Every finding on record at Alma Nursing and Rehab

Based on interview and record review, the facility failed to identify an incident of sexual abuse and to ensure interventions were put in place and effectively implemented to prevent subsequent incidents from occurring to protect one (Resident #16) of one resident from further sexual abuse. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10(c)(3) (Comprehensive Care Plans) at a scope and severity of J. The IJ began on 02/12/2026 at 10:35 AM, when Resident #89 was witnessed rubbing Resident #16's right inner thigh by facility staff. There were no interventions put in place to prevent subsequent incidents of sexual abuse to Resident #16. On 02/12/2026 at 7:35 PM, Resident #89 was witnessed with their hand inside Resident #16's brief. The Administrator and Director of Nursing (DON) were notified of IJ on 03/06/2026 at 2:22 PM. A removal plan was requested. The removal plan was accepted by the State Agency on 03/07/2026 at 1:20 PM. The findings include: Resident #16 A review of Resident #16's admission Record revealed the resident had diagnoses which included dementia, Alzheimer's Disease, cognitive communication deficit, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting the left dominant side. A review of Resident #16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2026, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. Resident #16's MDS also revealed the resident was dependent with Activities of Daily Living (ADLs), eating, transfers, and mobility. Resident #89 A review of Resident #89's admission Record revealed the resident had diagnoses which included major depressive disorder, congestive heart failure, and kidney disease. A review of Resident #89's quarterly MDS, with an ARD of 12/15/2025, revealed a BIMS score of 13, which indicated the resident was cognitively intact. Resident #89's MDS also revealed the resident used a wheelchair for mobility. A review of a Resident #89's Progress Notes, dated 02/12/2026 at 10:35 AM, indicated the Treatment Nurse saw Resident #89 sitting beside Resident #16 in the 300-Hall. She witnessed Resident #89 holding Resident #16's hand and rubbing Resident #16's right inner thigh. During an interview on 03/05/2026 at 1:30 PM, the Treatment Nurse indicated that on the morning of 02/12/2026, she did witness Resident #89 rubbing Resident #16's right inner thigh, while the residents were sitting in the 300-Hall. She indicated that as a result of this, she moved Resident #16 into the dining room with the Activity Director and reported the finding to the DON. She then explained after she informed the DON, the Treatment Nurse went back to providing resident care and reported she was unaware if any further interventions were put in place by the DON to protect Resident #16. A review of Resident #16's Skin Audit dated 02/12/2026 at 11:58 AM, indicated the Treatment Nurse completed a skin audit of Resident #16 with findings of scab to left temple, no s/s [signs/symptoms] infection noted, no drainage, bruise to left hand and wrist, no other skin issues noted at this time. During an interview on 03/05/2026 at 2:01 PM, the Administrator reported the first incident was not a concern for how it was described to her and stated, a CNA [Certified Nursing Assistant] was assigned to watch [Resident #89] before, and at change of shift, it was another CNA assigned. The Administrator then stated that record review and interviews did not reveal any one-on-one CNA duties, nor any assignment of staff, to watch Resident #89 after the first incident. During an interview on 03/05/2026 at 1:46 PM, the Activity Director indicated a CNA pushed Resident #16 into the dining room during an activity, on the morning of 02/12/2026. She reported the CNA told her what had happened (initial incident involving Resident #89) and told the Activity Director to make sure Resident #89 did not get near Resident #16. She indicated Resident #16 was present during the activity about an hour before the Activity Director wheeled Resident #16 back to the 300-Hall, and then unidentified CNAs took Resident #16 into Resident #16's room to lie down. During an interview on 03/05/2026 at 9:59 AM, the DON indicated that on 02/12/2026, the Treatment Nurse reported to her that she witnessed Resident #89 rubbing Resident #16's leg. The DON stated, it raised a flag for me. She indicated the Treatment Nurse took Resident #16 to the dining room where an activity was taking place because (Resident #16) cannot speak for [themself]. The DON then indicated she reported the incident to the Advanced Practice Registered Nurse (APRN) and the Administrator. The DON stated she alerted the staff to ensure Resident #89 did not go near Resident #16. The DON reported she did not have any documentation for telling the staff about the alert. She indicated she spoke with Licensed Practical Nurse (LPN) #22 and stated, [LPN #22], please make sure the staff CNAs on the hall are aware. The DON revealed to protect Resident #16 from further incident, there should have been one person right there watching Resident #89. During a phone interview on 03/05/2026 at 11:00 AM, CNA #28 indicated during her 7:00 PM to 7:00 AM shift on the 300-Hall on 02/12/2026, Resident #89 was removed from Resident #16's room three times: -She reported in the first incident at an unknown time, Resident #89 was just inside the door of Resident #16's room and CNA #29 wheeled Resident #89 back out. -She reported during the second incident, CNA #28 observed Resident #89 inside Resident #16's room and Resident #89 had a hand over Resident #16, but was not touching Resident #16, from what CNA #28 could see. She reported CNA #29 removed Resident #89 from Resident #16's room. CNA #28 then left to go find the nurse on 300-Hall (LPN #30) to report this incident to. -She reported the third incident happened when she left to find LPN #30 to report the second incident to, when CNA #29 found Resident #89 in Resident #16's room with a hand in Resident #16's brief. CNA #28 reported after the third incident, while assisting CNA #29 change Resident #16's brief, she saw a tear in Resident #16's eye and stated, we [the CNAs] were bothered by it. During a phone interview on 03/05/2026 at 11:30 AM, CNA #29 reported she worked the 3:00 PM to 11:00 PM shift on the 300-Hall on 02/12/2026. She reported Resident #89 went into Resident #16's room, I believe there was two times. She reported the last time Resident #89 was found in Resident #16's room was about 7:30 PM, when she saw Resident #89's hand in Resident #16's brief. She reported she told Resident #89 they had to leave the room, adding that Resident #89 wore gardening gloves for wheeling their wheelchair. She noted Resident #16 was incontinent of bowel at the time, and CNA #29 revealed they observed poop on [Resident #89's] gloves when Resident #89 removed their hand from Resident #16's brief. CNA #29 then reported that she found out 02/13/2026, that an (unknown) nurse was supposed to tell 300-Hall, LPN #30 about the morning incident on 02/12/2026 and LPN #30 was supposed to tell the CNAs on the 300-Hall. She stated, after she found out that she should have been told about the morning incident, I reported to the DON that day [02/13/2026], that no one told us [CNAs] about the morning incident on 02/12/2026. She stated of not being informed, that Resident #89 already had an incident with Resident #16, it was a very deep miscommunication, because hey, maybe we need to do a one on one indicating if she had known there had already been an incident with Resident #89 and Resident #16, she would have known to closely watch Resident #89. During an interview on 03/05/2026 at 3:12 PM, LPN #22 reported she worked the 3:00 PM to 11:00 PM shift, on the 400 and 100-Halls on 02/12/2026. She reported that the DON told her about Resident #89 rubbing Resident #16's thigh, and because of that, to keep a closer eye on [Resident #89]. LPN #22 reported she told LPN #30 (the nurse on the 300-Hall) about Resident #89 rubbing the inner thigh of Resident #16 in a morning incident on 02/12/2026. LPN #22 reported she met with LPN #30 in the medication room and told LPN #30 to keep a closer eye on Resident #89. During a follow-up phone interview on 03/06/2026 at 8:48 AM, CNA #28 reported she did not know anything about another incident with Resident #16 and Resident #89 earlier in the day on 02/12/2026. She reported no one had given her any instructions about specifically watching Resident #16 and Resident #89. During a phone interview on 03/06/2026 at 11:43 AM, LPN #30 reported she worked on the 300-Hall on 02/12/2026 during the 3:00 PM to 11:00 PM shift. She reported she was aware of the incident where Resident #89 had a hand in Resident #16's brief and revealed she called the Assistant Director of Nursing (ADON), the DON, the Administrator, and the police to report the incident. She reported that she found out about the initial, 02/12/2026 at 10:35 AM incident (when Resident #89 was rubbing on (Resident #16's) leg), after the later incident when Resident #89 had a hand in Resident #16's brief had already occurred on 02/12/2026. She stated, I was like WHAT?! She indicated if she had known about the incident earlier in the day, she would have kept (Resident #89) one-on-one supervision until we could get it figured out and talk with administration about what to do. A review of Resident #89 Behavior Note dated 02/12/2026 at 11:55 PM, indicated at 8:30 PM a body audit of Resident #16 was performed by LPN #30 with another nurse present. Results of the body audit indicated no bruises or redness or scratches noted to victims body. Victim unable to recall and or state events of incident. This note also indicated families of both parties were notified at 8:43 PM and [Resident #89] was on one-on-one supervision. Resident #89 verbalized, .I know what I did was wrong and I won't do it again . During a phone interview on 03/06/2026 at 12:53 PM, the APRN indicated facility staff had informed her that on 02/12/2026 at 10:35 AM, Resident #89 had touched or patted Resident #16. The APRN reported she spoke with both resident representatives and spoke with the Medical Director (MD). The APRN indicated the MD recommended starting a new anti-depressant medication for Resident #89. She then reported she found out later about the 7:30 PM incident on 02/12/2026. A review of Resident #16's APRN Note dated 02/13/2026 at 9:41 AM, indicated the APRN had a visit with Resident #16 and the APRN evaluated the resident with no overt evidence of active bleeding, visible external trauma, bruising or laceration noted at the time of my assessment. She indicated the resident had no acute distress. During a phone interview on 03/06/2026 at 1:10 PM, the MD indicated he was made aware of the incident when Resident #89 was observed rubbing the inner right thigh of Resident #16 and that he spoke with the APRN about starting Resident #89 on an anti-depressant medication, with the rationale that a side effect of the anti-depressant medication was a decrease in sexual desire. He reported that rubbing another resident's thigh was very inappropriate and hypersexual. The MD then indicated he was notified about the 7:30 PM incident on 02/12/2026 and it was his understanding Resident #89 would be on one-to-one until they were transferred. A review of Resident #89's February Medication Administration Record/Treatment Administration Record revealed an order dated 02/12/2026 at 11:40 AM, for a new anti-depressant medication. The first dose was documented given at 8:00 AM on 02/13/2026. During a phone interview on 03/06/2026 at 10:35 AM, Officer #31 reported getting to the facility on [DATE] just before 10:00 PM. He reported that he tried to interview Resident #16 and the resident was not oriented and did not verbalize anything. He reported while he was in the room with Resident #16, the nurse asked Resident #16 did something happen to you? Officer #31 reported that in response Resident #16 moved their hand and was making a grabbing motion at their waistline. He reported a staff member removed Resident #89's soiled glove from the trash to show the officer. Officer #31 then reported he interviewed CNA #28 and CNA #29. He indicated the CNAs reported Resident #89 had been in Resident #16's room three times that night [02/12/2026]. The first time, Resident #89 got just inside Resident #16's room. The second time, Resident #89 was found in Resident #16's room and Resident #89 had Resident #16's shirt pulled up. The third time, Resident #89 was in Resident #16's room with their hand in Resident #16's brief. He reported that after the second time Resident #89 was found in Resident #16's room, CNA #28 and CNA #29 indicated to him that both of them went to get the nurse. He stated, It bothers me one did not stay with the female resident. Because this form of inappropriate, unwanted sexual contact would reasonably cause severe psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm- dehumanization, and humiliation- as a result of the sexual abuse, placing Resident #16 at risk for serious injury, serious harm, serious impairment or death. Sexual fondling was defined by Legal Information Institute 34 USC 30309(11) as touching of the private body parts of another person (including . inner thigh) for the purpose of sexual gratification. A review of an in-service dated 03/18/2025, for Resident Rights and Abuse, Neglect, Misappropriation and Exploitation among other subjects was signed as attended by DON (ADON at the time), CNA #28, and LPN #22. LPN #30 and CNA #29 were not listed. A review of an in-service dated 06/17/2025, for 7 forms of abuse was signed as attended by CNA #29, LPN #22, and the DON. LPN #30 was not listed, and the in-service was not signed as attended by CNA #28. A review of an in-service titled Freedom from Abuse, Neglect, Misappropriation and Exploitation Competency Staff Training dated 09/23/2025, (page 13, extended survey #18 in-service abuse) indicated, Residents have the right to be free from abuse, neglect, misappropriation and exploitation. The facility must promote the residents' rights. Facility staff must be able to identify potential abuse and know what to do to protect residents. This in-service was signed as attended by CNA #29, CNA #28, LPN #22, DON, Treatment Nurse, A review of an in-service dated 03/06/2026, for Identifying Sexual Abuse, defined Sexual abuse as non-consensual sexual contact of any type with a resident. A review of an undated facility policy titled Abuse Investigation, & Reporting Policy, section II staff training and competency indicated the facility would conduct in-service programs at least annually for all employees .and the proper procedures for identifying, reporting and preventing abuse of residents. Section III of the policy indicated all alleged, witnessed or suspected resident maltreatment, including sexual abuse .shall be immediately reported to administrator or immediate supervisor and investigated by facility management. Section VI indicated residents' care plans will address interventions designed to prevent occurrences and the resident's physician will be notified of the investigation and to implement actions to prevent a recurrence. Section IX indicated sexual abuse was defined as sexual activity, sexual contact .with another person who was not the actor's spouse and who was incapable of consent because he or she was mentally defective, mentally incapacitate or physically helpless. The IJ was removed on 03/09/2026 at 11:40 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 03/09/2026 at 11:50 AM, when on 03/06/2026, at 4:15 PM, it was determined on 02/12/2026 at 10:35 AM, Element 1: Resident #89 was observed rubbing Resident #16's right inner thigh by facility staff. On 02/12/2026 at 7:35 PM Resident #89 was found, by facility staff, in Resident #16's room with a hand inside Resident # 16's brief. Progress note dated 02/12/2026 indicated Resident #16 was taken to dining room where activities were being conducted. APRN visit dated 02/13/2026 at 09:41 AM indicated the visit was medically necessary to evaluate resident post report of another resident being found in Resident #16's room with hand inside Resident #16's brief. One-on-One Supervision document for Resident #89 with staff statements one-on-one supervision was conducted with Resident #89 from 02/12/2026 to 02/13/2026 at 10:43 AM when Resident #89 departed facility to Senior Care. All staff in-service conducted on 02/13/2026 including cover page, Abuse Investigation & Reporting Policy, and sign in sheet. In-Service Identifying Sexual Abuse dated 03/06/2026 and sign in sheet. Mental Health evaluation dated 03/06/2026 by nurse practitioner. Element 2: Resident interviews conducted on 03/06/2026. Resident body audits conducted 02/12/2026 to 02/16/2026. Body audits conducted on 03/06/2026. Element 3: Expanded in-service education on Identifying Sexual Abuse and Mandated Reporting. Element 4: QA monitoring of orientation education. No new hires since IJ identified. Interview with Administrator. A total of 26 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Administrator, Director of Nursing, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeper, Dietary Aide, Laundry Aide, Dietary Manager, medical director, floor tech, transport aide, MDS Coordinator, HR Director, Medication Aide Certified (MAC), Medical Records. The staff interviewed verified they had been trained on Abuse, Neglect, types of abuse, identifying sexual abuse, how to report, and who to report to. A review of in-service sheets provided indicated 120 of 122 had been provided training. Those staff who were not physically present to receive the in-services were provided with the in-service prior to the start of their next shift.

