medications and required a mechanically altered diet while he was a resident.<BR/>Record review of Resident #45's care plan completed on 01/24/25 revealed he had a puree textured diet and nectar thickened liquids. The care plan noted, Resident may sit at the Feeding/Assist table. The resident sits at feeding table and is dependent x1 staff for eating pureed diet on divided plate with nectar thick liquids.<BR/>Record review of Resident #45's active orders report as of 02/25/25 revealed the following orders:<BR/>Regular diet Pureed texture, Nectar/Mildly Thick consistency . with a start date of 10/03/24.<BR/>May have a divided plate and right handed [sic] curved spoon for ease of loading utensils and promoting independence. with meals with a start date of 10/27/24.<BR/>During an observation and interview on 02/25/25 at 12:00 PM in the dining room LVN B was standing approximately 3 feet from residents seated at a large oval table made up of several skinny tables end to end with the middle left open for staff to sit and assist residents with eating. This table was located in the center of the dining room on the end closest to the kitchen. When LVN B was asked to point out Resident #45 she gestured to opposite side of the large oval table in the center of the dining room and stated, He's in the red sweater at the feeder table.<BR/>During an observation on 02/25/25 at 12:02 PM in the dining room a dry erase white board approximately 2 feet by 3 feet was hanging on the wall. It had diagrams of each table in the dining room with round magnets with numbers placed around the tables. The large oval table in the center of the dining room was labelled Feed/Assist. Two small tables on the same wall as the white board were labelled Assist and the remaining tables in the dining room were labelled Table 1- Table 6. <BR/>During an observation and interview on 02/25/25 at 12:14 PM in the dining room LVN B was again standing approximately 3 feet from residents seated the large oval table. When LVN B was asked to point out another resident she gestured to end of the large oval table and stated, He is at the feeder table in the green sweater.<BR/>During an interview on 02/26/25 at 02:08 PM CNA C stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, It is a dignity issue with them. Or if other residents hear that we are saying that to them. CNA C stated the whiteboard in the dining room was used by staff to know where residents sat in the dining room. She stated the magnets arranged around the diagrams of the tables had the room numbers of the residents. CNA C stated the white board might have a negative outcome for residents if they saw their room numbers on the table labelled Feed/Assist. She stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders.<BR/>During an interview on 02/26/25 at 02:13 PM LVN A stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated doing so could negatively affect their morale and self-esteem. LVN A stated of the residents who needed assistance eating, A lot of them still understand and can't help not being able to feed themselves. LVN A stated she had not noticed the whiteboard in the dining room with the large oval table labelled Feed/Assist. She stated she could see how the whiteboard might have a negative impact on residents' dignity. LVN A stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders.<BR/>During an interview on 02/26/25 at 02:28 PM ADON stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, It is degrading. It is a dignity issue. It doesn't present a homelike experience. She stated a possible negative outcome of the whiteboard in the dining room with the large oval table labelled as Feed/Assist was, Again, it is not a homelike experience which we try to create here, and it is embarrassing and does not maintain dignity and integrity of our residents as humans. ADON stated staff had been trained not to refer to residents who needed assistance eating as feeders. <BR/>During an interview on 02/26/25 at 02:34 PM DON stated referring to residents as feeders could be a dignity issue if outside people heard. She stated she did not think the whiteboard with the large oval table labelled as Feed/Assist was a dignity issue unless outside people saw it, but we don't really have outside people go into our dining room. I think it just depends on who sees it (the whiteboard).<BR/>During an interview on 02/26/25 at 02:53 PM ADM stated it was not okay for staff to refer to residents who needed assistance eating as feeders. She stated, It is a dignity issue.<BR/>Record review of facility policy titled Dignity and dated 2021 revealed the following:<BR/> . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: . e. provided with a dignified dining experience. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labelling' or referring to the resident by his or her room number, diagnosis, or care needs. Staff protect confidential clinical information. Examples include the following: . b. Signs indicating the resident's clinical status or care needs are not openly posted . 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity .<BR/>Record review of facility policy titled Resident Rights and dated 2021 revealed the following:<BR/>Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (Resident #26) of 18 residents reviewed for accuracy of assessments.<BR/>Resident #26 had an order for continuous oxygen dated 08/29/23 and her MDS with a completion date of 11/10/23 did not indicate she received oxygen while a resident.<BR/>This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care.<BR/>Findings Included:<BR/>Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).<BR/>Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. <BR/>Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats&gt;90%. This intervention was initiated on 06/22/23 and revised on 09/18/23.<BR/>Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat&gt;90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date.<BR/>Record review of Resident #26's O2 Sats Summary revealed 25 entries for the 14 days prior to completion of Resident #26's most recent MDS. Of those 25 entries, Resident #26 was receiving O2 17 times and was on room air 8 times.<BR/>During an interview on 01/18/24 at 11:09 AM MDS LVN stated she followed the RAI as her policy for completing MDS Assessments.<BR/>Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following:<BR/> . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 18 residents (Resident #41) reviewed for PASRR requirements. <BR/>The facility failed to ensure Resident #41 had an initial PASRR Level 1 before admission on [DATE].<BR/>This failure could place residents with an MI (Mental Illness), ID (Intellectual Disability) or DD (Developmental Disability) at risk for not receiving PASRR related services, if qualified. <BR/>The findings include:<BR/>Record review of Resident #41's face sheet, dated 01/16/2024, revealed a [AGE] year-old male admitted to the facility initially on 08/08/2023 with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease with (acute) lower respiratory infection, major depressive disorder, recurrent, unspecified, atherosclerosis (plaque build up) of native coronary artery of transplanted heart without angina pectoris (chest pain), muscle weakness, epitaxis (bleeding from the nose), essential primary hypertension. <BR/>Record review of Resident #41's quarterly MDS assessment, dated 11/24/2023, revealed a BIMS score of 11 out 15 which indicated his cognition was moderately impaired. He functional ability with eating, oral hygiene, toileting, and personal hygiene is classified as independent, with supervision or touching assistance with showering/bathing. Resident #41 is partial/moderate assistance with upper and lower body dressing and putting on/taking off footwear. <BR/>Record review of Resident #41's care plan, revised 11/27/2023, revealed no documentation regarding PASRR status. <BR/>Record review of Resident #41's PASRR Level 1 Screening, dated 01/22/2021, revealed, that in Section C, subsection C0100, C0200, and C0300 all sections are marked no. There was no new updated PASRR in Resident #41's chart. Resident #41 had no new PASRR performed with new admission on [DATE]. <BR/>During an observation and interview on 01/16/2024 at 09:34 AM, Resident #41 was in his room, Resident #41 was standing next to his dresser putting his laundry away. Resident #41 had a NC hooked to portable oxygen; he had a rolling walker close by to assist him to ambulate. Resident stated that everyone treated him fine and did not voice any concerns with his care.<BR/>During an interview on 01/18/2024 at 09:01 AM MDS LVN was asked about Resident #41's most recent PASRR. MDS LVN stated Yes, we saw that. I just didn't understand that a new one needed to be done. The new PASRR has been completed, but I can't submit it due to the admit date being more than 90 days out. MDS LVN was asked what a negative outcome would be for a resident not having and updated PASRR. MDS LVN stated since he is a resident that does not receive services there would be no negative outcome. MDS LVN stated that she had the email from the PASRR office and the email that she submitted to the PASRR office. Copies of this documentation was requested. <BR/>During an interview on 01/18/2024 at 09:13 AM with DON revealed that a negative outcome for not having an updated PASRR upon admission could lead to the resident would have no help from services if needed. <BR/>During an observation and interview on 01/18/2024 at 09:29 AM revealed paperwork provided by the MDS LVN that showed emails dated 01/17/2024 at 2:48pm, that she sent to PASRR support, it stated the following, Hi, I have missed completing a PASRR for a resident that was admitted on 08.08.2023. I have attempted to complete it for today's date and when it comes to adding in the NF admission date it says that it is an error. How can I correct this issue. The response email from PASRR support stated, Thank you for contacting the PASRR mailbox. Depending on the volume of emails received, it may take up to 3 business days to receive a response. We appreciate your patience.<BR/>Record review of facility policy, titled Admission-From Other Healthcare Facilities dated revised March 2017 states the following: <BR/> 2. The following information will be provided to the facility prior to or upon the resident's admission: <BR/> .I. PASARR (as appropriate);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored under proper temperature, and the expiration date when applicable on 2 of 2 medication carts and 1 of 1 medication rooms reviewed for medication storage. <BR/>- Medication cart for Side B revealed a Breo Ellipta inhaler for Resident #8 with no open date on inhaler. <BR/>- Medication cart for Side A revealed a Novolin R insulin bottle for Resident #10 with no open date on bottle. <BR/>- Refrigerator in medication room was below 36 degrees for 2 days. Refrigerator contained insulins for the following residents: <BR/>*Resident #2 had 1 unopened box for Tesiba flex touch<BR/>*Resident #2 had 2 bottles Novolin R<BR/>*Resident #5 had 2 flex pen boxes Novolin 70/30 <BR/>*Resident #5 had 1 bottle Novolin R<BR/>*Resident #10 had 3 KwikPen boxes for Basaglar<BR/>*Resident #10 had 2 bottles of Humulin R<BR/>*Resident #10 had 4 bottles of Novolin R<BR/>*Resident #15 had 3 bottles of Novolin R<BR/>*Resident #15 had 2 bottles of Humulin 70/30<BR/>*Resident #27 had 1 KwikPen Basaglar<BR/>*Resident #29 had 4 bottles of Lantus<BR/>*Resident #29 had 1 bottle of Humulin R<BR/>*Resident #35 had 2 bottles of Lantus <BR/>*Resident #38 had 1 pen box for Lantus Solostar<BR/>*Resident #48 had 1 bottle of Novolin R<BR/>*Resident #48 had 1 bottle of Humulin R 70/30<BR/>The facility's failures could place residents receiving medication at risk for lack of drug efficacy, and adverse reactions. <BR/>Findings included:<BR/>During an observation on [DATE] at 10:30 AM of Medication cart for side B contained a Breo Ellipta inhaler for Resident #8 with an open date of [DATE], but on the actual inhaler there was no open dated noted. <BR/>During an interview on [DATE] at 10:35 AM Interview with LVN A stated that a negative outcome for not writing an open date on the medication would be that the medication could be expired and not be effective. <BR/>During an observation on [DATE] at 10:40 AM of Medication cart for side A revealed that Resident #10's Novolin R had no open date written on it. <BR/>During an interview on [DATE] at 10:46 AM LVN B stated that a negative outcome for not writing the open date on a medication would lead to a waste of medication and could lead to harm if the medication is expired. <BR/>During an observation on [DATE] at 10:48 AM of the medication room with LVN A revealed that the refrigerator temperature log for the medications was out of range on [DATE] at 35 degrees and [DATE] at 35 degrees. Temperature was observed in fridge at 39 degrees when visually checked. Medications for the following residents were revealed to have been below recommended temperatures for 2 days: <BR/>*Resident #2 had 1 unopened box for Tesiba flex touch<BR/>*Resident #2 had 2 bottles Novolin R<BR/>*Resident #5 had 2 flex pen boxes Novolin 70/30 <BR/>*Resident #5 had 1 bottle Novolin R<BR/>*Resident #10 had 3 KwikPen boxes for Basaglar<BR/>*Resident #10 had 2 bottles of Humulin R<BR/>*Resident #10 had 4 bottles of Novolin R<BR/>*Resident #15 had 3 bottles of Novolin R<BR/>*Resident #15 had 2 bottles of Humulin 70/30<BR/>*Resident #27 had 1 KwikPen Basaglar<BR/>*Resident #29 had 4 bottles of Lantus<BR/>*Resident #29 had 1 bottle of Humulin R<BR/>*Resident #35 had 2 bottles of Lantus <BR/>*Resident #38 had 1 pen box for Lantus Solostar<BR/>*Resident #48 had 1 bottle of Novolin R<BR/>*Resident #48 had 1 bottle of Humulin R 70/30<BR/>During an interview on [DATE] at 10:56 AM LVN A stated that the negative outcome for having medication at a temperature below the recommended level could lead to the medications losing their efficacy and not perform like they should for the resident. <BR/>During an interview on [DATE] at 11:06 AM DON stated that it was the night nurse's responsibility to check the carts and the temperatures of the medication refrigerator. DON stated that the Nurse that performs the nightly duties is supposed to report abnormalities to the DON, however DON was not made aware of this discrepancy. DON stated that the negative outcome for the medications not having open dates on the medication could lead to the medication being expired and losing its effectiveness. DON stated that the negative outcome for having medications stored below their recommended storage temps could lead to the medications being compromised and losing their efficacy.