Every finding on record at Anchor Post Acute

Based on observation, interview, and facility policy review, the facility failed to ensure the kitchen's floor and equipment including two ovens, the shelves on two metal rolling carts, three stove top spill pans, three metal racks, one reach in freezer, five food preparation pans, and large manual can opener and its base attachment were kept clean. These failures had the potential to create an environment for food-borne illnesses which could affect 102 residents who consumed food prepared from the facility's kitchen. Review of the facility's policy titled, Sanitation revised on 04/2006 indicated, Policy Statement-The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchen, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish . 2. All utensils, counters, shelves, and equipment shall be kept clean .1. Observation during the initial kitchen inspection on 09/09/25 from 9:15 AM to 9:55 AM, with the Registered Dietitian (RD) present, revealed the floor behind the kitchen's ovens was unclean with accumulated food and debris. The RD confirmed the area behind the kitchen's ovens was unclean.2. Observation during the initial kitchen inspection on 09/09/25 from 9:15 AM to 9:55 AM, with the RD present, revealed the following unclean food preparation and service equipment that was stored and ready for use: the interior cooking compartments of the kitchen's two ovens were unclean with an accumulation of dried and burned food spills and debris; the stove top's three spill pans were unclean with a heavy accumulation of dried and burned food and debris; the interior bottom of one of the kitchen's reach in freezers was unclean with a brownish colored ice; the shelves on two metal rolling carts which had insulated tops and bottoms stored on them were unclean with dried food substance and loose debris; the shelves on a metal rolling cart which had sheet pans stored on it was unclean with dried food substances and loose debris; the kitchen's large manual can opener which was attached to a food preparation table was unclean with dried substances on its blade and on its base attachment; and five 24 cavity food preparation pans were unclean with greasy residues and/or burned on substances.During an interview on 09/09/25 at 9:55AM, the RD confirmed all of the kitchen equipment that was observed above was unclean. The RD stated it was expected that the dietary staff would keep all kitchen equipment clean as scheduled on the kitchen's cleaning schedule and as needed. The RD stated the brownish ice observed in the bottom of the reach in freezer must have come from a spill, and the only unclean observed items that were not on the kitchen's current cleaning schedule were the three stove top spill pans.

Based on observation, interview, record review, and policy review, the facility failed to ensure two of three residents (Resident (R)15 and R63) reviewed for respiratory care in a sample of 24 residents received oxygen as ordered by the physician and R15s oxygen unit was clean and sanitary. This failed practice has the potential to cause respiratory issues and /or infections for residents.Review of the facility's policy titled Oxygen Administration dated October 2001 documented, .Verify that there is a physician's order for this procedure.Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.1. Review of R63's Face Sheet located in the electronic medical record (EMR) under the Admissions tab documented R63 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD).Review of R63's Physician Orders located in the EMR under the Orders tab dated 06/03/25 revealed an order for Oxygen at 2 lpm [liters per minute] continuous via nasal cannula for COPD. There was no order for R63's oxygen filter to be cleaned.Review of R63's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/13/25 revealed a Brief Interview of Mental Status (BIMS) score of seven out of 15 indicating severe cognitive impairment and the resident used oxygen.Review of R63's Medication Administration Record (MAR) located in the EMR under the Orders tab, dated 09/01/25 to 09/11/25 revealed R63 received oxygen at 2 lpm.Observations conducted on 09/09/2025 at 12:04 PM and on 09/10/25 at 9:20 AM revealed R63's oxygen rate was at 3.5 lpm. There was a film of gray dust on the outside of the oxygen machine and there was visible dust on the filter, which when removed had a moderate amount of gray dust.During an interview on 09/10/25 at 3:46 PM, Licensed Practical Nurse (LPN) 3 said he was assigned to R63's unit on 09/10/25 between 7:00 AM and 7:00 PM. LPN3 said R63's oxygen rate was ordered at 2 lpm. He said although he checked the oxygen rate on residents' receiving oxygen each shift, he had not yet checked R63's oxygen rate He said the night nurse changed the oxygen tubing every Sunday and was to clean the oxygen machines and filters. LPN3 confirmed thatR63's oxygen rate was incorrectly set at 3.5 lpm, the