Based on record review, facility document review, facility policy review, it was determined that the facility failed to ensure one (Resident #50) of one resident reviewed was not pulled backwards in a wheelchair. The findings include: A review of Resident #50's admission Record indicated the resident admitted on [DATE], with diagnoses that included anxiety, depression, abnormalities of gait and mobility, restlessness, and agitation. A review of Resident #50's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 01/19/2026, revealed a Brief interview of Mental Status score of 06, which indicated the resident had severe cognitive impairment. Resident #50's MDS also revealed the resident used a manual wheelchair for mobility. A review of Resident #50's Care Plan Report, initiated on 01/08/2026, revealed the resident had a restorative nursing program need related to other abnormalities of gait and mobility, generalized muscle weakness, and repeated falls. Resident #50's Care Plan Report also specified interventions which included, allow resident adequate time to complete tasks. A review of the facility's OLTC [Office of Long-Term Care] Incident and Accident Report, dated 12/19/2025 at 3:00 PM, revealed Certified Nursing Assistant (CNA) #2 reported that CNA #1 was being aggressive with Resident #50. CNA #1 indicated that CNA #2 was pushing Resident #50 away from the dining room table in a wheelchair. Resident #50 did not want to leave the dining room and was in their wheelchair leaning forward when CNA #2 put their forearm across the resident's chest to get the resident to sit up. A review of an untimed OLTC Witness Statement Form, dated 12/19/2025 and signed by CNA #2, revealed CNA #1 was trying to remove Resident #50 from the dining room. The resident planted their feet on the floor, and CNA #1 pulled Resident #50 backwards. CNA #2 then indicated that Resident #50 was leaning forward and CNA #1 put their arm around the resident, to keep them from falling. A review of an OLTC Witness Statement Form, dated 12/19/2025 and signed by CNA #3 at 12:40 PM, indicated that Resident #50 was finished eating, and CNA #1 went to take the resident back to the hall. Resident #50 would not lift their feet up. A review of an OLTC Witness Statement Form, dated 12/19/2025 and signed by CNA #2 at 12:52 PM, indicated that CNA #1 was aggressive with Resident #50. CNA #1 told Resident #50 that [pronoun] was through and needed to go. The resident was fighting and asking for help. CNA #1 turned Resident #50 backwards and dragged them. Resident #50 was reaching for help. CNA #1 reached around and jerked the resident back. A review of an OLTC Witness Statement Form, dated 12/19/2025 and signed by Licensed Practical Nurse (LPN) #5 at 2:00 PM, indicated that CNA #1 was observed pulling Resident #50 backward in their wheelchair. A review of an OLTC Witness Statement Form, dated 12/19/2025 and signed by Registered Nurse (RN) #4 at 3:55 PM, indicated CNA #1 was pushing Resident #50 down the hall. CNA #1 was heard telling Resident #50 I'm tired of fighting this . A review of a [City] Police Department Incident Report dated 12/19/2025 at 4:29 PM, indicated that Police Officer #6, and Police Officer #7 reviewed the facility video footage of the incident between Resident #50 and CNA #1. Officer #6 indicated that CNA #1 was clearly observed on the video pulling Resident #50 backwards in their wheelchair. During an interview on 03/05/2026 at 3:55 PM, LPN #5 indicated that whenever the residents were finished eating, the staff removed them from the dining room. LPN #5 stated that Resident #50 did not want to leave the dining room and was trying to stand up while CNA #1 was pushing Resident #50. LPN #5 then stated that CNA #1 turned the resident's wheelchair around and started to pull the wheelchair backwards. CNA #1 was behind Resident #50, and she had her arm across the resident's chest with her hand on Resident #50's shoulders pulling the resident back in their wheelchair. LPN #5 indicated that she was in the middle of the 200-Hall at the nurse's station. LPN #5 indicated that CNA #1 said Resident #50 was finished eating but did not want to leave the dining room. LPN #5 confirmed that Resident #50 was a fall risk and that the resident had an alarm on their wheelchair. LPN #5 revealed that it was the residents' right to stay in the dining room after they finished eating, if they chose. LPN #5 further indicated that the incident was immediately reported, and that an in-service was completed on not pulling residents backwards in a wheelchair. During a phone interview on 03/06/2026 at 10:22 AM, CNA #1 indicated she had asked for help in the dining room multiple times. CNA #1 indicated that she asked CNA #2 to help her, and she was mad at CNA #2. CNA #1 indicated that Resident #50 was leaning forward, so the CNA put her hands across Resident #50's chest to keep them from falling. CNA #1 confirmed that she may have started pushing Resident #50's wheelchair backwards but eventually started pushing the wheelchair the other way. CNA #1 indicated that she was informed by the Administrators Assistant, and the Director of Nursing that she was not supposed to push the resident backwards and was educated to not push Resident #50 backwards anymore. CNA #1 indicated an in-service was completed on pushing a resident backwards. CNA #1explained she was pushing Resident #50 backwards in the wheelchair because the resident had their feet planted on the floor. CNA #1 then indicated that she knew it was wrong for pulling the Resident #50 backwards in their wheelchair. During a phone interview on 03/06/2026 at 10:44 AM, CNA #1 indicated that she did not know why Resident #50 planted their feet on the ground while CNA #1 was pushing the resident. During a phone interview on 03/06/2026 at 11:11 AM CNA #2 indicated that Resident #50 was sitting in the dining room happy after she had finished eating. CNA #2 then indicated that CNA #1 asked Resident #50 if they had finished eating, and the resident told CNA #1, no. CNA #2 revealed that CNA #1 pulled Resident #50 back in the wheelchair, and Resident #50 said no, I don't want to go back to my room. CNA #2 indicated that if the resident had fallen, it would have been worse since CNA #1 was pulling the resident backwards. CNA #2 then revealed that Resident #50 was saying help me and pulling on everything while CNA #1 was pulling the resident in the wheelchair. During an interview on 03/06/2026 at 4:35 PM, the Administrator indicated that CNA #1 was suspended based on an allegation that CNA #2 felt CNA #1 was too rough with Resident #50. The Administrator indicated that there was an allegation that Resident #50's feet were planted on the floor. A review of an in-service titled Abuse completed with all staff on 12/19/2025, indicated when a resident did not want to follow instructions, leave and come back at a different time; If feeling frustrated or impatient with a resident leave and ask a co-worker to take over for you; Do not push a resident backwards in wheelchair, and do not hold any resident down in a wheelchair; If any of the above negative behaviors are seen, report it immediately. A review of an Employee Memorandum signed by CNA #1 on 12/22/2025, revealed CNA #1 received a written warning for violating Resident #50's rights. The written warning indicated that CNA #1 pushed the resident away from the dining room table when the resident was not ready to leave. CNA #1 then pushed the resident backwards in their wheelchair. The written warning then indicated that residents should not be taken from the dining room if they are not ready to leave. The written warning lastly indicated that staff should get someone else to help when/if they begin to feel frustrated with a resident. A review of an in-service on Resident Rights was completed on 12/22/2025 with CNA #1. The policy indicated that residents should be free from abuse and neglect, including corporal punishment, involuntary seclusion, and the use of restraints as a punishment, The policy indicated that residents should be treated with consideration, respect and full recognition of dignity and individuality. A review of the facility's policy titled Resident Rights, revised 11/22/2016, indicated Each and every resident in the facility has the right to be treated with consideration, respect and full recognition of dignity and individuality.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect residents 6 residents on pureed diets and 21 residents on fortified food who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Manager. The findings are: 1. On 8/20/2024, a facility lunch menu indicated residents on pureed diets were to receive two #8 scoops of pureed chicken with bun, and residents on mechanical soft diets were to receive three ounces of chicken and two slices of bun. 2. On 8/20/2024 at 4:54 PM, the Dietary [NAME] (DC) used a #30 scoop equivalent to 1.25 ounces to serve a single portion of ground breaded fried chicken to the residents on mechanical soft diets, instead of 3 ounces as ordered. 3. On 8/20/2024 at 4:56 PM, DC used a # 8 scoop equivalent to 0.5 cup to serve a single portion of pureed breaded fried chicken breast to the residents on pureed diets, instead of two #8 scoops. 4. On 8/20/2024 at 5:41 PM, the DC was asked what scoop she used when serving mechanical soft meat to the residents on mechanical soft diets and residents on pureed diets, and how many servings she gave. The DC stated, I used #30, the black scoop, and I gave a single serving each, except if the tray card states otherwise and I used the gray scoop #8 and I gave a single serving each The DC was asked if she looked at the menu before serving supper meal. The DC stated, I did. I should have given two #8 scoops and used the right scoop for the ground meat.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen, the ice machine was maintained in clean and sanitary condition, and expired dressing products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria. The failed practices had the potential to affect 74 residents who received meals from the kitchen (total census: 74), as indicated on a list provided by the Dietary Manager. The findings are. 1. On [DATE] at 4:50 PM, the Dietary [NAME] picked up tray cards and placed them on the trays, contaminating her hands. Without washing her hands, she picked up clean plates from the plate warmer and placed them on the trays to be used in portioning food items to be served to the residents with her thumb inside of them. 2. On [DATE] at 4:58 PM, the Dietary [NAME] opened the oven door, removed a baked potato, and placed it on the plate. The Dietary [NAME] then picked up tray cards and placed them on the trays, contaminating her hands. Without washing her hands, she took clean plates from the plate warmer and placed them on the trays to be used for portioning food items to be served to the residents for supper meal. 3. On [DATE] at 5:46 PM, the areas above the ice machine panel where ice touched before dropping to the ice collector had a wet black residue collected on it. It was pointed out to the Dietary Manager and asked if the residue build up could be wiped off. She used tissue paper and wiped it off. The wet black residue easily transferred to the tissue. The Dietary Manager was asked who used the ice from the ice machine and how often they cleaned it. She stated, The maintenance man cleans it once a month. CNAs (certified nursing assistants) use it to fill beverages served to the residents at mealtimes and used it for the water pitchers in the resident's rooms. 4. On [DATE] at 8:35 AM, the following expired dressings were in a basket inside the refrigerator on a shelf in the dining room on the 400 Hall. a. A packet of Italian dressing had expiration date of [DATE]. b. A packet of Italian dressing had expiration date of [DATE]. 5. A review of a facility policy titled, Food safety-infection control Handwashing undated, provided by the Administrator on [DATE], indicated, We are responsible for ensuring we are not transmitting disease through direct contact. Diseases transmitted through food frequently originate from an infected food handler. Avoid touching the eating surfaces of plates. Engaging in any activities that may contaminate hands.