<BR/>Record review of the facility provided policy titled, Medication Labeling and Storage, undated, revealed the following:<BR/>Policy Statement<BR/>The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls .<BR/> .Medication Storage .<BR/> .3. If the facility has discontinued, outdated or deteriorated medications or biologicals <BR/> .6.Refrigeration temperature settings should e maintained between 36-46 degrees Fahrenheit.<BR/> .Medication Labeling .<BR/> .2 .d .expiration date, when applicable; .<BR/> .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect.<BR/>The facility failed to ensure Resident #1 was free from neglect. On 5/15/24 after lunch, CNA B performed a 1-person transfer of Resident #1, who was a 2-person transfer. The transfer resulted in CNA B and Resident #1 falling to the floor, causing the fracture of Resident #1's right femur. CNA B did not report the fall.<BR/>CNA C, who was in the room with CNA B at the time of the incident, did not report the fall until approximately 7 hours after the inappropriate transfer and fall occurred. <BR/>This failure could place residents at risk of major injury due to neglect in their care.<BR/>The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.<BR/>Findings included:<BR/>Record review of admission Notes revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment and a diagnoses of complete transverse atypical (abnormal) femoral (femur) fracture, right leg, sequela (consequence of previous disease), unspecified osteoarthritis (degenerative joint disease, in which the joint breaks down over time), unspecified site, pain in unspecified knee, other abnormalities of gait and mobility, repeated falls, presence of right artificial knee joint, and non-displaced fracture of greater trochanter (outside hip joint) of right femur. <BR/>Resident #1's Quarterly Care Plan dated 4/20/24 revealed an ADL self-care performance deficit related to Osteoarthritis, Abnormalities of Gait, Weakness and Right Femur Fracture. She had bilateral lower extremity contractures at the knee, which required the use of Podus Boots (lightweight, quality plastic shell brace with poly/pile liner) to both feet to prevent skin breakdown. Resident #1 required total assistance x 2 staff for all transfers and movement between surfaces. Resident #1 required the use of a Geri chair (a wheelchair designed for resident who may need a more substantial, and many times less restrictive, seating platform.) for mobility and postural support related to hip fracture. Resident #1 was at moderate risk for falls related to Alzheimer's Disease, along with weakness and contracture to her legs. A chair alarm was required while Resident #1 was seated, and a bed alarm was required while Resident #1 was in bed. Both were used to encourage safety awareness. Resident #1 required a fall mat at her bedside, while in bed, to decrease the risk of injury from falls. The resident's call light was to be in place and working at all times. Resident #1 had chronic pain related right knee and hip and was prescribed pain medications, including Tramadol, an opioid, to relieve discomfort.<BR/>Review of Vista Teleradiology notes dated 5/15/24 revealed an x-ray was taken of Resident #1's right leg at 10:16PM. Findings were as follows: <BR/>Bones: There is a mildly displaced metaphyseal fracture along the distal femoral bone, at the edge of the femoral prosthesis cap. Total left hip prosthesis changes. No sclerotic or destructive changes observed. <BR/>Soft tissues: Joint effusion. <BR/>Impression: Mild displaced metaphyseal fracture at the distal femoral bone, at the edge of the femoral prosthesis cap.<BR/>Record Review of facility Progress Notes dated 5/15/24 revealed Resident #1 sustained a complete transverse atypical femoral fracture to her right leg when CNA B attempted a 1-person transfer of Resident #1 (who was a 2-person assist for all ADL s according to the MDS and Care Plan dated 4/20/24), which resulted in both falling to the floor. CNA C was also in the resident's room at the time of the incident, caring for Resident #2, and did not witness what took place.<BR/>Record Review of facility in-services for the last 90 days revealed training on Abuse/Neglect, and Transfer of Residents had taken place for all staff on 5/14/24, the day prior to the incident. CNA B and CNA C attended this in-service.<BR/>On 5/30/24 at 9:38AM an interview with the Administrator revealed on 5/14/24 staff had been in-serviced on resident abuse and neglect, and transfer of residents. She stated on 5/15/24 at approximately 1:30PM, CNA B attempted a 1-person transfer of Resident #1, which resulted in both falling to the floor. CNA B, along with CNA C, who was in the resident's room at the time of the incident, failed to report the fall to facility staff, resulting in Resident #1 not being assessed by nursing staff. Sometime between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A to report the incident, after her shift had ended. LVN A immediately called the DON and the DON arrived at the facility at approximately 9:15PM to assess Resident #1. It was determined that an x-ray was required, and the mobile x-ray service arrived at the facility at approximately 10:15PM. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. <BR/>A phone interview with Resident #1's Representatives on 5/30/24 at 11:52AM revealed the facility had informed them of Resident #1's fall late in the evening of 5/15/24, and due to the late hour of the incident, requested that their resident not be transferred to the hospital, until morning. RR stated approximately 9:40AM on 5/16/24, Resident #1 was transported to the hospital via ambulance, where the fracture to the right femur was again confirmed, through x-ray. It was determined that the fracture was inoperable due to a prior knee replacement which took place in October of 2022, along with a previous fracture of the right hip, which took place in November of 2022. A leg immobilizer and additional pain medication were ordered, and the resident was returned to the facility.<BR/>Record review revealed Resident #1's Care Plan was updated on 5/16/24 to include the use of the leg immobilizer to her right leg and palliative care, including Morphine Sulfate, after the fall on 5/15/24. These measures were put into place to prevent any further contracture to the right leg and relieve residual pain. <BR/>Multiple observations throughout the investigation on 5/30/24 and 5/31/24 revealed that above each occupied resident bed was a sign indicating what type of transfer each resident required. <BR/>Multiple staff interviews throughout the investigation on 5/30/24 and 5/31/24 revealed that staff had received extensive training on 5/14/24 and 5/16/24 on abuse and neglect, reporting requirements, appropriate transfers and procedures to follow if a resident falls during a transfer. These interviews revealed that as a result of the incident, competency checks on transfers were initiated and completed for all staff on 5/16/24. <BR/>Record review of CNA B's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, the resulting fall and failure to report The Employee Warning Notice indicated that CNA B declined to write a statement. In the action to be taken section of the Employee Warning Notice, dismissal was checked. CNA B's employment with the facility was terminated on 5/16/24.<BR/>Record review of CNA C's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, CNA C's initial failure to report the subsequent fall. The Employee Warning Notice indicated that CNA C declined to write a statement. In the action to be take section of the Employee Warning Notice, other was checked and the following statement was written: Suspension x 2 weeks. Consequence should incident occur again - additional disciplinary action up to termination. CNA C was immediately suspended for 2 weeks.<BR/>Record Review of in-services for the last 90 days revealed staff were again in-serviced on Abuse/Neglect and Transfer of Residents on 5/16/24. The subject matter of these inservices included requirements for reporting any suspected abuse or neglect, responsibilities for reporting, what to report and who to report to, appropriate transfer of residents using the required number of staff and what to do in the event that a resident falls during a transfer. <BR/>An interview with the CNA Supervisor on 5/30/24 at 3:10PM revealed CNA B was not in attendance for these additional in-services due to being terminated from her position the morning of 5/16/24 and CNA C was not in attendance due to being placed on two-weeks leave without pay. The CNA Supervisor stated she had no prior issues with CNAs and suspected neglect of residents. She stated at the Stand Up meeting on the morning of 5/16/24 she was informed by an unnamed CNA, that Resident #1 had been dropped by CNA B, the previous day. CNA Supervisor then spoke with other facility staff to gain insight into what had happened to Resident #1. When CNA Supervisor spoke with CNA B, she could not explain what had happened to Resident #1 other than she had tried to transfer Resident #1 by herself, and both had fallen to the floor. CNA B stated she had panicked and didn't know what to do. She was aware she had done something bad but had not reported it and had asked CNA C to not report the incident, as well. CNA B was immediately terminated, and CNA C was placed on leave without pay, pending the internal investigation.<BR/>An interview with CNA C on 5/30/24 at 3:22PM revealed CNA C had been present in the room at the time of the incident, but had not seen what had taken place, due to providing care to Resident #1's roommate. CNA C stated both she and CNA B had worked the 5AM-5PM shift and had left the faciity on the day of the incident at their usual departure time of 5PM. Between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A and confessed to the fall taking place earlier that day, during her shift. She stated she had attended the in-service on Abuse/Neglect and Transfer of Residents on 5/14/24.<BR/>Multiple attempts were made to speak with CNA B. These calls were not returned.<BR/>Record Review of facility policy for Resident Neglect, dated July 10,2019 defined neglect as:<BR/>The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Furthermore, it is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional anguish.<BR/>To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain or death of a resident was due to the NF's failure to provide goods or services to a resident.<BR/>Example of neglect:<BR/>A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury.<BR/>The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all allegations involving neglect are reported immediately, but no later than 2 hours after the event, if the resident sustains serious bodily injury, to the Administrator of the facility and the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for neglect.<BR/>The facility failed to report an allegation of neglect for Resident #1 within 2 hours of the event. CNA C did not report a fall with potential injury until approximately 7 hours after the inappropriate transfer and fall occured. CNA B did not report the fall. <BR/>This failure could place residents at risk of not having incidents of neglect reported and investigated in a timely manner and delay in proper treatment of injury. <BR/>The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.