machine needed to be cleaned, the filterhad visible lint on the outside and inside of the filter and appeared not to have been recently cleaned.During an interview on 09/11/25 at 5:27 PM, LPN5 said he was the 7 PM to 7 AM nursing supervisor. He said residents receiving oxygen required a physician order that included, the rate and method of administration and change oxygen tubing and clean oxygen filter weekly (Sunday on R63's unit). He also confirmed he could not locate documentation that the oxygen filter had been cleaned.2. Review of R15's Face Sheet located in the EMR under the Admissions tab documented R15 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and COPD.Review of R15's Physician Orders located in the EMR under the Orders tab, dated 08/02/25 revealed an order for, Oxygen at 2 lpm continuous via nasal cannula and clean oxygen machine filter every Sunday.Review of R15's quarterly MDS located in the resident's EMR under the MDS tab, with an ARD of 06/18/25 revealed R15 had a BIMS score of 15 out of 15, which indicated intact cognition and the resident used oxygen.Review of R15's MAR located in the EMR under the Orders tab dated 09/01/25 to 09/11/25 revealed R15 received oxygen at 2 lpm and the oxygen filter was cleaned every Sunday.Observations conducted on 09/09/2025 at 12:34 PM and on 09/10/25 at 9:41 AM revealed R15's oxygen rate was at 4 lpm.During an interview on 09/10/25 at 3:40 PM, LPN3 said he was assigned to R15 on 09/10/25 between 7:00 AM and 7:00 PM. LPN3 said R15 had a physician order for oxygen at 2 lpm. He said he had not yet checked R15's oxygen rate during his shift. He said R15 was not able to change her oxygen rate. LPN3 said R15's oxygen rate was incorrectly set at 4 lpm and not per the physician's order.During an interview on 09/11/25 at 11:20 AM, the Director of Nurses (DON) said the nurses were to check a resident's oxygen rate every shift. She stated the nurses were to ensure residents received oxygen per the physician's orders and notify the physician if a resident's oxygen rate needed to be adjusted. The DON said the nurses changed the oxygen tubing and cleaned the filters on Sunday nights and all nurses were to ensure the oxygen machines and filters were clean.

Based on interview and record review, the facility failed to have medications available for administration for one (Resident (R) 57) of seven sampled residents whose drug regime was reviewed in a total sample of 24 residents. The facility failed to have R57's Clonazepam medication (Generic name- Klonopin which is an antianxiety medicine) available to administer as prescribed for two days, which caused the resident to not feel well and have increased anxiety.Review of R57's admission Record revealed R57 was admitted to the facility on [DATE] and had diagnoses of which included bipolar disorder, anxiety disorder, and major depressive disorder.Review of R57's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/16/25, located in the EMR under the MDS tab, indicated R57 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. The MDS also indicated R57 had an active diagnosis of anxiety disorder and received an antianxiety medication.Review of R57's current care plan most recently reviewed by staff on 08/20/25 and located in the EMR under the Care Plan tab contained the following Focus which was initiated on 12/29/23: Medication- Anti-Anxiety: Resident requires anti-anxiety medication related to anxiety disorder as evidenced by Verbalizations of feelings of nervousness/anxiety. The goal indicated, Medication use will result in the maintenance of the resident's functional status. The care plan approach included, Administer anti-anxiety medication as ordered by the physician.Review of R57's current Physician Orders located under the Orders tab in the EMR revealed an order for Clonazepam 1 milligram tablet to be given by mouth twice a day for anxiety.Review of R57's monthly September 2025 Medication Administration Records (MAR) provided by the facility, revealed R57 had an order to receive a one milligram tablet of Clonazepam twice a day at 9:00 AM and 8:00 PM for anxiety. Further review of R57's September 2025 MAR revealed she did not receive her prescribed Clonazepam twice a day as order on 09/02/25 and on 09/03/25. On 09/02/25 and 09/03/25, Licensed Practical Nurse (LPN) 2 noted on the MAR that R57 did not receive her 9:00 AM dose of Clonazepam because the medication was not available.Review of R57's Progress Notes located under the Prog [Progress] Note tab of the EMR, revealed the following entries:A Nurse Practitioner Note written on 08/28/25 at 09:38 AM, specified, Clonazepam order refilled at this time.A Behavior Note dated 09/03/25 at 11:14 AM, written by LPN 2, specified, Resident upset due to medication not delivered by pharmacy and threatening to call EMS [emergency medical services] if medication is not here this evening. Resident also c/o [complain of] chest pain since