Based on observation, and interview, the facility failed to ensure cold food items were maintained at or above 41 degrees Fahrenheit while awaiting to be served to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; foods stored in the freezer and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; ice machine and ice scoop holder were maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 74 residents who received meals from the kitchen (total census: 77) as documented on a list provided by the Dietary Supervisor on [DATE] at 11:35 AM. The findings are: 1. On [DATE] at 11:42 AM, the temperature of the pureed bread with milk in a pan on top of the steam table bar when checked by the Dietary Employee (DE) #1 was 48 degrees Fahrenheit. At 11:53 AM, the Surveyor asked DE #1 when she was about to serve the pureed bread, How did you prepare the pureed bread? She stated, I used milk, and I should have set it on ice. 2. On [DATE] at 11:55 AM, DE #2 was on the tray line assisting with the lunch meal. She picked up cartons of milk, shakes and ice cream and placed them on the lunch trays. Without washing her hands, she picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents for lunch. At 12:52 PM, the Surveyor asked DE #2 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 3. On [DATE] at 11:59 AM, there were bags of turkey/cheese sandwiches on a tray on the food cart by the serving line. At 12:04 PM, DE #2 picked up a bag of turkey/cheese sandwiches from the tray to serve to the residents. The Surveyor asked the Dietary Supervisor to check the temperature of the turkey sandwiches. He did so and stated, Regular turkey and cheese sandwich was 47 degrees Fahrenheit and mechanical soft diet turkey and cheese sandwich was 55 degrees Fahrenheit. They should have set them on ice. 4. On [DATE] at 12:09 PM, the following food items were on a shelf in the walk-in freezer not completely covered or sealed: a. A box of flat dough. b. A box of Salisbury steak. c. A box of broccoli. d. Two boxes of chocolate chip cookies. e. A box of pork fritters. 5. On [DATE] at 12:17 PM, the following observations were made in the Storage Room: a. A box of hamburger buns with a received date of [DATE] was on a shelf. The manufacturer specification on the box documented, Keep frozen 0-degree Fahrenheit or below. The Surveyor asked the Dietary Supervisor how long the box had been kept on the shelf in the Storage Room. He stated, Since [DATE] when it came in. It should have been put in the freezer. b. 21 boxes of baking soda with a received date of [DATE] were on a shelf in the Storage Room. All 21 boxes had a best if used by [DATE]. The Dietary Supervisor stated, I think we just took them out of the box. 6. On [DATE] at 1:00 PM, the ice scoop holder on the wall opposite the ice machine by the door leading to the kitchen had a wet black/brown residue on it. The ice scoop was setting directly in contact with the residue. The Surveyor asked the Dietary Supervisor to wipe the black/brown residue at the bottom of the scoop holder. He did so, and the black/brown substance easily transferred to the paper towel. The Dietary Supervisor stated, It has a black/brown residue. The Surveyor asked, Who uses the ice from the ice machine and how often do you clean ice machine? He stated, We use it to fill beverages served to the residents at meals. CNAs used it for the water pitchers in the residents' rooms. We clean it once a week. 7. On [DATE] at 11:33 AM, DE #1 picked up a can of cream of mushroom soup from the Storage Room and placed it on the counter. At 11:34 AM, DE #1 took a can of cream of mushroom soup back to the Storage Room and placed it on the rack. Without washing her hands, she picked up a cheese sandwich and wrapped it with foil and stated, I am to grill for the resident. The Surveyor asked DE, What should you have done after touching dirty objects and before handling food items? She stated, I should have washed my hands.