<BR/>Findings included:<BR/>Record review of admission Notes revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment and a diagnoses of complete transverse atypical (abnormal) femoral (femur) fracture, right leg, sequela (consequence of previous disease), unspecified osteoarthritis (degenerative joint disease, in which the joint breaks down over time), unspecified site, pain in unspecified knee, other abnormalities of gait and mobility, repeated falls, presence of right artificial knee joint, and non-displaced fracture of greater trochanter (outside hip joint) of right femur. <BR/>Resident #1's Quarterly Care Plan dated 4/20/24 revealed an ADL self-care performance deficit related to Osteoarthritis, Abnormalities of Gait, Weakness and Right Femur Fracture. She had bilateral lower extremity contractures at the knee, which required the use of Podus Boots (lightweight, quality plastic shell brace with poly/pile liner) to both feet to prevent skin breakdown. Resident #1 required total assistance x 2 staff for all transfers and movement between surfaces. Resident #1 required the use of a Geri chair (a wheelchair designed for resident who may need a more substantial, and many times less restrictive, seating platform.) for mobility and postural support related to hip fracture. Resident #1 was at moderate risk for falls related to Alzheimer's Disease, along with weakness and contracture to her legs. A chair alarm was required while Resident #1 was seated, and a bed alarm was required while Resident #1 was in bed. Both were used to encourage safety awareness. Resident #1 required a fall mat at her bedside, while in bed, to decrease the risk of injury from falls. The resident's call light was to be in place and working at all times. Resident #1 had chronic pain related right knee and hip and was prescribed pain medications, including Tramadol, an opioid, to relieve discomfort.<BR/>Record Review of x-ray notes dated 5/15/24 revealed an x-ray was taken of Resident #1's right leg at 10:16PM. Findings were as follows: <BR/>Bones: There is a mildly displaced metaphyseal fracture along the distal femoral bone, at the edge of the femoral prosthesis cap. Total left hip prosthesis changes. No sclerotic or destructive changes observed. <BR/>Soft tissues: Joint effusion. <BR/>Impression: Mild displaced metaphyseal fracture at the distal femoral bone, at the edge of the femoral prosthesis cap.<BR/>Record Review of facility Progress Notes dated 5/15/24 revealed Resident #1 sustained a complete transverse atypical femoral fracture to her right leg when CNA B attempted a 1-person transfer of Resident #1 (who was a 2-person assist for all ADL s according to the MDS and Care Plan dated 4/20/24), which resulted in both falling to the floor. CNA C was also in the resident's room at the time of the incident, caring for Resident #2, and did not witness what took place.<BR/>Record Review of facility in-services for the last 90 days revealed training on Abuse/Neglect, and Transfer of Residents had taken place for all staff on 5/14/24, the day prior to the incident. CNA B and CNA C attended this in-service.<BR/>Record Review of in-services for the last 90 days revealed staff were again in-serviced on Abuse/Neglect and Transfer of Residents on 5/16/24. The subject matter of these inservices included requirements for reporting any suspected abuse or neglect, responsibilities for reporting, what to report and who to report to, appropriate transfer of residents using the required number of staff and what to do in the event that a resident falls during a transfer.<BR/>On 5/30/24 at 9:38AM an interview with the Administrator revealed on 5/14/24 staff had been in-serviced on resident abuse and neglect, and transfer of residents. She stated on 5/15/24 at approximately 1:30PM, CNA B attempted a 1-person transfer of Resident #1, which resulted in both falling to the floor. CNA B, along with CNA C, who was in the resident's room at the time of the incident, failed to report the fall to facility staff, resulting in Resident #1 not being assessed by nursing staff. Sometime between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A to report the incident, after her shift had ended. LVN A immediately called the DON and the DON arrived at the facility at approximately 9:15PM to assess Resident #1. It was determined that an x-ray was required, and the mobile x-ray service arrived at the facility at approximately 10:15PM. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. <BR/>A phone interview with Resident #1's Representatives on 5/30/24 at 11:52AM revealed the facility had informed them of Resident #1's fall late in the evening of 5/15/24, and due to the late hour of the incident, requested that their resident not be transferred to the hospital, until morning. RR stated approximately 9:40AM on 5/16/24, Resident #1 was transported to the hospital via ambulance, where the fracture to the right femur was again confirmed, through x-ray. It was determined that the fracture was inoperable due to a prior knee replacement which took place in October of 2022, along with a previous fracture of the right hip, which took place in November of 2022. A leg immobilizer and additional pain medication were ordered, and the resident was returned to the facility.<BR/>Record review revealed Resident #1's Care Plan was updated on 5/16/24 to include the use of the leg immobilizer to her right leg and palliative care, including Morphine Sulfate, after the fall on 5/15/24. These measures were put into place to prevent any further contracture to the right leg and relieve residual pain. <BR/>An interview with the CNA Supervisor on 5/30/24 at 3:10PM revealed CNA B was not in attendance for these additional in-services due to being terminated from her position the morning of 5/16/24 and CNA C was not in attendance due to being placed on two-weeks leave without pay. The CNA Supervisor stated she had no prior issues with CNAs and suspected neglect of residents. She stated at the Stand Up meeting on the morning of 5/16/24 she was informed by an unnamed CNA, that Resident #1 had been dropped by CNA B, the previous day. CNA Supervisor then spoke with other facility staff to gain insight into what had happened to Resident #1. When CNA Supervisor spoke with CNA B, she could not explain what had happened to Resident #1 other than she had tried to transfer Resident #1 by herself, and both had fallen to the floor. CNA B stated she had panicked and did not know what to do. She was aware she had done something bad but had not reported it and had asked CNA C to not report the incident, as well. CNA B was immediately terminated, and CNA C was placed on leave without pay, pending the internal investigation.<BR/>An interview with CNA C on 5/30/24 at 3:22PM revealed CNA B had asked her to not report the incident to facility staff. CNA C stated both she and CNA B had worked the 5AM-5PM shift and had left the faciity on the day of the incident at their usual departure time of 5PM, without notifying staff of the fall. Between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A and confessed to the fall taking place earlier that day, during her shift. CNA B had not reported the incident to facility staff. CNA B was immediately terminated, and CNA C was placed on leave without pay, pending the internal investigation. <BR/>Multiple attempts were made to speak with CNA B. These calls were not returned.<BR/>Multiple observations throughout the investigation on 5/30/24 and 5/31/24 revealed that above each occupied resident bed was a sign indicating what type of transfer each resident required. <BR/>Record review of CNA B's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1. The Employee Warning Notice indicated that CNA B declined to write a statement. In the action to be taken section of the Employee Warning Notice, dismissal was checked. CNA B's employment with the facility was terminated on 5/16/24.<BR/>Record review of CNA C's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, CNA C's initial failure to report the subsequent fall. The Employee Warning Notice indicated that CNA C declined to write a statement. In the action to be take section of the Employee Warning Notice, other was checked and the following statement was written: Suspension x 2 weeks. Consequence should incident occur again - additional disciplinary action up to termination. CNA C was immediately suspended for 2 weeks.<BR/>Multiple staff interviews throughout the investigation on 5/30/24 and 5/31/24 revealed that staff had received extensive training on 5/14/24 and 5/16/24 on abuse and neglect, reporting requirements, appropriate transfers and procedures to follow if a resident falls during a transfer. These interviews revealed that as a result of the incident, competency checks on transfers were initiated and completed for all staff on 5/16/24. <BR/>Record Review of facility policy for Resident Neglect, dated July 10,2019 defined neglect as:<BR/>The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Furthermore, it is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional anguish.<BR/>To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain or death of a resident was due to the NF's failure to provide goods or services to a resident.<BR/>Example of neglect:<BR/>A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury.<BR/>Record Review of facility policy for Abuse, Neglect and Reporting/Investigation of Incidents, dated September 2022, revealed the following:<BR/>Reporting Allegations to the Administrator and Authorities<BR/>1. If resident neglect is suspected, the suspicion must be reported immediately to the Administrator and other officials, according to state law. Immediately is defined as within two hours of an allegation involving serious bodily injury or within 24 hours if the allegation does not result in serious bodily injury.<BR/>6. Upon receiving any allegation of neglect, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents.<BR/>Investigating Allegations<BR/>1. All allegations are thoroughly investigated. The Administrator initiates investigations.<BR/>4. The Administrator is responsible for keeping the resident and his/her representative(s) informed of the progress of the investigation.<BR/>6. Any employee who has been accused of resident neglect is place on leave with no further contact until the investigation is complete.<BR/>7. The individual conducting the investigation as a minimum:<BR/>a. reviews documentation and evidence;<BR/>b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident;<BR/>c. observes the alleged victim, including his or her interactions with staff and other residents;<BR/>d. interviews the person(s) reporting the incident;<BR/>e. interview any witnesses to the incident;<BR/>f. interviews the resident (as medically appropriate) or resident's representative;<BR/>g. interviews resident's attending physician to determine resident's condition; <BR/>h. interviews staff members on all shifts who have had contact with the resident during the period of the alleged incident; <BR/>i. interviews the resident's roommate, family members and visitors; <BR/>j. interviews other residents to whom the accused employee provides care or services;<BR/>k. reviews all events leading up to the alleged incident; and<BR/>l. documents the investigation completely and thoroughly.<BR/>Corrective Actions<BR/>1. All relevant professional and licensing boards are notified when an employee is found to have committed abuse/neglect.<BR/>2. If the investigation reveals that the allegation(s) are founded, the employee is terminated.<BR/>3. Any allegations of abuse/neglect are filed in the accused employee's personnel record along with any statement by the employee disputing the allegation if the employee chooses to make one.<BR/>4. Of the investigation reveals that the allegations of abuse/neglect are unfounded, the employee may be reinstated to his/her former position with back pay.<BR/>5. Records concerning allegations that are determined to be unfounded are destroyed or archived per human resources policy.<BR/>6. Corrective action may include a full review of the incident by the QAPI committee.<BR/>The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/30/24 at 4:40PM and ended on 5/31/24 at 8:30AM. The facility had corrected the non-compliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the resident environment remains free of accidents and hazards, as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for adequate supervision to prevent accidents and hazards.<BR/>The facility failed to ensure that Resident #1 was assisted x 2 staff for all transfers and movement <BR/>between surfaces. CNA B transferred Resident #1 independently which resulted in CNA B and Resident #1 falling to the floor. As a result of the fall, Resident #1 suffered a fractured right leg. <BR/>This failure could place residents at risk for falls with serious injuries.<BR/>The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.