last night due to her not having clonazepam stating, Not only do I need it. I am addicted to it. I have been taking it since I was 23 and I feel like I am having withdrawals. Nurse did reach out to pharmacy to get status of medication and get it in stat. Nothing was given in report resident c/o chest pain. Will continue to monitor.A Nurse Practitioner Note written on 09/03/25 at 11:22 AM, specified, Clonazepam order refilled again per pharmacy request.During an interview on 09/09/25 at 10:45AM, R57 stated she went without her Klonopin for two or three days during the prior week. R57 stated she had a physician's order to receive Klonopin twice a day, but the facility did not have it available last week, so she did not receive it. R57 stated as a result of not receiving her Klonopin she experienced sweating and was more anxious than normal. R57 explained when the facility could not obtain her Klonopin from the pharmacy she received a dose of Ativan during the afternoon of the second day (09/03/25) which did help ease her anxiety. R57 stated the following morning (09/04/25) she received her 9:00 AM dose of Klonopin as scheduled.During an interview on 09/10/25 at 4:50 PM, LPN2 stated she worked with R57 and administered her medications during the 7:00 AM to 7:00 PM shift. LPN2 confirmed that R57 missed doses of Klonopin a week ago because the medication was not available in the facility because the pharmacy did not send it to the facility. LPN2 explained that the staff called the pharmacy about the resident's Klonopin not being available, but the medication was not received for a couple days. LPN2 stated she did not observe R57 experiencing any sweating or signs of withdrawal, but she may have been more anxious than normal related to missing her medication.During an interview on 09/10/25 at 5:03 PM, the Director of Nursing (DON) confirmed R57 missed a total of four doses of Klonopin on 09/02/25 and 09/03/25 because the medication was not available. The DON stated she was notified on 09/03/25 that R57's Klonopin was not available in the facility. The DON explained that she contacted the pharmacy on 09/03/25 and was informed that R57's Klonopin would not arrive at the facility until after the resident's 8:00 PM dose was scheduled. The DON stated an order was written on 09/03/25 for R57 to receive stat dose of Ativan to help ease her anxiety until her Klonopin could be administered during the morning of 09/04/25. The DON stated she spoke with R57 on 09/03/25 and did not observe the resident experiencing any signs of withdrawal from not receiving the medication.During an interview on 09/11/25 at 12:25 PM, R57's physician, who was also the facility's Medical Director, stated the resident's Klonopin should have been available for administration as ordered. The MD stated it was appropriate for the facility to obtain a stat order on 09/03/25 to administer Ativan in place of the Klonopin to reduce the resident's anxiety, because the Ativan would likely be available in the facility's emergency medication kit. The MD stated that he did not feel the resident experienced any serious consequences, but most likely experienced an increase in anxiety as a result of the missed doses of Klonopin.During an interview on 09/11/25 at 12:40 PM, the Administrator explained R57's Klonopin was reordered on 08/28/25. However, the pharmacy did not dispense the medication at this time because the refill order was submitted too early, so the resident's insurance would not reimburse the pharmacy. The resident's Klonopin was again reordered by staff on 09/03/25 after the resident had run out of the medication.During an interview on 09/11/25 at 12:50 PM, the Administrator stated the facility did not have a policy for obtaining medications from the facility's pharmacy

Based on interview, test tray observation, record review, and facility policy review, the facility failed to serve food that was palatable and hot to four of four residents (Resident (R) 4, R35, R57, and R80) reviewed for food palatability out of a total sample of 24 residents. This failure had the potential to affect 102 residents who consumed food prepared from the facility's kitchen and could result in residents skipping meals and experiencing weight loss.Review of the facility's policy titled Food and Nutrition Services dated 10/17 indicated, Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature .1. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/25 and located in the electronic medical record (EMR) under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.During an interview on 09/09/25 at 12:53 PM, R4 stated the food served at the facility did not always taste good and was not always hot. R4 stated she would like the food to be seasoned and served hot at meals.2. Review of R35's quarterly MDS with an ARD of 06/13/25 and located in the EMR under the MDS tab revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact.During an interview on 09/09/25 at 9:05 AM, R35 stated the food served at the facility did not taste good. R35 specified the breakfast food including eggs and toast were always served cold. R35 stated the meals sat in the food delivery cart on the hallway for long periods before being served. R35 explained all meals needed to be improved, not just breakfast.3. Review of R57's quarterly MDS with an ARD of 08/16/25 and located in the EMR under the MDS tab revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.During an interview on 09/09/25 at 10:45 AM, R57 stated the food served at the facility was not consistent. R57 explained that some meals taste good and other meals do not taste good at all. R35 stated food was cold when served. R35 specified that she ate most of her meals in her roomand nursing staff did not serve meals timely on the hallway which resulted in food being served cold.4. Review of R80's admission MDS with an ARD of 07/01/25 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 09/09/25 at 12:55 PM, R80 stated the food was cold when served at meals and she was served very few good meals at the facility. R80 specified at breakfast she was served cold eggs and toast.5. In response to resident complaints about food, a test tray was requested to be sent to the facility's 200 hallway during the breakfast meal on 09/11/25. Observation revealed before the meal tray cart, which contained the test tray, left the kitchen at 8:22 AM, resident meals were observed being served on unheated plates. Observation of the kitchen's plate warmer which contained the plates staff were serving resident meals on was turned off. Food temperatures on the kitchen tray line were monitored by staff and were at acceptable levels of 135 degrees Fahrenheit (F) and above for the hot foods. The test tray and other resident meal trays were placed on an enclosed tray cart that had no heating element and were delivered to the 200 hallway at 8:23 AM. The last resident's breakfast tray was observed to be served on the 200 hallway on 09/11/25 at 8:56 AM. At this time, the food and beverages on the test tray were sampled in the presence of the facility's Registered Dietitian (RD). The RD utilized a calibrated facility thermometer to obtain temperatures of the food and beverages served on the test tray. The RD also tasted the food served on the requested test tray. Temperature checks and tasting of the food served on the test tray revealed the following:a. The grits on the test tray registered 115 degrees Fahrenheit (F) and were barely warm when tasted. The grits were observed to be served directly on the plate and had started to solidify. The RD also tasted the grits and confirmed the grits tasted barely warm and needed to be hotter.b. The pancakes on the test tray registered 117 degrees F and were barely warm when tasted. The RD also tasted the pancakes and confirmed they were barely warm and needed to be hotter.During an interview on 09/11/25 at 9:05 AM, the RD stated the kitchen's plate warmer should have been turned on by staff prior to the breakfast meal service and the grits and pancakes should be hot when served to resident

Based on observations, record review, interview, and review of Centers for Disease Control (CDC) guidelines, the facility nursing staff failed to wear Personal Protective Equipment (PPE) when providing direct care for one of one (Resident (R)1) reviewed for Enhanced Barrier Precautions (EBP) in the sample of 24 residents. This could place this resident and other residents and staff at risk of infection by cross-contamination.Observation on 09/09/25 at 10:30 AM of R1 lying in bed revealed a small black bag hanging on the side of her bed. Interview with Certified Nursing Assistant (CNA)3 at this time confirmed that R1 has a nephrostomy tube.Observations on 09/09/25 at 10:30 AM, 09/10/25 at 2:00 PM, and 09/11/25 at 10:00 AM, and 3:00 PM revealed CNA3 entered R1's room to provide direct care without wearing any PPE.Review of R1's Electronic Medical Record (EMR) Clinical Census under the Clinical Census tab revealed admitted on [DATE] with diagnoses of nephrostomy tube since 2022 due to hydronephrosis (extra fluid in the kidney) and acute kidney injury with tubular necrosis (dead tissue in the kidney).Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which showed she had moderate cognitive impairment.Interview on 09/11/25 at 4:00 PM, the Director of Nursing (DON) revealed the Infection Preventionist (IP) was out of the facility. The DON agreed that since R1 had a nephrostomy tube and is on EBP. The DON stated that nursing staff were to wear PPE when providing direct resident care.Review of CDC guidelines, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html indicated EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Further, under the section Implementation of EBP indicated gowns and gloves are the minimum level of PPE required for these high-contact resident care activities.