Based on observation, record review, and interview, the facility failed to ensure nail care and facial grooming was regularly provided or offered to maintain good hygiene for 1 (Resident #11) of 20 (Residents #11, #17, #19, #22, #25, #28, #29, #30, #32, #34, #43, #55, #56, #59, #61, #65, #68, #74, #285 and #290) sampled residents who required assistance with nail care and facial grooming. This failed practice had the potential to affect 74 residents who required staff assistance for nail care as documented on a list provided by the Director of Nursing (DON) on 06/08/23 at 11:44 AM. The findings are: 1. Resident #11's Care Plan with an initiated date of 11/15/21 documented the staff to check nail length and trim and clean on bath days and as needed. 2. On 06/05/23 at 1:06 PM, Resident #11 was sitting up in a wheelchair at a table in the Dining Room eating with her fingers. Her fingernails were 1/4 inch in length past the fingertips with a brown substance underneath them. 3. On 06/06/23 at 10:09 AM, Resident #11 was lying in bed. Her fingernails were 1/4 inch in length past the fingertips with a brown substance underneath them. 4. On 06/07/23 at 8:54 AM, Resident #11 was sitting up in her room in a wheelchair. Her fingernails remained 1/4 inch in length past the fingertips and had a brown substance underneath them. She also had 4 or 5 long whiskers on her chin approximately 1/4 inch or more in length. The Surveyor asked Resident #11 if she liked her nails. Resident #11 answered, No. 5. On 06/07/23 at 1:13 PM, Resident #11 was lying in bed awake. Her fingernails remained 1/4 inch in length past the fingertips with brown substance underneath them and the whiskers on her chin remained approximately 1/4 inch in length. The Surveyor asked Resident #11 if she was aware of the whiskers on her chin. Resident #11 answered, Oh I don't like those things. I like to pull them out. Some time when you aren't so busy, maybe you can pull them out. 6. On 06/08/23 at 8:50 AM, Resident #11 was lying in bed with her eyes closed. The Surveyor asked Certified Nursing Assistant (CNA) #2 to describe Resident #11's fingernails and chin hairs. CNA #2 answered, [Resident #11] got a little dirt under her nails and I see a little hair growing on [Resident #11's] chin. The Surveyor asked who was responsible for nailcare and facial grooming. CNA #2 answered, CNA's generally. The Surveyor asked how often nails were cleaned and trimmed and chin hairs were groomed or plucked. CNA #2 answered, We try to provide nail care as often as needed. The Surveyor asked if it looked like the resident needed nail care and to have her chin whiskers plucked. CNA #2 answered, Yes, it looks like she could use a bit of nail care and to have that plucked if she would allow it. 7. On 06/08/23 at 10:30 AM, the Surveyor asked the Assistant Director of Nursing (ADON) who was responsible for nail care and facial grooming of the residents. She answered, The Certified Nursing Assistants unless they are Diabetic. If they need Podiatry, we notify Podiatry. The Surveyor asked how often nail care and facial grooming should be done. She answered, Daily. The Surveyor asked why nail care and facial grooming is important. She answered, So they look nice and are clean, unless they don't want that. A lot of residents refuse. 8. On 06/08/23 at 11:44 AM, the DON informed the Surveyor that the facility didn't have an Activities of Daily Living (ADL) policy.

Based on observation, interview, and record review, the facility failed to obtain a Physician's Order before administering supplemental oxygen to 1 (Resident #56) of 3 (Residents #19, #34 and #43) sampled residents who received oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 06/08/23 at 11:45 AM. The findings are: Resident #56 had diagnoses of Interstitial Pulmonary Disease, Unspecified and Acute and Chronic Respiratory Failure with Hypoxia. The Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 05/26/23 documented the resident required oxygen therapy while not a resident and while a resident. a. The Care Plan with an initiated date of 05/19/23 did not address oxygen therapy. b. The June 2023 Physician Orders did not contain an order for oxygen therapy. c. On 06/05/23 at 11:20 AM, Resident #56 was sitting up in a wheelchair in his room receiving oxygen via nasal canula connected to an oxygen concentrator at 3 liters per minute (LPM). The oxygen tubing and humidifier bottle were not dated. The humidifier bottle was empty. d. On 06/06/23 at 9:30 AM, the Surveyor observed the oxygen concentrator in Resident #56's room turned on and set at 3 LPM. The oxygen tubing and humidifier bottle were not dated. The humidifier bottle was empty. The resident's wheelchair was stored in the resident's room with a portable oxygen tank installed and with tubing attached. The tubing connected to the portable tank was not dated or bagged. The nasal cannula was lying in the wheelchair seat unbagged. e. On 06/07/23 at 4:15 PM, Resident #56 was in his room sitting in a recliner with his eyes closed. The oxygen concentrator was turned on and set to 3 LPM. The tubing and humidifier bottle were not dated. The humidifier bottle was empty. f. On 06/08/23 at 9:14 AM, Resident #56 was sitting up in a wheelchair in the dining area visiting with family. The Surveyor asked Resident #56 if he puts his nasal cannula on by his self or did staff help. He responded, I do it all by myself unless I can't get it on in time, then the staff helps me. They do ok, but sometimes they don't get it in my nose just right. g. On 06/08/23 at 10:13 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 how Resident #56 was ordered to wear his oxygen. LPN #2 replied, [Resident #56] takes it off a lot his self. He has it on most of the time. They [staff] don't remember to put it back on when they transfer him from the wheelchair to the recliner, or when he goes to the bathroom. The Surveyor asked LPN #2 to pull up the orders for oxygen for Resident #56 on the computer. LPN #2 replied after checking, Um, [Resident #56] doesn't have an order set up. The Surveyor asked who was responsible for setting up oxygen and making sure orders were followed on the flow rate settings, and that tubing, and humidifier bottles were dated and functional. LPN #2 stated, The way it's supposed to work is I'm supposed to check it every shift. The nurses are responsible. I will get this rectified right away. h. On 06/08/23 at 10:28 AM, the Surveyor asked the Assistant Director of Nursing (ADON) who was responsible for monitoring and assessing residents' oxygen and making sure it is set up correctly. The ADON answered, The nurses. The Surveyor asked how often oxygen tubing and humidifier bottles were checked and dated. The ADON answered, Weekly if it's ordered. The Certified Nursing Assistant (CNA) can notify the nurse if they see it's not dated or needs to be changed. The Surveyor asked if oxygen should be administered without a documented order. The ADON answered, No, unless it's an emergency. Then we call the doctor or the APN [Advanced Practice Nurse] for an order. After hours we call on call [On Call Provider]. i. A facility policy titled, Oxygen Safety, provided by the DON on 06/08/23 at 11:45 AM documented, .Oxygen therapy is administered to the resident upon the order of licensed physician .

Based on observation, record review, and an interview, the facility failed to ensure fortified food was prepared and served according to the planned written Quantified recipe and or menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received fortified foods and 6 residents who received a pureed diet from 1 of 1 kitchen according to a list provided by the Assistant Administrator on 06/08/23. The findings are: 1. The facility quantified recipe for super cream soup documented for 5 servings, Use 3/4 cup nonfat dry milk, 1 1/4 cup heavy cream or whole milk and 2 1/4 cup of cream of chicken soup condensed. Serving size 3/4 cup. 2. On 06/07/23 at 12:02 PM, Dietary Employee (DE) #1 used a 4 ounce spoon (1/2 cup) to serve a single portion of fortified cream of chicken soup to the residents who required fortified foods for lunch. The recipe specified 3/4 cup of super cream soup for each resident. On 06/08/23 at 1:00 PM, the Surveyor asked DE #1 what size spoon did you use to serve super cream of soup to the residents who required fortified food at the lunch meal on 06/07/23 and how many servings did you give each. She stated, I used a 4-ounce spoon, and I gave a serving each. 3. The menu for the enhanced foods documented, 1 cup of super cereal. a. On 06/08/23 at 7:22 AM, DE #1 used a 4-ounce spoon to serve a single portion of fortified oatmeal and fortified grits to the residents who required fortified foods. b. On 06/08/23 at 7:26 AM, the Surveyor asked DE #1 how do you prepare super oatmeal and super grits. She stated, I used one cup of heavy cream and 2 tablespoons of butter. c. The facility recipe for super cereal provided by the Assistant Administrator on 06/08/23 at 11:35 AM documented for 5 servings use, 3/4 cup plus 3 tablespoon of water, 3 tablespoon plus 2 1/2 teaspoon of nonfat dry milk, 1/4 cup plus 2 tablespoons of evaporated milk. 1. Mix water, nonfat dry milk, and evaporated milk. Bring it to boil. Add 1/2 cup plus 2 tablespoon dry oatmeal cereal. 2. Pour in oatmeal and cook until done (Approximately 5 minutes. 3. Add 5 3/4 ounce of margarine, 3 3/4 ounce of light brown sugar, 1/2 cup of granulated sugar and 1/2 c cup plus 3 tablespoon additional evaporated milk. Stir until creamy. Portion size one cup.