<BR/>Findings included:<BR/>Record review of admission Notes revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment and a diagnoses of complete transverse atypical (abnormal) femoral (femur) fracture, right leg, sequela (consequence of previous disease), unspecified osteoarthritis (degenerative joint disease, in which the joint breaks down over time), unspecified site, pain in unspecified knee, other abnormalities of gait and mobility, repeated falls, presence of right artificial knee joint, and non-displaced fracture of greater trochanter (outside hip joint) of right femur. <BR/>Resident #1's Quarterly Care Plan dated 4/20/24 revealed an ADL self-care performance deficit related to Osteoarthritis, Abnormalities of Gait, Weakness and Right Femur Fracture. She had bilateral lower extremity contractures at the knee, which required the use of Podus Boots (lightweight, quality plastic shell brace with poly/pile liner) to both feet to prevent skin breakdown. Resident #1 required total assistance x 2 staff for all transfers and movement between surfaces. Resident #1 required the use of a Geri chair (a wheelchair designed for resident who may need a more substantial, and many times less restrictive, seating platform.) for mobility and postural support related to hip fracture. Resident #1 was at moderate risk for falls related to Alzheimer's Disease, along with weakness and contracture to her legs. A chair alarm was required while Resident #1 was seated, and a bed alarm was required while Resident #1 was in bed. Both were used to encourage safety awareness. Resident #1 required a fall mat at her bedside, while in bed, to decrease the risk of injury from falls. The resident's call light was to be in place and working at all times. Resident #1 had chronic pain related right knee and hip and was prescribed pain medications, including Tramadol, an opioid, to relieve discomfort.<BR/>Record review revealed Resident #1's Care Plan was updated on 5/16/24 to include the use of the leg immobilizer to her right leg and palliative care, including Morphine Sulfate, after the fall on 5/15/24. These measures were put into place to prevent any further contracture to the right leg and relieve residual pain after the fall which resulted in fracture. <BR/>Record review of Resident #1's fall assessment dated [DATE] revealed Resident #1 had intermittent confusion related to Alzheimer's Disease. She had a history of 1-2 falls in the past 3 months. She was chair-bound and required assistance with bowel and bladder voiding. Her vision was adequate without the use of glasses, and she required the use of assistive devices related to gait and balance. Her fall assessment score was 13, indicating she was at high risk for falls and accidents.<BR/>An interview with the Administrator on 5/30/24 at 9:38AM revealed all staff had been in-serviced on 5/14/24, one day prior to the incident, regarding resident abuse and neglect, reporting of incidents and transfer of residents. She stated on 5/15/24 at approximately 1:30PM, CNA B attempted a 1-person transfer of Resident #1, which resulted in both falling to the floor. CNA B, along with CNA C, who was in the resident's room at the time of the incident, failed to report the fall to facility staff, resulting in Resident #1 not being assessed by nursing staff. Sometime between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A to report the incident, after her shift had ended. LVN A immediately called the DON and the DON arrived at the facility at approximately 9:15PM to assess Resident #1. It was determined that an x-ray was required, and the mobile x-ray service arrived at the facility at approximately 10:15PM. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. The facility informed Resident #1's representative and due to the late hour, they requested that their resident not be transferred to the hospital, until morning. At approximately 9:40AM on 5/15/24, Resident #1 was transported to the hospital via ambulance, where the fracture to the right femur was again confirmed, through x-ray. It was determined that the fracture was inoperable due to a prior knee replacement which took place in October of 2022, along with a previous fracture of the right hip, which took place in November of 2022.<BR/>Multiple observations throughout the investigation on 5/30/24 and 5/31/24 revealed that above each occupied resident bed was a sign indicating what type of transfer each resident required. <BR/>Record review of CNA B's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1. The Employee Warning Notice indicated that CNA B declined to write a statement. In the action to be taken section of the Employee Warning Notice, dismissal was checked. CNA B's employment with the facility was terminated on 5/16/24.<BR/>Record review of CNA C's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, CNA C's initial failure to report the subsequent fall. The Employee Warning Notice indicated that CNA C declined to write a statement. In the action to be take section of the Employee Warning Notice, other was checked and the following statement was written: Suspension x 2 weeks. Consequence should incident occur again - additional disciplinary action up to termination. CNA C was immediately suspended for 2 weeks.<BR/>Multiple staff interviews throughout the investigation on 5/30/24 and 5/31/24 revealed that staff had received extensive training on 5/14/24 and 5/16/24 on abuse and neglect, reporting requirements, appropriate transfers and procedures to follow if a resident falls during a transfer. These interviews revealed that as a result of the incident, competency checks on transfers were initiated and completed for all staff on 5/16/24. <BR/>Record review of the facility's Safety Precautions, Nursing Services Policy dated December 2009 revealed in part:<BR/>o Report all unsafe acts or condition to your supervisor as soon as possible.<BR/>o Pick up debris from the floor. Clean up spills immediately.<BR/>o Report all injuries, no matter how small.<BR/>o Follow proper lifting procedures when lifting residents or heavy objects.<BR/>Record review of the facility's undated Fall Assessment and Management Policy and Procedure, revealed the following:<BR/>Purpose<BR/>To ensure fall assessment and management is carried out in a prompt and consistent manner utilizing validated best practice assessment tools.<BR/>To identify resident fall risk factors.<BR/>To provide direction for the interdisciplinary team to incorporate and develop best practice fall prevention.<BR/>To decrease the incidence of falls and fall injuries.<BR/>Policy<BR/>All resident's will be assessed for fall risk upon admission.<BR/>The resident's care plan shall be developed and updated to include individualized and appropriate interventions to prevent falls and reduce the risk of injury based on risk.<BR/>If a resident has a fall, an assessment shall be undertaken to assess the risk for further falls and determine additional strategies to reduce fall and injury risk.<BR/>Regardless of risk, fall risk factor and interventions shall be reviewed by the interdisciplinary team at least quarterly.<BR/>Documentation in resident's health record shall be completed by the care plan manager. All unusual observations and resident's responses will be documented.<BR/>Procedure<BR/>If the resident is considered a HIGH RISK, the falls assessment form does not need to be repeated with each fall but does need to be reviewed for possible risk factor changes.<BR/>A care plan shall be formulated by the interdisciplinary team which includes individualized multi-factorial fall and injury prevention strategies to address risk factors identified from the fall risk form, regardless of the resident's level of risk.<BR/>Interventions reviewed and updated based on the findings of the reassessments and/or post-fall investigations, including individualized interventions which are re-evaluated and updated to prevent or minimize the risk of falls.<BR/>Individualized interventions based on causal factors and/or identified risk factors.<BR/>Date of falls and causal factors identified.<BR/>Outcomes<BR/>Individualized interventions identified in the care plan are implemented.<BR/>Effectiveness of the individualized interventions are monitored and evaluated.<BR/>Post-fall Assessment, Clinical Review<BR/>Assess immediate danger to all involved.<BR/>Call for assistance.<BR/>Do not move the resident until he/she has been assessed for safety to be moved.<BR/>Identify all visible injuries and initiate first aid; for example, cover wounds.<BR/>Assist resident to move using safe handling practices.<BR/>Notify the physician.<BR/>Notify family of incident, any new orders, or possible transfer<BR/>Initiate risk management and follow prompts in Point Click Care for fall prevention.<BR/>The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for one (Resident #54) of 18 residents reviewed for significant change.<BR/>The facility failed to update Resident #54's MDS assessment within 14 days of Resident #54 being admitted to hospice.<BR/>This failure could result in residents not receiving the care and coordination of services necessary to meet their needs and/or desires. <BR/>Findings Included:<BR/>Record review of Resident #54's admission record, dated 01/18/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia severe with agitation (a group of thinking and social symptoms that interferes with daily functioning), nausea, dizziness and giddiness, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). The admission record made no mention of Resident #54 receiving hospice care.<BR/>Record review of Resident #54's EHR MDS front sheet revealed a significant change MDS that was export ready with an ARD of 01/17/24. <BR/>Record review of Resident #54's quarterly MDS completed on 11/25/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS indicated Resident #54 was not receiving hospice care While a Resident. <BR/>Record review of Resident #54's care plan revealed the following focus area dated 12/14/23: The resident has a terminal prognosis r/t Severe Dementia. One of the interventions listed for this focus area was: Resident with [Name of Hospice]. This intervention was initiated on 12/14/23. Another intervention listed for this focus area was initiated on 01/16/24 and stated, Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.<BR/>Record review of Resident #54's active orders, dated 01/18/24 revealed an order of Admit to [Name of Hospice] dated 12/14/23.<BR/>During an observation on 01/16/24 at 10:40 AM Resident #54 was being pushed in her wheelchair down the hallway of the locked unit. She was neatly dressed, and her hair was neatly combed. Resident #54 was able to say hello and shake hands. When asked what her name was, Resident #54 was unable or unwilling to answer and looked down and to the left.<BR/>During an observation on 01/16/24 at 12:06 PM Resident #54 was seated in her wheelchair at a table in the dining room. She had her eyes closed and staff were attempting to feed her bites from a plate of pureed food. Staff called her name repeatedly until she would open her eyes and take a bite. This pattern was repeated for each bite.<BR/>During an interview on 01/16/24 at 06:51 PM Resident #54's family member stated he was pleased with the care she was receiving in the facility. He stated he chose to place Resident #54 in hospice care due to her condition and conversations he had with facility staff. <BR/>During an interview on 01/18/24 at 11:09 AM when asked what policy she used for determining MDS assessment timing, MDS LVN stated, I follow the RAI manual. She said when a resident had a significant change the MDS assessment was to be completed within 14 days. When asked why this timing was not followed for Resident #54's significant change due to being admitted to hospice, MDS LVN stated, She was an interesting case. We had a care plan meeting with [Resident #54's family member] and we discussed steady decline. We discussed palliative care etcetera. A few days later he [Resident #54's family member] contacted hospice himself and I put it in the care plan and everywhere else but did do the dadgum MDS. I missed it. She said a possible negative outcome of not following the assessment timing as laid out in the RAI was, You know, state was not notified when they needed to be.<BR/>During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not having a significant change MDS in the allotted 14 days was, What is the payer source? Because I can see that being an issue.<BR/>Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following:<BR/> .For the other comprehensive MDS assessments, Significant Change in Status Assessment the . Completion Date must be no later than . 14 days from the determination date of the significant change in status . <BR/>An SCSA [Significant Change in Status Assessment] is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD must be within 14 days from the effective date of the hospice election .<BR/>Record review of facility policy titled, Hospice Program and dated 08/09/23 revealed the following:<BR/>Palliative/End-of-Life Care-Clinical Protocol Assessment and Recognition . 5. The comprehensive assessment will recur on a regular basis and in response to significant changes of condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (Resident #26) of 18 residents reviewed for accuracy of assessments.<BR/>Resident #26 had an order for continuous oxygen dated 08/29/23 and her MDS with a completion date of 11/10/23 did not indicate she received oxygen while a resident.<BR/>This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care.<BR/>Findings Included:<BR/>Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).<BR/>Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. <BR/>Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats&gt;90%. This intervention was initiated on 06/22/23 and revised on 09/18/23.<BR/>Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat&gt;90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date.<BR/>Record review of Resident #26's O2 Sats Summary revealed 25 entries for the 14 days prior to completion of Resident #26's most recent MDS. Of those 25 entries, Resident #26 was receiving O2 17 times and was on room air 8 times.