Based on record review, interview, and policy review, the facility failed to ensure one of 24 (Residents (R)1) reviewed for comprehensive care plans failed to include the care required for R1's nephrostomy tube. care plan directing measurable goals and interventions for one of a total sample of 29 residents. This failure placed the resident at risk for unmet care needs, and the inability to meet their maximum practicable level of functioning.Review of the facility's policy titled, Care Planning - Interdisciplinary Team dated March 2022 included, .the Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (lDT).Review of R1's Electronic Medical Record (EMR) in the Clinical Census found under the Clinical Census tab revealed admitted on [DATE] with diagnoses of nephrostomy tube since 2022 due to hydronephrosis (extra fluid in the kidney) and acute kidney injury with tubular necrosis (dead tissue in the kidney).Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment.Review of R1'sComprehensive Care Plan found in the EMR under the Care Plan tab initiated on 08/30/25 and revised 09/05/25 revealed, At risk for complications with urinary system related to having right side nephrostomy with the goal, Will have no complications or infections r/t [related to] urinary device. Interventions included, Administer medications as ordered. Encourage fluids if not contraindicated. Labs as ordered. Notify physician of results. Notify physician of signs and symptoms of UTI [urinary tract infection] such as mental status changes, foul smelling urine, color change in urine, hematuria, sedimentation, burning with urination, increased temperature. Urology/Nephrology consults/ follow-up as ordered. R1's care plan did not address what type of care was required for the nephrostomy tube.Interview on 09/09/25 at 10:30 AM, Certified Nursing Assistant (CNA)3 confirmed that R1 had a nephrostomy tube.Interview on 09/11/2025 at 10:54 AM, the MDS Coordinator (MDSC)2 agreed that the care for the nephrostomy should have been included in her care plan.

Based on review of facility policy, record review, observations and interviews, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL) assistance received services for one of four residents (Resident (R) R63) reviewed for fingernail care and bathing in a total sample of 24 residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issueReview of the facility's policy titled Fingernails/Toenails, Care of dated 2002 documented, .Nail care includes daily cleaning and regular cleaning. Proper nail care can aid in the prevention of skin problems around the nail bed.Review of R63's Face Sheet located in the electronic medical record (EMR) under the Admissions tab documented R63 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), depression, and adult failure to thrive.Review of R63's Care Plan located in the EMR under the Care Plan tab dated 04/10/25 revealed the resident was at risk for Activities of Daily Living (ADL)/mobility decline and requires assistance related to fracture, weakness, will have ADL and mobility needs met. Interventions included that staff would assist with bathing and hygiene as needed.Review of R63's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/13/25 revealed the resident had a Brief Interview of Mental Status (BIMS) score of seven out of 15 indicating severe cognitive impairment, had no behaviors and/or rejection of care, and required maximal staff assistance for personal hygiene that included nail care.Review of the Shower Schedule provided by Licensed Practical Nurse (LPN) 3 assigned to R63 on 09/11/25 revealed R63 was to receive a shower on Tuesday and Friday during the 7AM to 7 PM shift.Observations conducted on 09/09/2025 at 12:02 PM, on 09/10/25 at 9:21 AM, and on 09/11/25 at 12:50 PM revealed R63 had dark brown material under all his fingernails and needed nail care.During an interview on 09/10/25 at 4:18 PM, Certified Nursing Assistant (CNA) 2 stated that R63 was confused, and the staff had to clean his nails. She stated R63 receives two showers per week, and the staff clean his fingernails during the shower. During an interview on 09/11/25 at 12:54 PM, LPN3 stated that R63 was confused, compliant with fingernail care, and the staff provided his nail care during his showers and as needed. He confirmed R63's fingernails were dirty, had dark material under his nails, and they needed to be cleaned.During an interview on 09/11/25 at 1:54 PM, the Director of Nursing (DON) stated that staff were to provide fingernail care during showers, which were provided to the residents twice per week and as needed (prn). She said R63 did not have a history of refusing personal care and/or nail care. The DON said the CNAs were to assess a resident's fingernails every shift and provide nail care as needed.