Based on observation, interview, and record review, the facility failed to pull the privacy curtain when providing care for one (Resident #17) of 20 (Residents #8, #11, #17, #19, #22, #25, #28, #29, #30, #32, #34, #43, #55, #56, #59, #61, #65, #68, #74 and #290) sampled residents who required privacy. The findings are: 1. On 06/07/23 at 1:35 PM, Resident #17 was sitting up in a specialty chair in her room. Licensed Practical Nurse (LPN) #1 came into the room and exposed Resident #17's abdominal area and administered medications and a feeding via the percutaneous endoscopic gastrostomy (PEG) tube. Resident #17's roommate had a visitor of the opposite sex in the room visiting. 2. On 06/07/23 at 1:47 PM, the Surveyor asked LPN #1 if she always leaves the privacy curtain open during tube feedings. She replied, Oh my gosh, I didn't even think about it, I was so focused on giving the medications. Write me up for that. I won't do that again and I will be more careful next time. 3. On 06/07/23 at 2:57 PM, the Surveyor asked the Administrator for the facility's privacy policy. The Administrator answered, We really don't have a privacy policy. The Surveyor asked if it was an issue to expose a resident's body part without drawing the privacy curtain or closing the door during medication administration or tube feeding procedure. The Administrator answered, It would depend on the body and the resident. 4. On 06/07/23 at 3:01 PM, the Surveyor asked the Assistant Director of Nursing (ADON) if it would be an issue to expose body parts of a resident during a tube feeding procedure by not pulling the privacy curtain when the roommate had a visitor of the opposite sex. The ADON answered, Yes, it would be a privacy issue.

Based on interview, and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) screening was readily available in the electronic record for 1 (Resident #59) of 1 sampled resident. The findings are: 1. Resident #59 had a diagnosis of Schizophrenia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/23 documented Schizophrenia as an active diagnosis. a. A Physicians Order dated 03/02/21 documented a diagnosis of Schizophrenia. b. A Care Plan with an initiated date of 10/04/21 documented, Resident has a current diagnosis of Schizophrenia, Anxiety, Bi-Polar Disorder . The Care Plan did not address the recommendations from the PASARR screening. 4. On 06/08/23 at 3:00 PM, the Electronic Medical Record (EMR) did not contain Level II PASARR documentation. 5. On 06/08/23 at 3:15 PM, during a phone interview with a State Designated Professional Associates Representative to determine if there were recommendations for a level II PASARR screening for Resident #59. The Representative stated that the recommendations were a Mental Illness Evaluation/Diagnosis, Medication Management, Master Treatment Plan and Periodic Review Master Treatment Plan. 6. On 06/08/23 at 4:00 PM, the Surveyor asked LPN #3 if she had the recommendations for the PASARR II from the State Designated Professional Associates for Resident #59. LPN #3 replied, It's not in her chart, so right now I don't have it. The Surveyor asked who was responsible for ensuring that the PASSAR II documentation was in Resident #59's medical record. LPN #3 responded, Yes, I am responsible. The Surveyor asked if the PASARR II recommendations for Resident #59 should be in her medical record. LPN #3 answered, Yes. The Surveyor asked why it was important to have the PASARR II in the medical record. LPN #3 answered, We need to know how to treat the patient. It was the middle of Covid, and we were all working the floor and that's what happened.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, hot food was maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchens; and expired food items were promptly removed/discarded by the expiration or use by dates. These failed practices had the potential to affect 69 residents who received meals from the kitchen (total census:71 ) as documented on a list provided by Dietary Supervisor. The findings are: 1. On [DATE] at 12:15 PM, the temperature of the food items when checked and read on the steam table by dietary Employee #1 were: Pureed hamburger sandwich 112 degrees Fahrenheit. The above food item was reheated before been served to the residents on pureed diets. 2. On [DATE] at 12:16 PM, Dietary Employee #2 took out bags of flour tortillas and placed them on the counter, picked up a pan and placed it on the counter, picked up a pan liner from a box under the food preparation counter and laid it inside a pan. She took out a container of shredded cheese from the refrigerator and placed it on the counter. Without washing her hands, she picked up gloves from the glove box contaminated the gloves. She placed the contaminated gloves on top of the pan liner inside a pan. She washed her hands, then placed the same gloves on her hands. She opened the bags of flour tortilla with her gloved hands. She picked up a recipe binder from the counter and placed it on top of the big mixer. Without changing gloves and washing her hands, she removed flour tortillas from the bag and placed them on the pan, used a spoon to place shredded cheese on each flour tortilla and rolled them up to be served to the residents for supper. 3. On [DATE] at 12:25 PM, Dietary Employee #3 held onto the box of gloves with one hand when she removed gloves from the glove box. The Dietary Employee did not wash her hands before putting the gloves on her hands. She removed cold meat from a zip lock bag and placed them on a pan liner on the counter to be used in preparing ham and cheese sandwiches to be served to the residents who requested a sandwich with their meal. On [DATE] at 11:27 AM, Dietary Employee #3 was asked what should have done after touching dirty objects and before handing clean equipment. He stated, Should have washed my hands. 4. On [DATE] at 2:20 PM, there were 14 boxes of raisins stored on a shelf in the storage room with an expiration date of [DATE]. 5. On [DATE] at 2:48 PM, Dietary Employee #2 used a rag to wipe off the counter. She took a clear bag that contained cloth napkins and placed it on the food preparation counter. Without washing her hands, she picked up clean dishes and stacked them up in the plate warmer with her fingers touching the interior surfaces of the plates. 6. On [DATE] at 2:53 PM, Dietary Employee #2 took out a container of soap from the janitor's closet and gave it to Dietary Employee #3. Without washing her hands, she picked up clean dishes from a rack on the clean side of the dish machine and was ready to put them on the plate warmer. She was stopped and was asked what should you have done after touching dirty objects and before handling clean equipment and or foods? She stated, Washed my hands. 7. On [DATE] at 11:16 AM, Dietary Employee #1 gave a beard mask to Dietary Employee #4 to cover his beard. He took it from her and covered his beard. Without washing his hands, he picked up utensils and wrapped them in individual napkins that residents will use to wipe their mouths when eating their lunch meal. At 11:29 AM Dietary Employee #4 was asked what should have done after touching dirty objects and before handing clean equipment. He stated, Washed my hands. 8. On [DATE] at 11:22 AM, Dietary Employee #5 was wearing gloves on her hands; she opened the microwave and took out a glass of warm milk and placed it on the counter. Without changing gloves and washing her hands, she picked up a blade and attached it the base of the blender. At 11:25 AM, she placed 8 servings of rolls, added milk and pureed. She covered the pureed rolls with foil and placed it in the oven. At 11:34 AM, Dietary Employee #5 was asked what should have done after touching dirty objects and before handing clean equipment. She stated, I should have removed the gloves and washed my hands. 9. The facility policy on hand washing under purpose documented , To remove contamination after, entering the kitchen, eating or drinking, handling soiled utensils or equipment, during food preparation, when working with ready to eat food, before donning gloves for working with food, after engaging in other activities that contaminate the hands.

Based on observation, record review and interview, the facility failed to ensure fingernails were clean, groomed, and free from jagged edges to promote good personal hygiene and grooming for 1 (Resident #17) of 23 (Resident #1, #4,#5 #7, #8, #10, #12 #17, #18, #24, #32, #34, #35, #38, #44, #45, #47, #48, #52,#54, #57 #64, and #115) sampled residents that were dependent on staff for fingernail care. This failed practice had the potential to affect 65 residents who were dependent on staff for nail care according to a list provided by Director of Nursing on 3/30/22 at 4:00 PM. The findings are: 1. Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/21 documented the resident scored 11 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS) and required extensive assistance personal hygiene. a. The Care Plan with a revision date of 3/25/22 documented, . Focus: The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] impaired intellectual impairment . Goal: The resident will maintain current level of function . Interventions/Tasks: . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 03/28/22 at 12:52 PM, Resident #17 was sitting in a chair eating her lunch. The resident's fingernails varied in length up to 1/8 of an inch past the end of the nail bed and some had jagged edges and a brown substance under them. c. On 03/29/22 at 09:37 AM, Resident #17 was in the hall in her wheelchair. The resident's fingernails varied in length up to 1/8 of an inch past the end of the nail bed and some had jagged edges and a brown substance under them. d. On 03/29/22 at 10:20 AM, Resident #17 was sitting in her room. The resident's fingernails varied in length up to 1/8 of an inch past the end of the nail bed and some had jagged edges and a brown substance under them. The resident was asked, Do staff help you to clean your nails when you take a shower. The resident stated, They usually take me to the shower. I got one yesterday. d. On 03/30/22 at 08:20 AM, Resident#17 was sitting in the chair in her room. The resident asked Licensed Practical Nurse (LPN) #1, who had just given her morning medications, Will you look at my ear, I think I have a scratch on it. I might need to go to the hospital. LPN #1 looked at the resident's right ear and stated, I see a tiny scratch on it. I think it will be alright. You do not need to go to the hospital. The surveyor asked Resident #17, Will you show the nurse your fingernails like you showed them to me yesterday? Resident #17 put her hands flat with her fingernails showing so the nurse could look at them. LPN #1 was asked, Can you describe [Resident #17's] fingernails for to me? LPN #1 stated, They need to be trimmed. They are jagged and there is some brown dirt under some of the nails. She likes getting her nails done. LPN #1 was asked, Who is responsible for doing nail care? LPN #1 stated, If the resident is not a diabetic CNA's [Certified Nursing Assistants] are. LPN #1 was asked, How often should nail care be done? LPN #1 stated, They should be checked on shower days at least and they get showers twice a week. I think her shower day might be today. LPN #1 was asked, Is [Resident #17] diabetic? LPN #1 stated, No she is not a diabetic. LPN #1 was asked, What could happen if a resident's fingernails are jagged and not clean? LPN #1 stated, She could get a skin tear. The nail could get caught on her clothing. She could potentially hurt someone else with her nails by scratching them. e. On 03/30/22 at 10:55 AM, CNA #1 was asked, How much assistance does [Resident #17] need with Activities of Daily Living? CNA #1 stated, It depends on the day. She is limited assistance for the most part. She needs help with her shower. CNA #1 was asked, How much assistance does [Resident #17] require with nail care? CNA #1 stated, She would be total assistance for that. She would not be safe with scissors or nail clippers. CNA #1 was asked, Who is responsible for nail care? CNA #1 stated, The CNA's. Activities has a nail care day, and the charge nurse do the nails if the resident is diabetic. CNA #1 was asked, How often should nail care be done? CNA #1 stated, It should be done twice a week with showers. CNA#1 was asked, Does [Resident #17] refuse nail care? CNA #1 stated, I cannot say for sure yes or no, but she has never refused for me during the time she has been here. CNA #1 was asked, What could happen if a resident's nails are jagged and not clean? The CNA stated, The nails could cause a skin tear. It could cause an infection. Dirty nails are just gross when a resident is eating their meals. The resident might also accidentally scratch another resident. f. On 03/30/22 at 11:00 AM, CNA # 2 was asked, How much assistance with ADL's does [Resident #17] need? CNA #2 stated, She is limited assistance with most activities. CNA #2 was asked, How much assistance with nail care does [Resident # 17] need? CNA #2 stated, Someone definitely has to do that for her. CNA#2 was asked, Who is responsible for doing nail care? CNA#2 stated, The CNA's, Activities, and the nurse if the resident is diabetic. CNA#2 was asked, How often should nail care be done? CNA #2 stated, Twice weekly with the resident's shower. CNA #2 was asked, Does [Resident #17] ever refuse nail care? CNA #2 stated, No she never has. CNA #2 was asked, What could happen if a resident's nails are jagged and not clean? CNA#2 stated, She could scratch herself, another resident or a staff member. It could lead to an infection if she hit her nail on something. g. On 03/30/22 at 12:15 PM, the Director of Nursing (DON) was asked, Who is responsible for nail care? The DON stated, The aides on the floor do the nails during the residents' showers. It is also done as an activity. The DON was asked, How often should nail care be done? The DON stated, It needs to be done every day. It should be done after every meal. The staff are supposed to wipe their hand with Theriworx wipes. I think I just in-serviced on that. The DON was informed that Resident #17's fingernails had jagged edges and a brown substance under them. The DON stated, I saw her at Activities yesterday where they were doing nails. She is impulsive and will not wait. She probably got up and walked away, but staff should have gone and encouraged her to come back. The DON was asked, What could happen if a residents' nails are jagged and not clean? The DON stated, The resident could cut themselves and because the nails are not clean, they could get an infection. h. On 03/30/22 at 03:35 PM, The Director of Nursing stated, We do not have a policy for ADL's (Activities of Daily Living) or nail care.