<BR/>During an interview on 01/18/24 at 11:09 AM MDS LVN stated she followed the RAI as her policy for completing MDS Assessments.<BR/>Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following:<BR/> . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 18 residents (Resident #41) reviewed for PASRR requirements. <BR/>The facility failed to ensure Resident #41 had an initial PASRR Level 1 before admission on [DATE].<BR/>This failure could place residents with an MI (Mental Illness), ID (Intellectual Disability) or DD (Developmental Disability) at risk for not receiving PASRR related services, if qualified. <BR/>The findings include:<BR/>Record review of Resident #41's face sheet, dated 01/16/2024, revealed a [AGE] year-old male admitted to the facility initially on 08/08/2023 with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease with (acute) lower respiratory infection, major depressive disorder, recurrent, unspecified, atherosclerosis (plaque build up) of native coronary artery of transplanted heart without angina pectoris (chest pain), muscle weakness, epitaxis (bleeding from the nose), essential primary hypertension. <BR/>Record review of Resident #41's quarterly MDS assessment, dated 11/24/2023, revealed a BIMS score of 11 out 15 which indicated his cognition was moderately impaired. He functional ability with eating, oral hygiene, toileting, and personal hygiene is classified as independent, with supervision or touching assistance with showering/bathing. Resident #41 is partial/moderate assistance with upper and lower body dressing and putting on/taking off footwear. <BR/>Record review of Resident #41's care plan, revised 11/27/2023, revealed no documentation regarding PASRR status. <BR/>Record review of Resident #41's PASRR Level 1 Screening, dated 01/22/2021, revealed, that in Section C, subsection C0100, C0200, and C0300 all sections are marked no. There was no new updated PASRR in Resident #41's chart. Resident #41 had no new PASRR performed with new admission on [DATE]. <BR/>During an observation and interview on 01/16/2024 at 09:34 AM, Resident #41 was in his room, Resident #41 was standing next to his dresser putting his laundry away. Resident #41 had a NC hooked to portable oxygen; he had a rolling walker close by to assist him to ambulate. Resident stated that everyone treated him fine and did not voice any concerns with his care.<BR/>During an interview on 01/18/2024 at 09:01 AM MDS LVN was asked about Resident #41's most recent PASRR. MDS LVN stated Yes, we saw that. I just didn't understand that a new one needed to be done. The new PASRR has been completed, but I can't submit it due to the admit date being more than 90 days out. MDS LVN was asked what a negative outcome would be for a resident not having and updated PASRR. MDS LVN stated since he is a resident that does not receive services there would be no negative outcome. MDS LVN stated that she had the email from the PASRR office and the email that she submitted to the PASRR office. Copies of this documentation was requested. <BR/>During an interview on 01/18/2024 at 09:13 AM with DON revealed that a negative outcome for not having an updated PASRR upon admission could lead to the resident would have no help from services if needed. <BR/>During an observation and interview on 01/18/2024 at 09:29 AM revealed paperwork provided by the MDS LVN that showed emails dated 01/17/2024 at 2:48pm, that she sent to PASRR support, it stated the following, Hi, I have missed completing a PASRR for a resident that was admitted on 08.08.2023. I have attempted to complete it for today's date and when it comes to adding in the NF admission date it says that it is an error. How can I correct this issue. The response email from PASRR support stated, Thank you for contacting the PASRR mailbox. Depending on the volume of emails received, it may take up to 3 business days to receive a response. We appreciate your patience.<BR/>Record review of facility policy, titled Admission-From Other Healthcare Facilities dated revised March 2017 states the following: <BR/> 2. The following information will be provided to the facility prior to or upon the resident's admission: <BR/> .I. PASARR (as appropriate);

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for one (Resident #26) of 18 residents reviewed for medical records.<BR/>The facility failed to ensure Resident #26 had the most current physician's order in her chart for oxygen. The order in Resident #26's chart was for continuous oxygen but the most recent verbal order from the physician was to begin weaning Resident #26 off continuous oxygen. <BR/>This failure could place residents at risk of having records that do not reflect their current status or needs.<BR/>Findings Included:<BR/>Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).<BR/>Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. <BR/>Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats&gt;90%. This intervention was initiated on 06/22/23 and revised on 09/18/23.<BR/>Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat&gt;90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date.<BR/>Record review of Resident #26's progress notes revealed a note by LVN A dated 01/07/24 at 02:34 PM. This note stated, This nurse monitoring resident without O2. O2 reading of 92% RA [Room Air]. No s/s of distress noted.<BR/>During an observation on 01/16/24 at 10:23 AM Resident #26 was lying in her bed on her right side in the fetal position under a blanket. She was not receiving O2. Her O2 concentrator machine was next to the bed with the tubing gathered together into a zipped plastic bag taped to the top of the machine.<BR/>During an observation on 01/16/24 at 12:05 PM Resident #26 was sitting in her w/c with her eyes closed at a dining room table. She was not receiving O2.<BR/>During an observation on 01/17/24 at 07:36 AM Resident #26 was sitting in her w/c at the dining room table eating her breakfast. She was not receiving O2. She did not respond when spoken to.<BR/>During an observation on 01/17/24 at 08:19 AM Resident #26 was sitting in her w/c in the common room with several other residents. She was not receiving O2.<BR/>During an observation on 01/17/24 at 11:25 AM Resident #26 was sitting in the common room in her w/c. She was not receiving O2.<BR/>During an observation on 01/18/24 at 08:44 AM Resident #26 was sitting in her w/c in the common area having her hair curled by a staff member. She was not receiving O2.<BR/>During an observation and interview on 01/18/24 beginning at 10:41 AM LVN A stated she had worked for the facility for 5 years. She said if a resident had orders for continuous O2 to keep O2 saturation above 90% the resident was supposed to have it [O2] on all the time. She stated nurses checked the residents' O2 sats in the morning. She stated nurses, Special Care staff, and CNAs were responsible for to make sure O2 orders were followed. She clarified that the nurse was responsible for setting levels and ensuring the order was followed and CNAs and Special Staff could adjust or apply the nasal cannulas. When asked why Resident #26 had an active order for continuous O2 and was not receiving O2, LVN A stated, We were gonna try to wean her and I think I have a note in there. At this point LVN A began to search her computer screen and printed off a note dated 01/07/24 at 02:34 PM. When asked if the physician said to wean Resident #26 off oxygen, LVN A looked at her computer screen and stated, Yes, but I didn't write it down. It is not in there. She stated a possible negative outcome of having the wrong orders in the chart was a resident could become disoriented, agitated, combative or restless.<BR/>During an interview on 01/18/24 at 10:47 AM ADON stated if a resident had orders for continuous oxygen that resident should always be receiving oxygen. She stated she, the DON, and the nurses were responsible to ensure orders were followed. When asked about Resident #26 having orders for continuous oxygen and LVN A saying Resident #26 was being weaned from oxygen, ADON stated, Nurse would be responsible for noting that in the chart and would contact the doctor and get doctor orders and the nurse would be responsible to put those orders in the chart too. She stated a possible negative outcome of having the wrong orders in the chart was, Shortness of breath, they [residents] can't breathe. <BR/>During an interview on 01/18/24 at 10:55 AM SC B said she knew which residents to put oxygen on because the nurse tells us. When asked how she knew which residents needed oxygen sometimes or all the time she stated, I ask the nurse. Has to be passed down through communication. They tell us who needs it all day. When asked why Resident #26 was not receiving oxygen she said, They [nurses] told us awhile back that she did not need it anymore. So, they leave her on it for a little bit and they take it off of her.<BR/>During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not following the orders in the EHR was, You could have someone go hypoxic (low levels of O2 in the blood). When asked about Resident #26 having orders in her EHR for continuous oxygen and LVN A stating they were weaning her off oxygen, DON stated, Nurse should have changed the order from continuous to PRN on the day that she spoke to the doctor.<BR/>Record review of facility policy titled Oxygen Administration and dated 08/09/23 revealed the following:<BR/> . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.<BR/>Record review of facility policy titled Medication and Treatment Orders and dated July 2016 revealed the following:<BR/> . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.<BR/>Record review of facility policy titled Telephone Orders and dated February 2014 revealed the following:<BR/> . 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.<BR/>Record review of facility policy titled Verbal Orders and dated February 2014 revealed the following:<BR/> . Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. 1. Only authorized, licensed practitioners or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 2. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone. 4. The individual receiving the verbal order must write it on the physician's order sheet as 'v.o.' (verbal order) or 't.o.' (telephone order). 5. The individual receiving the verbal order will: . b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for one (Resident #26) of 18 residents reviewed for medical records.<BR/>The facility failed to ensure Resident #26 had the most current physician's order in her chart for oxygen. The order in Resident #26's chart was for continuous oxygen but the most recent verbal order from the physician was to begin weaning Resident #26 off continuous oxygen. <BR/>This failure could place residents at risk of having records that do not reflect their current status or needs.<BR/>Findings Included:<BR/>Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).<BR/>Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. <BR/>Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats&gt;90%. This intervention was initiated on 06/22/23 and revised on 09/18/23.<BR/>Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat&gt;90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date.<BR/>Record review of Resident #26's progress notes revealed a note by LVN A dated 01/07/24 at 02:34 PM. This note stated, This nurse monitoring resident without O2. O2 reading of 92% RA [Room Air]. No s/s of distress noted.<BR/>During an observation on 01/16/24 at 10:23 AM Resident #26 was lying in her bed on her right side in the fetal position under a blanket. She was not receiving O2. Her O2 concentrator machine was next to the bed with the tubing gathered together into a zipped plastic bag taped to the top of the machine.<BR/>During an observation on 01/16/24 at 12:05 PM Resident #26 was sitting in her w/c with her eyes closed at a dining room table. She was not receiving O2.<BR/>During an observation on 01/17/24 at 07:36 AM Resident #26 was sitting in her w/c at the dining room table eating her breakfast. She was not receiving O2. She did not respond when spoken to.<BR/>During an observation on 01/17/24 at 08:19 AM Resident #26 was sitting in her w/c in the common room with several other residents. She was not receiving O2.<BR/>During an observation on 01/17/24 at 11:25 AM Resident #26 was sitting in the common room in her w/c. She was not receiving O2.<BR/>During an observation on 01/18/24 at 08:44 AM Resident #26 was sitting in her w/c in the common area having her hair curled by a staff member. She was not receiving O2.<BR/>During an observation and interview on 01/18/24 beginning at 10:41 AM LVN A stated she had worked for the facility for 5 years. She said if a resident had orders for continuous O2 to keep O2 saturation above 90% the resident was supposed to have it [O2] on all the time. She stated nurses checked the residents' O2 sats in the morning. She stated nurses, Special Care staff, and CNAs were responsible for to make sure O2 orders were followed. She clarified that the nurse was responsible for setting levels and ensuring the order was followed and CNAs and Special Staff could adjust or apply the nasal cannulas. When asked why Resident #26 had an active order for continuous O2 and was not receiving O2, LVN A stated, We were gonna try to wean her and I think I have a note in there. At this point LVN A began to search her computer screen and printed off a note dated 01/07/24 at 02:34 PM. When asked if the physician said to wean Resident #26 off oxygen, LVN A looked at her computer screen and stated, Yes, but I didn't write it down. It is not in there. She stated a possible negative outcome of having the wrong orders in the chart was a resident could become disoriented, agitated, combative or restless.<BR/>During an interview on 01/18/24 at 10:47 AM ADON stated if a resident had orders for continuous oxygen that resident should always be receiving oxygen. She stated she, the DON, and the nurses were responsible to ensure orders were followed. When asked about Resident #26 having orders for continuous oxygen and LVN A saying Resident #26 was being weaned from oxygen, ADON stated, Nurse would be responsible for noting that in the chart and would contact the doctor and get doctor orders and the nurse would be responsible to put those orders in the chart too. She stated a possible negative outcome of having the wrong orders in the chart was, Shortness of breath, they [residents] can't breathe. <BR/>During an interview on 01/18/24 at 10:55 AM SC B said she knew which residents to put oxygen on because the nurse tells us. When asked how she knew which residents needed oxygen sometimes or all the time she stated, I ask the nurse. Has to be passed down through communication. They tell us who needs it all day. When asked why Resident #26 was not receiving oxygen she said, They [nurses] told us awhile back that she did not need it anymore. So, they leave her on it for a little bit and they take it off of her.<BR/>During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not following the orders in the EHR was, You could have someone go hypoxic (low levels of O2 in the blood). When asked about Resident #26 having orders in her EHR for continuous oxygen and LVN A stating they were weaning her off oxygen, DON stated, Nurse should have changed the order from continuous to PRN on the day that she spoke to the doctor.<BR/>Record review of facility policy titled Oxygen Administration and dated 08/09/23 revealed the following:<BR/> . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.<BR/>Record review of facility policy titled Medication and Treatment Orders and dated July 2016 revealed the following:<BR/> . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.<BR/>Record review of facility policy titled Telephone Orders and dated February 2014 revealed the following:<BR/> . 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.<BR/>Record review of facility policy titled Verbal Orders and dated February 2014 revealed the following:<BR/> . Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. 1. Only authorized, licensed practitioners or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 2. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone. 4. The individual receiving the verbal order must write it on the physician's order sheet as 'v.o.' (verbal order) or 't.o.' (telephone order). 5. The individual receiving the verbal order will: . b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 18 residents (Resident #41) reviewed for PASRR requirements. <BR/>The facility failed to ensure Resident #41 had an initial PASRR Level 1 before admission on [DATE].<BR/>This failure could place residents with an MI (Mental Illness), ID (Intellectual Disability) or DD (Developmental Disability) at risk for not receiving PASRR related services, if qualified. <BR/>The findings include:<BR/>Record review of Resident #41's face sheet, dated 01/16/2024, revealed a [AGE] year-old male admitted to the facility initially on 08/08/2023 with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease with (acute) lower respiratory infection, major depressive disorder, recurrent, unspecified, atherosclerosis (plaque build up) of native coronary artery of transplanted heart without angina pectoris (chest pain), muscle weakness, epitaxis (bleeding from the nose), essential primary hypertension. <BR/>Record review of Resident #41's quarterly MDS assessment, dated 11/24/2023, revealed a BIMS score of 11 out 15 which indicated his cognition was moderately impaired. He functional ability with eating, oral hygiene, toileting, and personal hygiene is classified as independent, with supervision or touching assistance with showering/bathing. Resident #41 is partial/moderate assistance with upper and lower body dressing and putting on/taking off footwear. <BR/>Record review of Resident #41's care plan, revised 11/27/2023, revealed no documentation regarding PASRR status. <BR/>Record review of Resident #41's PASRR Level 1 Screening, dated 01/22/2021, revealed, that in Section C, subsection C0100, C0200, and C0300 all sections are marked no. There was no new updated PASRR in Resident #41's chart. Resident #41 had no new PASRR performed with new admission on [DATE]. <BR/>During an observation and interview on 01/16/2024 at 09:34 AM, Resident #41 was in his room, Resident #41 was standing next to his dresser putting his laundry away. Resident #41 had a NC hooked to portable oxygen; he had a rolling walker close by to assist him to ambulate. Resident stated that everyone treated him fine and did not voice any concerns with his care.<BR/>During an interview on 01/18/2024 at 09:01 AM MDS LVN was asked about Resident #41's most recent PASRR. MDS LVN stated Yes, we saw that. I just didn't understand that a new one needed to be done. The new PASRR has been completed, but I can't submit it due to the admit date being more than 90 days out. MDS LVN was asked what a negative outcome would be for a resident not having and updated PASRR. MDS LVN stated since he is a resident that does not receive services there would be no negative outcome. MDS LVN stated that she had the email from the PASRR office and the email that she submitted to the PASRR office. Copies of this documentation was requested. <BR/>During an interview on 01/18/2024 at 09:13 AM with DON revealed that a negative outcome for not having an updated PASRR upon admission could lead to the resident would have no help from services if needed. <BR/>During an observation and interview on 01/18/2024 at 09:29 AM revealed paperwork provided by the MDS LVN that showed emails dated 01/17/2024 at 2:48pm, that she sent to PASRR support, it stated the following, Hi, I have missed completing a PASRR for a resident that was admitted on 08.08.2023. I have attempted to complete it for today's date and when it comes to adding in the NF admission date it says that it is an error. How can I correct this issue. The response email from PASRR support stated, Thank you for contacting the PASRR mailbox. Depending on the volume of emails received, it may take up to 3 business days to receive a response. We appreciate your patience.<BR/>Record review of facility policy, titled Admission-From Other Healthcare Facilities dated revised March 2017 states the following: <BR/> 2. The following information will be provided to the facility prior to or upon the resident's admission: <BR/> .I. PASARR (as appropriate);

**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 the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans, as appropriate for 11 of 11 residents (Resident #4, Resident #5, Resident #11, Resident #18, Resident #35, Resident #39, Resident #50, Resident #51, Resident #55, Resident #57, Resident #116) reviewed for comprehensive care plans. <BR/>The facility failed to ensure Resident #4, Resident #5, Resident #11, Resident #18, Resident #35, Resident #39, Resident #50, Resident #51, Resident #55, Resident #57, and Resident #116's care plans contained the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>This failure could place all residents at risk for not having their discharge preferences known.<BR/>The findings include:<BR/>Record review of Resident #4's face sheet, dated 11/29/22, revealed an [AGE] year-old female admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance, dermatitis (skin conditions characterized by red, itchy rashes), and edema (swelling).<BR/>Record review of Resident #4's most recent comprehensive MDS assessment, an admission MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Resident's Overall Expectation . Select one for resident's overall goal established during assessment process . Unknown or uncertain . Indicate information source . Resident . Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #4's care plan, revised 11/09/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #5's face sheet, dated 11/29/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic periodontitis (gum infection that damages the soft tissue), abnormalities of gait (manner of walking) and mobility, edema, weakness, reduced mobility, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (damage to the kidney due to chronic high blood pressure), heart failure, peripheral vascular disease (disease affecting the blood vessels), obstructive sleep apnea (hoarse or harsh sound from nose or mouth that occurs when breathing is partially obstructed), type 2 diabetes, major depressive disorder, recurrent, hypertension and atrial fibrillation (irregular heart rhythm).<BR/>Record review of Resident #5's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #5's care plan, revised 09/20/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #11's face sheet, dated 11/29/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hyperlipidemia (is abnormally elevated levels of any or all lipids or lipoproteins in the blood), anemia (lack enough healthy red blood cells to carry adequate oxygen to the body's tissues), abnormalities of gait and mobility, weakness, hemiplegia, unspecified affecting left nondominant side (paralysis of one side of the body), legal blindness, and edema.<BR/>Record review of Resident #11's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #11's care plan, revised 10/21/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #18's face sheet, dated 11/29/22, revealed an [AGE] year-old male admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to, chronic cholecystitis (inflammation of gallbladder), fracture of right shoulder girdle, part unspecified, initial encounter for closed fracture (broken right shoulder), paroxysmal atrial fibrillation (intermittent irregular heart rhythm), cellulitis of left lower limb (bacterial skin infection), weakness, difficulty in walking, insomnia, chronic kidney disease state 3, presence of right artificial hip joint, hepatic failure unspecified without coma (liver failure), diabetes mellitus due to underlying condition with diabetic nephropathy (damage to your kidneys caused by diabetes), atherosclerotic heart disease of native coronary artery without angina pectoris (thickening or stiffening of the arteries of the heart), and heart failure. <BR/>Record review of Resident #18's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #18's care plan, revised 11/09/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #35's face sheet, dated 11/29/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, chronic kidney disease stage 3, hereditary lymphedema (swelling of the leg or arm that occurs due to blockage in the lymphatic system which is part of the immune system), type 2 diabetes mellitus, hypertensive chronic kidney disease with stage 1 through stage 4 kidney disease, chronic atrial fibrillation, anxiety disorder due to known physiological condition, unspecified dementia with behavioral disturbance, hypertension, and chronic diastolic (congestive) heart failure (chamber of the heart loses it's ability to relax normally (because the muscle has become stiff) so the heart cannot properly fill with blood during rest).<BR/>Record review of Resident #35's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #35's care plan, revised 10/26/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #39's face sheet, dated 11/29/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, dysphagia (difficulty swallowing food or liquid), anorexia (eating disorder characterized by an abnormally low body weight), major depressive disorder recurrent, difficulty in walking, unsteadiness on feet, weakness, complete traumatic amputation at level between elbow and wrist, unspecified dementia with behavioral disturbance, and legal blindness. <BR/>Record review of Resident #39's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .No . Family or significant other participated in assessment .No . Guardian or legally authorized representative participated in assessment .No .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #39's care plan, revised 10/26/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #50's face sheet, dated 11/29/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, pressure ulcer of right buttock, unstageable (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), cellulitis of right lower limb, anxiety disorder due to known physiological condition, Alzheimer's disease, hypertension, and rheumatoid arthritis (chronic inflammatory disease that affects the joints).<BR/>Record review of Resident #50's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #50's care plan, revised 11/28/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #51's face sheet, dated 11/28/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, painful micturition (urination) and dysphagia.