Based on observation, record review and interview the facility failed to ensure visitors were screened for signs and symptoms of the Coronovirus Disease before entering facility, and also failed to ensure staff were tested following manufacture guidelines for testing using the Rapid Test. These failed practices had the potential to affect all 61 Residents per the Director of Nursing (DON) on 05/06/2021 at 8:40 AM. The findings are: 1. On 05/06/2021 at 8:30 AM, upon entrance to the facility, Screener #1 took both surveyors name, phone number, temperature and checked hands washed or ABR [Alcohol Based Hygiene] used. Screener #1 did not ask surveyors any questions about International travel within last 14 days, COVID (Coronovirus Disease)-19 signs or symptoms, nor if worked in a facility or location with COVID-19 cases, been in community or adjacent community in last 14 days where COVID-19 case reported, travel out of state in last 14 days or verified negative COVID-19 test per their Surveillance Log for Visitors. a. The Surveillance Log Visitors copied on 5/6/2021 at 1:00 PM documented, .Name/Address: [Surveyor #1] no address documented, Phone #: [Surveyor #1 phone number], checked Hands washed or ABR used, Intl [International] travel within last 14 days marked n (indicating no), Cough marked n, Shortness of breath marked n, fever marked n, repeated shaking w/chills marked n, headache marked n, new loss of taste marked n, diarrhea marked n, chills marked n, muscle pain marked n, sore throat marked n, vomiting marked n, have you worked in a facility or location w [with]/COVID-19 case marked n, Been in community or adjacent community in last 14 d [days] marked n, Coronavirus case reported marked n, Travel out of state in last 14 d marked n, Covid test verified marked n, temperature marked 97.7, Access denied marked n, initials marked [Screener #1] b. On 05/06/2021 at 2:00 PM, the DON was asked if the Screeners are supposed to ask all visitors and staff questions regarding signs and symptoms, and all other questions regarding COVID test results, working in facility's or locations with confirmed COVID cases, etc. [etcetera] per their Surveillance Log for Visitors? She said, Yes. c. On 05/07/2021 at 9:26 AM, Screener #1 was asked if she screened [Surveyor #1] and [Surveyor #2] in yesterday? She said, Yes. She was asked if she asked us signs and symptoms of COVID and all of the other questions regarding COVID per their Surveillance Log for Visitors to determine access to the facility? She said, No, I didn't. She was asked why she went back after we entered the facility and marked n indicating no to all the screening questions? She stated, Out of habit. She was asked if that was her routine to not ask staff or visitors all the screening questions? She said, No. She was asked if she had been trained on the Screening Process? She said, Yes, about a month ago and [Screener #2] trained me, it's not her fault. She was asked if she was trained to ask all staff and visitors all the required screening questions per their Surveillance Log for Visitors? She said, Yes, I was. 2. On 05/06/2021 at 9:28 AM, Infection Control Preventionist (ICP) was asked the process they use to perform a Rapid Test for COVID? She said, .Using swab go in one side of their nares until you meet resistance, rotate swab 5 times then stick swab up the bottom hole of the testing card up to the top hole . She was then asked if they only go in one side of the nares? (To confirm above statement) She said, Yes, just one side. a. On 05/21/2021 at 10:42 AM, the ICP was asked about the swabbing of one nare for the rapid test? She said, We were doing two nares for a long time and then at some point we were told we could do just one. I am going to have to check and see when that changed and who told me. b. At 11:16 AM, she called back and said, I do not have anything on that. [Nurse Consultant] told me when I called her that she did tell us it was one nostril but that was when we were doing nasal pharyngeal. We just misunderstood and was doing them all one nostril. We will definitely do both nares again when doing the rapid test. 3. The Guidelines for Suspected or Confirmed COVID-19 Policy and Procedure received by the Administrator on 05/06/2021 at 11:10 am documented, .Visitor Restrictions Facility will follow the current CMS [Centers for Medicare and Medicaid Services] guidelines including the following: Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., [that is] temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor's vaccination status) . 4. The BinaxNOW COVID-19 Ag (Antigen) card insert page 2 documented, .Nasal Swab .To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage or the nostril that is most congested if drainage is not visible. Using gentle rotation, push the swab until resistance is met at the level of the turbinates (less than one inch into the nostril) Rotate the swab 5 times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril.

Based on record review and interview, the facility failed to ensure written information regarding the right to formulate an advanced directive was provided to residents or their responsible parties, to enable them to make informed decisions regarding which measures would be provided or withheld at end of life for 2 (Residents #202 and #203) sample residents whose clinical records were reviewed for advanced directive information. The failed practice had the potential to affect all 54 residents who resided in the facility, as documented on the Resident Census form dated 1/18/21. The findings are: 1. Resident #202 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) was incomplete. The Admission assessment dated [DATE] documented resident is limited assist for bed mobility, eating, and extensive assist for transfers and toilet use. Dressing and personal hygiene were not assessed. a. As of 1/20/21, the electronic clinical chart did not have an advance directive documented or scanned into the system. b. On 01/19/21 at 3:39 PM, the Social Director provided a capacity verification form documenting, .The Resident .unable to sign forms. Has the capacity, or waxing and waning capacity, to understand the nature of his or her medical condition and the consequence of treatment decisions; and acknowledges that he or she understands the content of the admission forms. Resident is physically unable to sign forms due to fatigue from transport/hard of hearing . The form was signed and dated by the resident's son on 1/8/21. c. 01/19/21 3:39 PM, the Social Director stated, I just watched a training video. The resident is not able to sign an advance directive. We cannot let the POA (Power of Attorney) sign an advance directive. The Social Director was asked, You do not have an advanced directive signed by the resident or the son? The Social Director stated, No. If the resident is unable to sign, we cannot let the POA formulate the resident's advance directive. d. On 1/22/21 at 8:38 AM, The Social Director was asked, Do you have an advanced directive on Resident #202? The Social Director stated, No, Ma'am. The Social Director asked, Do you have any documentation where you offer the resident or the family representative the option to formulate an advance directive? Social stated, Yes. This is what I was taught in my training. The social director provided the surveyor a blank advanced directive and she had documented at the top, (Attempted to complete Advance Directive but resident could not understand due to hard of hearing). They informed me when it comes to advance directives, if they do not have the capacity to fill one out, the family, POA or family representative cannot fill one out on them due to my instructions of the arbitration training. The week we transitioned to the new company, I was informed by (Admission Liaison) the information above was correct. 2. Resident #203 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) was incomplete. The Admission assessment dated with an Assessment Reference Date of 1/9/21 documented resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); and was dependent for transfers and bed mobility; toilet use and personal hygiene activity did not occur. a. On 01/20/21 at 08:29 AM, the advance directive was not in the electronic chart. b. A capacity verification form documented, .The Resident .unable to sign forms. has the capacity, or waxing and waning capacity, to understand the nature of his or her medical condition and the consequence of treatment decisions; and acknowledges that he or she understands the content of the admission forms. Resident is physically unable to sign forms due to fatigue from transport . The form was signed and dated by the resident's son on 1/12/21. c. On 01/19/21 at 3:39 PM, the Social Director stated, I just watched a training video. The resident is not able to sign an advance directive. We cannot let the POA sign an advance directive. The Social Director was asked, You do not have an advanced directive signed by the resident or the son? Social Director stated, No. If the resident is unable to sign, we cannot let the POA formulate the resident's advance directive. d. On 1/22/21 at 8:38AM, The surveyor asked Social Director, Do you have an advanced directive on Resident 203? Social stated, No, Ma'am. The Social Director was asked, Do you have any documentation where you offer the resident or the family representative the option to formulate an advance directive? The Social stated, I do not due to my training. They informed me when it comes to advance directives. If they do not have the capacity to fill one out, the family, POA or family representative cannot fill one out on them due to my instructions of the arbitration training. The week we transitioned to the new company. I was informed by Admission Liaison the information above was correct.