<BR/>Record review of Resident #51's most recent comprehensive MDS assessment, an annual MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #51's care plan, revised 11/16/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #55's face sheet, dated 11/29/22, revealed a [AGE] year-old male admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, secondary pulmonary arterial hypertension (increased pressure of the blood vessels of the lungs as a result of other medical conditions), nonrheumatic mitral valve insufficiency (heart valve disorder), abdominal aortic aneurysm without rupture (enlarged area in the lower part of the major vessel that supplies blood to the body), insomnia, hypertension, unspecified atrial fibrillation, unspecified diastolic (congestive) heart failure, muscle weakness, neuromuscular dysfunction of bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), personal history of transient ischemic attack (TIA) and cerebral infarction without residual side effects (stroke) and presence of a cardiac pacemaker.<BR/>Record review of Resident #55's most recent comprehensive MDS assessment, an admission MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes . Resident's Overall Expectation . Select one for resident's overall goal established during assessment process . Expects to remain in this facility .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #55's care plan, revised 11/16/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #57's face sheet, dated 11/29/22, revealed a [AGE] year-old female admitted to he facility on 04/28/22 with diagnoses that included, but were not limited to, extraarticular fracture of lower end of left radius (a fracture of the left arm occurring outside a joint), displaced fracture of left ulna styloid process (a fracture of the left arm), displaced fracture of left phalanx of left thumb (fracture of left thumb) and hypertension. <BR/>Record review of Resident #57's most recent comprehensive MDS assessment, an admission MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes . Resident's Overall Expectation . Select one for resident's overall goal established during assessment process . Expects to remain in this facility .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #57's care plan, revised 11/28/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>Record review of Resident #116's face sheet, dated 11/29/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified injury of lower back, major depressive disorder, other idiopathic scoliosis (spinal deformity that affects the curvature of the spine), and acute respiratory failure with hypoxia (below-normal level of oxygen in your blood, specifically in the arteries).<BR/>Record review of Resident #116's most recent comprehensive MDS assessment, an admission MDS assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in Assessment .Resident participated in assessment .Yes . Resident's Overall Expectation . Select one for resident's overall goal established during assessment process . Expects to remain in this facility .Discharge Plan . Is active discharge planning already occurring for the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.<BR/>Record review of Resident #116's care plan, revised 11/28/22, revealed no documentation of the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.<BR/>During an interview on 11/29/22 at 11:16 AM, the MDSC stated she was responsible for updating care plans. She stated everything in the CAA (section of the MDS), medications and typically everything, needed to be included in a comprehensive care plan. She stated she was not sure if it was required to document discharge planning in the care plan unless there was an actual plan of discharge. She stated she did not know if their preference for discharge had to be documented in the care plan. She stated she did not know if not having a resident's discharge preference documented in the care plan would negatively affect the resident, but she could see how it could negatively affect a resident if it was not assessed at all. She stated resident's discharge preferences were assessed, they were just not documented in the care plan. She stated the facility tried to provide her with care plan training, but her in-person training was stopped due to COVID-19. She stated she had received more care plan training from when a consultant was in their facility recently. <BR/>Record review of a facility policy titled, Care Plan Goals and Objectives, dated 03/14/18, revealed, in part, .3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. Are resident oriented; b. Are behaviorally stated; c. Are measurable; and d. Contain timetables to meet the resident's needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 (CNA, NA in Training and Special Care Aide) of 7 employees observed during lunch dining observation.<BR/>CNA did not disinfect hands between feeding 4 residents.<BR/>NA in Training touched her face and then delivered a resident tray without sanitizing hands. NA in Training carried 2 resident plates on one tray and delivered plates to different tables in the dining room without sanitizing hands between plates.<BR/>Special Care Aide put hands in pockets and then delivered a resident tray without sanitizing hands. Special Care Aide carried 2 resident plates on one tray and delivered plates to different tables in the dining room without sanitizing hands between plates.<BR/>This failure could place residents at risk of transmission of a communicable disease or infection.<BR/>Finding included:<BR/>In an interview on 8/15/23 at 10:38AM DON stated that she conducted in-services regarding hand hygiene and infection control about every 2 weeks. DON stated that she had done skills training with all staff on hand hygiene and had posters which indicated proper hand hygiene techniques and infection control procedures, placed around the building. DON stated that all newly hired employees had to pass a skills-based training on hand hygiene and infection control before they were allowed to work with residents. <BR/>On 8/15/23 at 11:44AM during observation of lunch service, CNA prepared a dietary supplement drink for 4 residents and used the same spoon for all 4 drinks. CNA picked up the same spoon and fed one resident, set the spoon down, touched her pant leg and then proceeded to pick up another spoon to feed another resident. CNA did not sanitize her hands throughout the lunch service observation.<BR/>On 08/15/23, during multiple observations during lunch service, NA in Training was observed to touch her face and then pick up a resident tray. NA in Training failed to sanitize hands between each resident tray delivery. NA in Training was observed carrying 2 plates of resident food on one tray and delivered both plates to different tables in the dining room without sanitizing her hands between plates. Special Care Aide was observed to put his hands in his pockets and then pick up a resident tray. Special Care Aide was observed carrying 2 plates of resident food on one tray and delivered both plates to different tables in the dining room without sanitizing his hands between plates.<BR/>On 8/15/23 at 12:35PM while this surveyor was reviewing policies and procedures and in-services, DON stated that she witnessed a break in hand hygiene during the lunch service. DON stated she had worked with the dietary staff to ensure everyone practiced proper hand hygiene when working with resident food. DON stated that she would conduct an in-service with the 3 employees, before the next meal service.<BR/>In an interview on 8/15/23 at 12:51PM NA in Training stated that she was nervous because this surveyor was in the dining room and forgot to sanitize her hands between trays. NA in Training stated that she should have sanitized her hands between every resident tray. NA in Training stated that she should not put 2 resident plates on the same tray. NA in Training stated that the negative outcome of not sanitizing hands between plates and trays would be that the residents could become sick. <BR/>In an interview on 8/15/23 at 12:57PM Special Care Aide stated that he should sanitize his hands between the delivery of every resident tray. Special Care Aide stated that he should not put 2 resident plates on the same tray. Special Care Aide stated that the negative outcome of not sanitizing hands between plates and trays would be that the residents could become sick.<BR/>In an interview on 8/15/23 at 4:04PM CNA stated that she should sanitize her hands between feeding residents. CNA stated that feeding 4 residents at the same time was not hard and that she did not need any assistance in feeding those 4 residents. CNA stated that the negative outcome would be cross-contamination between the residents and residents could become sick.<BR/>Record Review of Infection Control Policies and Procedures and Infection Control in-services revealed that in-services regarding infection control and hand hygiene were conducted on 5/30/23 and 8/8/23.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 (CNA, NA in Training and Special Care Aide) of 7 employees observed during lunch dining observation.<BR/>CNA did not disinfect hands between feeding 4 residents.<BR/>NA in Training touched her face and then delivered a resident tray without sanitizing hands. NA in Training carried 2 resident plates on one tray and delivered plates to different tables in the dining room without sanitizing hands between plates.<BR/>Special Care Aide put hands in pockets and then delivered a resident tray without sanitizing hands. Special Care Aide carried 2 resident plates on one tray and delivered plates to different tables in the dining room without sanitizing hands between plates.<BR/>This failure could place residents at risk of transmission of a communicable disease or infection.<BR/>Finding included:<BR/>In an interview on 8/15/23 at 10:38AM DON stated that she conducted in-services regarding hand hygiene and infection control about every 2 weeks. DON stated that she had done skills training with all staff on hand hygiene and had posters which indicated proper hand hygiene techniques and infection control procedures, placed around the building. DON stated that all newly hired employees had to pass a skills-based training on hand hygiene and infection control before they were allowed to work with residents. <BR/>On 8/15/23 at 11:44AM during observation of lunch service, CNA prepared a dietary supplement drink for 4 residents and used the same spoon for all 4 drinks. CNA picked up the same spoon and fed one resident, set the spoon down, touched her pant leg and then proceeded to pick up another spoon to feed another resident. CNA did not sanitize her hands throughout the lunch service observation.<BR/>On 08/15/23, during multiple observations during lunch service, NA in Training was observed to touch her face and then pick up a resident tray. NA in Training failed to sanitize hands between each resident tray delivery. NA in Training was observed carrying 2 plates of resident food on one tray and delivered both plates to different tables in the dining room without sanitizing her hands between plates. Special Care Aide was observed to put his hands in his pockets and then pick up a resident tray. Special Care Aide was observed carrying 2 plates of resident food on one tray and delivered both plates to different tables in the dining room without sanitizing his hands between plates.<BR/>On 8/15/23 at 12:35PM while this surveyor was reviewing policies and procedures and in-services, DON stated that she witnessed a break in hand hygiene during the lunch service. DON stated she had worked with the dietary staff to ensure everyone practiced proper hand hygiene when working with resident food. DON stated that she would conduct an in-service with the 3 employees, before the next meal service.<BR/>In an interview on 8/15/23 at 12:51PM NA in Training stated that she was nervous because this surveyor was in the dining room and forgot to sanitize her hands between trays. NA in Training stated that she should have sanitized her hands between every resident tray. NA in Training stated that she should not put 2 resident plates on the same tray. NA in Training stated that the negative outcome of not sanitizing hands between plates and trays would be that the residents could become sick. <BR/>In an interview on 8/15/23 at 12:57PM Special Care Aide stated that he should sanitize his hands between the delivery of every resident tray. Special Care Aide stated that he should not put 2 resident plates on the same tray. Special Care Aide stated that the negative outcome of not sanitizing hands between plates and trays would be that the residents could become sick.<BR/>In an interview on 8/15/23 at 4:04PM CNA stated that she should sanitize her hands between feeding residents. CNA stated that feeding 4 residents at the same time was not hard and that she did not need any assistance in feeding those 4 residents. CNA stated that the negative outcome would be cross-contamination between the residents and residents could become sick.<BR/>Record Review of Infection Control Policies and Procedures and Infection Control in-services revealed that in-services regarding infection control and hand hygiene were conducted on 5/30/23 and 8/8/23.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 (CNA, NA in Training and Special Care Aide) of 7 employees observed during lunch dining observation.<BR/>CNA did not disinfect hands between feeding 4 residents.<BR/>NA in Training touched her face and then delivered a resident tray without sanitizing hands. NA in Training carried 2 resident plates on one tray and delivered plates to different tables in the dining room without sanitizing hands between plates.<BR/>Special Care Aide put hands in pockets and then delivered a resident tray without sanitizing hands. Special Care Aide carried 2 resident plates on one tray and delivered plates to different tables in the dining room without sanitizing hands between plates.<BR/>This failure could place residents at risk of transmission of a communicable disease or infection.<BR/>Finding included:<BR/>In an interview on 8/15/23 at 10:38AM DON stated that she conducted in-services regarding hand hygiene and infection control about every 2 weeks. DON stated that she had done skills training with all staff on hand hygiene and had posters which indicated proper hand hygiene techniques and infection control procedures, placed around the building. DON stated that all newly hired employees had to pass a skills-based training on hand hygiene and infection control before they were allowed to work with residents. <BR/>On 8/15/23 at 11:44AM during observation of lunch service, CNA prepared a dietary supplement drink for 4 residents and used the same spoon for all 4 drinks. CNA picked up the same spoon and fed one resident, set the spoon down, touched her pant leg and then proceeded to pick up another spoon to feed another resident. CNA did not sanitize her hands throughout the lunch service observation.<BR/>On 08/15/23, during multiple observations during lunch service, NA in Training was observed to touch her face and then pick up a resident tray. NA in Training failed to sanitize hands between each resident tray delivery. NA in Training was observed carrying 2 plates of resident food on one tray and delivered both plates to different tables in the dining room without sanitizing her hands between plates. Special Care Aide was observed to put his hands in his pockets and then pick up a resident tray. Special Care Aide was observed carrying 2 plates of resident food on one tray and delivered both plates to different tables in the dining room without sanitizing his hands between plates.<BR/>On 8/15/23 at 12:35PM while this surveyor was reviewing policies and procedures and in-services, DON stated that she witnessed a break in hand hygiene during the lunch service. DON stated she had worked with the dietary staff to ensure everyone practiced proper hand hygiene when working with resident food. DON stated that she would conduct an in-service with the 3 employees, before the next meal service.<BR/>In an interview on 8/15/23 at 12:51PM NA in Training stated that she was nervous because this surveyor was in the dining room and forgot to sanitize her hands between trays. NA in Training stated that she should have sanitized her hands between every resident tray. NA in Training stated that she should not put 2 resident plates on the same tray. NA in Training stated that the negative outcome of not sanitizing hands between plates and trays would be that the residents could become sick. <BR/>In an interview on 8/15/23 at 12:57PM Special Care Aide stated that he should sanitize his hands between the delivery of every resident tray. Special Care Aide stated that he should not put 2 resident plates on the same tray. Special Care Aide stated that the negative outcome of not sanitizing hands between plates and trays would be that the residents could become sick.<BR/>In an interview on 8/15/23 at 4:04PM CNA stated that she should sanitize her hands between feeding residents. CNA stated that feeding 4 residents at the same time was not hard and that she did not need any assistance in feeding those 4 residents. CNA stated that the negative outcome would be cross-contamination between the residents and residents could become sick.<BR/>Record Review of Infection Control Policies and Procedures and Infection Control in-services revealed that in-services regarding infection control and hand hygiene were conducted on 5/30/23 and 8/8/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 (Resident #214) of 15 residents reviewed for comprehensive assessments.<BR/>The facility failed to complete an admission MDS on Resident #214 within 14 calendar days after admission date of 02/11/25.<BR/>This failure could place residents at risk of not having their needs met due to lack of information.<BR/>Findings Included:<BR/>Record review of Resident #214's admission record dated 02/25/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body) and melena (dark, tarry stool).<BR/>Record review of Resident #214's EHR revealed an admission MDS with ARD of 02/19/25 which was not competed. It was noted to be in progress. <BR/>Record review of Resident #214's care plan revealed it was initiated on 02/19/25.<BR/>During an interview on 02/26/25 at 02:17 PM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when completing MDS assessments. MDS LVN stated an admission MDS was to be completed within 14 days of a resident's admission to the facility. MDS LVN stated she thought she had completed Resident #214's admission MDS timely. She looked at her computer screen and said, Oh, it is still in progress, and I need to sign it. MDS LVN stated a possible negative outcome of not completing an admission MDS timely was, We might not get paid as well and it could lead to care plan not being updated as quickly.<BR/>During an interview on 02/26/25 at 02:28 PM ADON stated an admission MDS not being completed timely could lead to we cannot completely take care of the residents due to not having a complete assessment of care areas.<BR/>During an interview on 02/26/25 at 02:34 PM DON stated having an admission MDS completely timely was important to the care of a resident so everyone can be on the same page.<BR/>During an interview on 02/26/25 at 02:53 PM ADM stated MDS LVN was responsible for completing MDS assessments. She stated an admission MDS not being completed timely could negatively impact resident care. ADM stated, You need to know everything you can about a resident as soon as they show up. Find out as much as you can as soon as you can.<BR/>Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed a chart on page 38 with the following: Assessment Type .admission .MDS Completion Date .no later than 14th calendar day of the resident's admission (admission date + 13 calendar days) .

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure stored food was properly labeled and dated. <BR/>The facility failed to store food at least 6 inches above the floor. <BR/>This failure could place Residents at risk for foodborne illness. <BR/>Findings Included: <BR/>Observation of shelved/refrigerated foods on 1/16/2024 beginning at 10:03 am revealed the following: <BR/>Observation of pantry on 1/16/24 at 10:06 am revealed 1 container of Jif peanut butter individual packs with no label or date. <BR/>Observation of pantry on 1/16/ 24 at 10:11 am revealed 1 container of individual jelly packets with no label or date. <BR/>Observation of pantry room on 1/16/24 at 10:26 am revealed 1 container of croutons with no label or date. <BR/>Observation of refrigerator 1 on 1/16/24 at 10:43 am revealed 1 box of cabbage with no date. <BR/>Observation of refrigerator 1 on 1/16 at 10:43 am revealed 1 box of tomatoes on shelf with no date. <BR/>Observation of serving cart on 1/16/2 at 10:43 am revealed jelly packets in a bin with no label or date. <BR/>Observation of serving cart on 1/16/24 at 1043 am revealed butter packets with no label or date. <BR/>Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed I tray of honey mustard in individual cups with no date. <BR/>Observation of refrigerator 2 on 1/16/24 at 10: 48 am revealed unidentified I tray of salsa in fridge with no label or date. <BR/>Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed 1 bottle of ketchup with no date. <BR/>Observation of freezer 1 on 1/16/24 at 11:02 am revealed 6 boxes of frozen meat on the floor not 6 inches off the floor. <BR/> During an interview on 1/16/2024 at 11:20 pm, the cook stated that all kitchen staff are responsible for safe food storage per their policy. The cook said that she would go to the policy to see what the policy stated concerning food storage. The cook stated that the negative outcome for not practicing food storage would be contamination. <BR/>During an interview on 1/16/24 at 1:27 pm, Dietary Manager stated that she is responsible for training kitchen staff. The Dietary Manager said kitchen staff are to follow facility policy for proper food storage. The Dietary Manager said that a negative outcome for Residents would be contamination. She said that a former DM told her that they could store items in the freezer on the floor. <BR/>During an interview with the FSA on 1/17/24 at 10:33 am, FSA said she would go to the DM with any questions concerning food storage. She said a negative outcome would be a resident could get sick from bad food. FSA has not had any training on labeling and food storage. <BR/>Record review of Food Receiving and Storage Policy dated /11/22 at 2:30 PM revealed the following: Dry foods that are stored in bins are removed from the original packaging, label and dated (use by date). Such foods are rated using a fist in-first out system. Food in designated dry storage areas is kept at least six inches off the floor. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). <BR/>Record review of Dietary Services Policy & Procedure Manual dated 11- 2022, for storage area stated all stored items must be 6 inches above the floor. <BR/>Record review of Food and Drug Administration on, dated 1/18/23, stated in section 5-305.11 food storage should be at least 15cm (6 inches) above the floor.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure stored food was properly labeled and dated. <BR/>The facility failed to store food at least 6 inches above the floor. <BR/>This failure could place Residents at risk for foodborne illness. <BR/>Findings Included: <BR/>Observation of shelved/refrigerated foods on 1/16/2024 beginning at 10:03 am revealed the following: <BR/>Observation of pantry on 1/16/24 at 10:06 am revealed 1 container of Jif peanut butter individual packs with no label or date. <BR/>Observation of pantry on 1/16/ 24 at 10:11 am revealed 1 container of individual jelly packets with no label or date. <BR/>Observation of pantry room on 1/16/24 at 10:26 am revealed 1 container of croutons with no label or date. <BR/>Observation of refrigerator 1 on 1/16/24 at 10:43 am revealed 1 box of cabbage with no date. <BR/>Observation of refrigerator 1 on 1/16 at 10:43 am revealed 1 box of tomatoes on shelf with no date. <BR/>Observation of serving cart on 1/16/2 at 10:43 am revealed jelly packets in a bin with no label or date. <BR/>Observation of serving cart on 1/16/24 at 1043 am revealed butter packets with no label or date. <BR/>Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed I tray of honey mustard in individual cups with no date. <BR/>Observation of refrigerator 2 on 1/16/24 at 10: 48 am revealed unidentified I tray of salsa in fridge with no label or date. <BR/>Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed 1 bottle of ketchup with no date. <BR/>Observation of freezer 1 on 1/16/24 at 11:02 am revealed 6 boxes of frozen meat on the floor not 6 inches off the floor. <BR/> During an interview on 1/16/2024 at 11:20 pm, the cook stated that all kitchen staff are responsible for safe food storage per their policy. The cook said that she would go to the policy to see what the policy stated concerning food storage. The cook stated that the negative outcome for not practicing food storage would be contamination. <BR/>During an interview on 1/16/24 at 1:27 pm, Dietary Manager stated that she is responsible for training kitchen staff. The Dietary Manager said kitchen staff are to follow facility policy for proper food storage. The Dietary Manager said that a negative outcome for Residents would be contamination. She said that a former DM told her that they could store items in the freezer on the floor. <BR/>During an interview with the FSA on 1/17/24 at 10:33 am, FSA said she would go to the DM with any questions concerning food storage. She said a negative outcome would be a resident could get sick from bad food. FSA has not had any training on labeling and food storage. <BR/>Record review of Food Receiving and Storage Policy dated /11/22 at 2:30 PM revealed the following: Dry foods that are stored in bins are removed from the original packaging, label and dated (use by date). Such foods are rated using a fist in-first out system. Food in designated dry storage areas is kept at least six inches off the floor. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). <BR/>Record review of Dietary Services Policy & Procedure Manual dated 11- 2022, for storage area stated all stored items must be 6 inches above the floor. <BR/>Record review of Food and Drug Administration on, dated 1/18/23, stated in section 5-305.11 food storage should be at least 15cm (6 inches) above the floor.