Based on observation, record review, and interview, the facility failed to ensure a urinary catheter drainage tubing and bag was kept off the floor to prevent potential cross contamination for 1 (Resident #31) of 3 residents who required a urinary catheter and failed to ensure and consistently provided catheter care to prevent Urinary Tract Infection, and documented input and output as ordered for 2 (Resident #31 and 43) of 4 residents who residents who had an indwelling urinary catheter. These failed practices had the potential to affect 4 residents who had an indwelling urinary catheter, as documented on lists provided by the Director of Nursing (DON) on 1/21/21. The findings are: 1. Resident #31 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/20 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); and required extensive assistance with activities of daily living, and had an indwelling urinary catheter. a. The Care Plan dated 9/25/18 documented, The resident has Indwelling Suprapubic Catheter: R/T (related to) [MEDICAL CONDITION] bladder, Allergic To Latex, Uses A Silicone Catheter, Cath Changed At Urology .Cath Changed Monthly At Urology .Monitor and document intake and output as per facility policy.Provide catheter care every shift and as needed. b. physician's orders [REDACTED]. May flush supra pubic cath with 60cc normal saline prn blockage as needed for blockage every shift . c. On 1/18/21 at 1:00 PM, Personal Protective Equipment (PPE) supplies hanging and signage on the resident's door documented the resident was on Droplet Isolation. The resident was resting in bed watching tv (television). The foley catheter bag was lying on the floor / carpet. d. On 1/18/21 at 2:12 PM, Licensed Practical Nurse (LPN) #3 accompanied the surveyor to Resident #31's room. The resident was resting in bed. The foley catheter bag was laying on the floor/carpet. LPN #31 was asked, Should the foley catheter bag be laying on the floor/ carpet? She stated, No. It should be hanging from the side of the bed. I'll fix that right now. e. The January 2021 Treatment Administration Record (TAR) documented, FLUSH SUPRA PUBIC CATH WITH 60CC NORMAL SALINE OR STERILE WATER every day and evening shift. On January 7th the evening shift, the 15th on the day shift and on the 16th on the evening shift, there was no documentation the catheter was flushed as ordered. There was no documentation found in the TAR or Electronic Heart Record (EHR) for urinary output. SUPRA PUBIC CATH CARE Q SHIFT WITH SOAP AND WATER every shift. On January 7th, the evening and night shift, there was no documentation the catheter care was completed as ordered. 2. Resident #43 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/20 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); and required extensive assistance with activities of daily living and had an indwelling urinary catheter. a. The Care Plan dated 10/17/18 documented, The resident has Indwelling FOLEY Catheter r/t (related to) [MEDICAL CONDITION] bladder and urine retention.CATHETER: The resident has a 22 Fr (French)/30 cc (centimeters) Foley Catheter. Position catheter bag and tubing below the level of the bladder. Change Foley Catheter and down drain per facility policy/MD (doctor) orders.Monitor and document intake and output as per facility policy. b. A Physicians Order dated 11/0/19 documented, CHANGE FOLEY CATH (catheter) AND COLLECTION BAG Q (every) 2 WEEKs ON SATURDAYS every evening shift every 2 weeks on Sat (Saturdays) .CHANGE FOLEY CATH PRN (as needed) BLOCKAGE every 1 hours as needed related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED 02/15/20 .IRRIGATE FOLEY CATH WITH 60CC NORMAL SALINE PRN BLOCKAGE every 1 hours as needed .ROUTINE FOLEY CATH CARE Q SHIFT WITH SOAP AND WATER every shift .2/15/19. c. On 1/18/21 at 1:04 AM, the resident was sitting in her electronic wheelchair, the foley catheter was hanging on the side in a privacy bag. d. The January (2021) Treatment Administration Record documented, ROUTINE FOLEY CATH CARE Q SHIFT WITH SOAP AND WATER every shift. On January 7 the evening and night shift, on the 9th the day shift and on the 12th (2021) during the day shift, there was no documentation that the catheter care was completed. 22 FR 30CC FOLEY CATH TO DOWNDRAIN every shift . On January 7 the evening and night shift, on the 9th the day shift and on the 12th during the day shift, there was no documentation that the down drain was completed. e. There was no documentation found in the January 2021 TAR or the Electronic Heart Record for urinary output. f. On 1/20/21 at 4:12 PM, the progress notes were reviewed from 1/1/21 - 1/21/21 and there was no documentation found as to why the catheter care or the Down drain was not completed. 3. On 1/21/21 at 10:04 AM, Certified Nursing Assistant (CNA) #3 was asked, Do you empty the resident's foley catheters? She stated, Yes. CNA #3 was asked, Do you record the resident's urinary output? She stated, Yes. We did on the old program, the new program on POC (Plan of Care) the task just asks us if it's a catheter; it does not have a place to document the amount. So, we are not documenting the output. CNA #3 was asked, Do you document the amount somewhere else? CNA #3 stated, No. CNA #3 was asked, Do you let the nurse know the urinary output? She stated, No. 4. On 1/21/21 at 10:12 AM, LPN #4 was asked, Do you monitor the resident's with catheters their urinary output? She stated, Yes. LPN #4 was asked, How? She stated, The CNA empties the catheters and records it in the tasks. If there is no urinary output, the computer will trigger us. 5. On 1/21/20 at 9:25 AM, the Director of Nursing (DON) was asked, Do the nurses monitor the urinary output from the resident's that have catheters? She stated, Yes. The DON was asked for a copy of for R #31 and R#43's urinary output. The DON stated they are not recording the urinary output on them because they do not have a physician's orders [REDACTED].? She stated, It does? Well we are not monitoring or documenting intake or output because we do not have Physicians order. 6. On 1/21/21 at 1:30 pm, the DON was asked, At what level should the foley catheter bag be at? The DON stated, Below the bladder, covered in a privacy bag, and hung from the bed frame. The DON was asked, Should the foley catheter bag be laying on the floor / carpet? The DON stated, No. 7. A policy Output, Measuring and Recording documented, The purpose of this procedure is to determine accurately the amount of urine that a resident excretes in a 24- hour period.Review the resident's care plan .drain the urine from the .catheter into the graduate (measuring container) . Record the amount noted on the .output record, record in mls (milliliters). Record the time the output was measured.

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for [MEDICAL CONDITION] or other respiratory complications for 1 (Residents #8) of 6 (Residents #46, #27, #31, #42, #8 and #34) sampled residents who had physician's orders [REDACTED]. The facility failed to ensure a nasal cannula and updraft mask was stored in a bag or other closed container when not in use to prevent potential contamination or infection for 1 (Resident #42) of 6 (Residents #46, #27, #31, #42, #8, and #34) sampled residents who had oxygen in use and 1 (Resident #34) of 3 (Resident # 34, #42 and #8) sampled residents whom received updrafts. These failed practices had the potential to affect 11 residents who had physician's orders [REDACTED]. The findings are: 1. Resident #34 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/20 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); and required total assist with two person for transfer, one person for bathing, extensive assist with two person for bed mobility, extensive assist with one person for dressing, toilet use and personal hygiene, was occasionally in continent of bowel and bladder, and required oxygen therapy. a. A Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) MG/3ML (milligrams / milliliters) 1 vial inhale orally every 6 hours as needed for SOB (Short of Breath)/WHEEZING 9/22/18 . b. The Care Plan dated 1/8/2021 documented, The resident has altered cardiovascular status r/t (related to) Hypertension .Give oxygen and updrafts as ordered, see MAR/TAR (Medication Administration Record [REDACTED].The resident has altered respiratory status r/t (related to) [MEDICAL CONDITION] .Administer medication and updrafts as ordered. Monitor for effectiveness and side effects. Change mask and tubing q (every) week and prn (as needed). Keep bagged when not in use. Revision on: 01/08/2021 . c. The January (2021) Medication Administration Record [REDACTED]. d. On 1/18/21 at 12:54 PM, the resident was resting in bed, oxygen was in place at 2 liters via (by way of) nasal cannula. The updraft mask / machine was sitting up on top of recliner, the updraft mask laying was on a package of peri - wipes. No storage bag was noted. e. On 1/18/21 at 1:57 PM, Licensed Practical Nurse (LPN) #3 accompanied the surveyor to the resident's room. The resident was resting in bed, the updraft mask and machine were sitting on top of the recliner. The updraft mask was laying on top of a peri - wipe package. LPN #3 was asked, Is that the proper way to store an updraft mask when it's not in use? She stated, No. It should be in a plastic bag with her name and date on it. I will fix that now. 2. Resident #8 had a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/20 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); and required total assist with one person for bathing, extensive assist with two person for transfers, toilet use, extensive assist with one person for bed mobility, dressing, locomotion on the unit and personal hygiene, was frequently incontinent of bowel and bladder and required oxygen therapy. a. A Physician order [REDACTED]. b. The Care Plan dated 7/24/19 documented, The resident has [MEDICAL CONDITION] .OXYGEN SETTINGS: O2 via (by way of) nasal cannula as ordered .humidify per resident comfort.The resident has oxygen therapy .Give medication as ordered by physician. See MAR (Medication Administration Record) as part of the POC (Plan of Care) Monitor/document side effects and effectiveness. c. On 1/19/21 at 10:24 AM, the resident was resting in bed, oxygen in place via nasal cannula at 3 liters with a humidity bottle. d. On 1/19/21 at 10:50 AM, the Director of Nursing (DON) accompanied the surveyor to the resident's room, and was asked, How many liters is the residents oxygen on? She stated, 2.5 liters. The DON was asked, How many liters should the oxygen be on? The DON reviewed the physician's orders [REDACTED]. 3. Resident #42 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/20 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); and required extensive assist with one person for bed mobility, transfers locomotion off the unit, dressing, bathing, supervision with one person assist for Bed mobility, transfer, ambulation, toilet use, independent with set - up only for locomotion, dressing, personal hygiene, and bathing, was independent with set up for eating., was occasionally in continent of bowel and bladder. a. A Physician order [REDACTED].O2 AT 3LPM VIA NC (Nasal Cannula) MAY REMOVE FOR SHOWERS OR AT RESIDENT REQUEST every shift 1/7/21 . b. The Care Plan dated 1/18/2021documented, The resident has oxygen therapy .OXYGEN SETTINGS: O2 via nasal cannula @ 3lpm, may removes for showers or meals. Humidified per resident comfort . c. On 1/18/21 at 1:38 PM, the resident was resting in bed, HOB (head of bed) up, oxygen in place at 3 Liters. Wheelchair with an oxygen tank, near the end of bed with oxygen tubing wrapped around the top of the oxygen tank. No storage bag was noted. d. On 1/18/21 at 1:40 PM, the LPN #3 entered the resident's room and was asked, Is wrapping the oxygen tubing around the oxygen tank the proper way to store oxygen tubing, when not in use? She stated, No. It should be in a plastic bag, that is dated, she had therapy this morning and they did not put it in a bag when transferring her back to bed. e. On 1/22/21 at 8:10 AM, a copy of the Oxygen Storage and Administration was requested from the DON. The DON stated they (the facility) did not have one.

Based on observation, record review, and interview the facility failed to ensure food items in the freezer were properly labeled or dated to prevent food borne illnesses. These failed practices had the potential to affect 52 residents (Census: 54) as documented on the Resident Listing Report provided by the Director of Nursing (DON) on 01/22/20 at 08:41 a.m. The findings are: 1. On 01/18/21 12:09 PM, in the kitchen, located in the freezer, contained the following: a. A bag of ½ gallon potato (French fries) opened, with no label or date. b. An opened clear bag of Tator tots with no label or date. c. A opened, blue gallon size bag of peas and carrots, with no label or date. d. A opened bag of a green peppers, with no label or date. e. A gallon bag with chicken with no label or date. f. A gallon clear bed with chicken strips opened, with no label or date. g. 1 bag of grilled chicken with no label or date of when opened. h. On 01/18/21 12:09 PM., the Dietary Manager was asked, Should these bags be labeled and dated? She stated, Yes. It will be. The Dietary Manager was asked, Should it be dated before it is placed in the freezer? She stated, I have someone that does that, and she was worried about them thawing out. The Dietary Manager was asked, Should it be labeled when in the freezer? She stated, Yes

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag to promote dignity and maintain privacy for 1 (Resident #202) of 4 sample resident wo required a catheter drainage bag. These failed practices had the potential to affect 4 residents who had an indwelling urinary catheter, as documented on lists provided by the Director of Nursing (DON) on 1/21/21. The findings are: 1. Resident #202 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) was incomplete. The Admission assessment dated [DATE] documented resident was limited assist for bed mobility, eating, and extensive assist for transfers and toilet use. a. As of 1/19/2021, there was no Brief Interview for Mental Status or Staff Assessment for Mental Status in the residents medical record. b. On 01/19/21 at 9:17 AM, Resident # 202 was lying in his bed. There was a foley catheter hanging on the side of the bed. The foley catheter was not in a privacy bag. A photograph of the catheter was taken at this time. c. On 01/19/21 at 9:19 AM Certified Nursing Assistant (CNA) #1 was in the resident room assisting with his TV (television) remote. CNA #1 was asked, Should his foley be in a privacy bag? CNA #1 stated, Yes. They haven't had one in his room yet. d. On 01/19/21 at 9:22 AM, Licensed Practical Nurse (LPN) #2 was asked, Should the resident's foley catheter be in a privacy bag? LPN #2 stated, Yes. It should. I will take care of it right now. e. A form titled Catheter Care, Urinary did not have any documentation regarding the foley catheter being in a privacy bag.

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 (Residents #3) of 13 (Residents #3, #8, 9, 38, 21, 28, 33, 20, 46, 1, 29, 51 and #34) sampled residents who were dependent for nail care. The failed practice had the potential to affect 7 residents who were diabetics and dependent for nail care on the 300 hall, according to the list provided by the Director of Nursing (DON) on 1/21/21. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/2/20 documented the resident required extensive assistance of two-person for bed mobility, and one person assistance for personal hygiene and bathing. a. The Care Plan date 5/14/18 documented, Increased Risk For Skin Breakdown R/T (Related To) Decreased Mobility, Incontinence, Use Of Assistive Devices, Dementia, Weakness.Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.Increased Risk For Complications R/T (related to) DX (Diagnose) Of Diabetes.Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease .nails should always be cut straight across, never cut corners. File rough edges with emery board . b. On 1/18/21 at 1:14 PM, the resident was sitting in the bed, eating lunch with a spoon in her left hand. Her fingernails on her left hand and right thumb extended one quarter inch past the tips of her fingertips and had a brownish black colored substance under them. c. On 1/18/21 at 2:08 PM, Licensed Practical Nurse (LPN) #3 was asked, Who is responsible for providing nail care to the residents? She stated, The CNAs (Certified Nursing Assistants) if the residents are non-diabetic. If they're a diabetic the nurses do the nail care. LPN #3 was asked, When is nail care performed on the resident's? She stated, On shower days and as needed. LPN #3 accompanied the surveyor to the resident's room. The resident was resting in bed, while observing the resident's nails, the surveyor asked, what is under her nail tips? She stated, Food. LPN #3 was asked, Should her fingernails be cleaned and trimmed? She stated, Yes. LPN #3 was asked, When was the last time her fingernails were cleaned or trimmed? LPN #3 stated, It's been while. d. On 1/22/20 at 8:10 AM, a copy of the Nail Care Policy was requested from the DON. The DON stated they do not have one.

Based on observation, record review, and interview, the facility failed to ensure physician orders [REDACTED].#204) of 1 residents who had orders for bedrest. This failed practice had the potential to affect 1 residents who had a physician order [REDACTED]. Resident #204 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference date of 1/15/21 documented the resident scored 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS); and required limited assistance for bed mobility, requires extensive assistance for transfers, dressing, eating, personal hygiene and toilet use did not occur. a. The Closet Care Plan dated 1/17/21 and updated 1/18/21 documented, Order to remain flat on back times 21 days. b. On 01/20/21 at 9:56 AM, Physical Therapy (PT) #1, who was standing at the resident's door, asked the resident who got him up out of bed. Resident #204 was setting in a recliner. Certified Nursing Assistant (CNA) #2 was walking by. CNA #2 was asked, Did you get (Resident #204) up out of bed? CNA #2 stated, Yes. I got him up at 9:15 am to weigh him and place him in the recliner. The CNA was asked, Did he stand? CNA #2 stated, Yes. He did. The CNA was asked, Did he transfer himself? CNA #2 stated, No. Me and the other CNA transferred him. CNA #2 was asked, Do you have a closet care plan on him? CNA #2 stated, Yes. CNA #2 was asked, Can you get it for me to look at? CNA #2 removed the closet care plan from the wardrobe and provided it to the surveyor. CNA #2 was asked, Is it ok for the resident to be up in the recliner? CNA #2 stated, No. CNA #2 was asked, How do you know it is not ok for him to be up in the recliner? CNA #2 stated, I just read it on his closet care plan. CNA #2 was asked, What can happen with him being up in the recliner? CNA #2 stated, I don't know. I am really not sure. c. On 01/20/21 at 11:07 AM, Licensed Practical Nurse (LPN) #1 was asked, Are you the nurse providing care for (Resident #204) today? LPN #1 stated, Yes. I am. LPN #1 was asked, Is it ok for the resident to be out of bed? LPN #1 stated, He is non-weight bearing. LPN #1 asked, Is it ok for him to be in the recliner? LPN #1 stated, No. He is supposed to be in bed. LPN #1 was asked, What can happen to him being up in the recliner? LPN #1 stated, His hip could break more. LPN #1 was asked, So with him being up in a recliner, is that following physician orders? LPN #1 stated, No. d. On 01/20/21 at 10:10 AM, the Nurse Consultant was standing at the Resident #204's door. Nurse Consultant #1 was asked, What are you doing with the resident? Nurse consultant #1 stated, We are getting him in bed right now. e. On 1/20/21 at 10:23 AM, Physical Therapy #1 was asked, You were the therapist that observed Resident #204 up in the recliner, is that correct? PT #1 stated, Yes. PT #1 asked, Is he supposed to be out of bed? PT #1 stated, No. PT #1 asked, What can happen while he is out of bed? PT#1 stated, It could dislocate his hip. PT #1 asked, With the resident being out of bed, is that following physician orders? PT#1 stated, No. It is not. f. On 1/20/21 at 10:50 AM, LPN #1 was asked, You completed the admission assessment on Resident, how was he transported to the facility? LPN #1 stated, He was brought by transport in a wheelchair. The surveyor asked, Did the orders for him to remain flat come with him from the hospital? LPN #1 stated, Yes. It was in his paperwork. LPN #1 was asked, Has he been up out of bed before? LPN #1 stated, No. Not to my knowledge. The LPN was asked, Is today the first time he's been up? LPN #1 stated, That is correct. LPN #1 stated, I have called (physician). I left a message for his orthopedist. He has a follow up appointment with Ortho on 2/2/21. I did let his son know as well.