Based on observation, interview, and review of the facility policy, the facility failed to ensure safe and secure storage of medications and biologicals in 2 of 2 medications observed. Findings include: Review of the facility policy titled, Storage of Medications last revised November 2023, states, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Furthermore it states, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Observation on 09/03/24 at 2:01 PM and 2:30 PM of Hall 400 Medication Carts, revealed, an unattended and unlocked medication cart with 1 bottle of Clear Lax sitting on the top of the cart. Observation and interview on 09/03/24 at 3:16 PM of Hall 400 Medication Carts, revealed, an unattended and unlocked medication cart with 1 bottle of Clear Lax sitting on the top of the cart and one medicine cup with a mixture of applesauce and pills. Licensed Practical Nurse (LPN)1 stated that the medicine cup was left on top due to a resident refusing medication and that her cart was unlocked because she was called away to do something. LPN1 stated that per policy, the medications should have been disposed of in the medications storage room. During an interview on 09/03/24 at 3:40 PM with the Director of Nursing (DON), the DON stated that medication carts are to be locked when not in use.

Based on observations, interviews, document review, and facility policy review, the facility failed to ensure the ice machine remained clean and not contaminated, ensure proper hand hygiene when serving food from the steam table, ensure proper handwashing when going from a dirty to a clean area, and ensure staff (Cook1) wore a beard guard for one of one kitchen. These failures had the potential to affect 105 residents in the facility who consumed food from the kitchen. Findings include: Review of facility policy titled, ''Ice,'' revised 09/17, revealed, ''Ice will be prepared and distributed in a safe and sanitary manner .4. Ice bins will be cleaned monthly and as needed .Staff will adhere to proper utensil usage or clean gloved hands for handling.'' Review of facility policy titled, ''Food: Preparation,'' revised 09/17, revealed, ''All foods are prepared in accordance with the Food and Drug Administration (FDA) Food Code. 1. All staff will practice proper hand washing techniques and glove use .4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit (F) and/or less than 135 F, or per regulation .13. All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding .15. All staff will use serving utensils appropriately to prevent cross contamination.'' During the initial tour with the Registered Dietitian (RD) on 06/30/24 between 10:15 AM-11:00 AM, revealed the following concerns: 1. There was light pink colored unknown substance on the inside of the ice machine, right side of the white lip. In addition, there was an eight-ounce bottle of Shasta ginger-ale buried into the ice on the right side of the machine. The surveyor took a paper towel and ran it under the white lip, which obtained slimy pink colored unknown substance on the paper towel. The RD confirmed the pink colored unknown substance and stated that the ice machine was cleaned weekly. The RD removed the Shasta ginger-ale out of the ice. 2. Cook1 was over at the stove cooking without a beard guard. Cook1 had facial hair on his chin area. During an observation on 07/01/24 at 12:58 PM, Cook1 removed his gloves, and went over to the handwashing sink, turned on the water, and washed his hands for less than 20 seconds. After washing and rinsing his hands, cook1 turned the water off with his left hand, then used paper towels to dry hands. Cook1 placed on new gloves and rejoined the tray line. Cook1 was placing food on the trays and during this, cook1 was observed using his left gloved hand, touching his face and beard guard three times, then went back to the tray line and pick up several rolls with his same gloved hand and placed them on resident trays. During an interview on 07/02/24 at 5:17 PM, the Dietary Manager (DM) confirmed that beard guards were to always be worn while working in the kitchen. The DM confirmed that the ice machine was cleaned daily, and the plastic part could be unscrewed and washed in the dish machine. The DM stated that there was no certain time for it to be cleaned daily and confirmed it had not been cleaned on 06/30/24. In addition, she stated that there should have been nothing placed in the ice. She confirmed that after staff washed their hands, the staff should have turned off the faucet with a paper towel and should have washed their hands for at least 20 seconds. She stated that staff should not go from a dirty surface to a clean surface, indicating that staff should have not touched their face then touched food with the same hand.

Based on interviews, observations, record review, and facility policy review, the facility failed to serve food that was palatable as expressed by five of five residents (Resident (R) 26, R27, R52, R53, and R55) in a group interview, in that the hot foods when served to the residents did not taste hot and the food was not seasoned. This had the potential to affect 105 residents who consumed food prepared from the facility's kitchen. Findings include: Review of facility policy titled, ''Food: Quality and Palatability,'' revised 02/23, revealed, ''Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature .1. The Dining Services Director and Cook(s) are responsible for food preparation .4. The cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention.'' During the resident group meeting that was held on 07/01/24 at 4:30 PM, five residents (R26, R27, R52, R53 and R55), whom the Activity Director identified as alert and oriented stated that the hot foods were served cold, and that the food was not seasoned. Five of Five residents stated that during the lunch meal on 07/01/24, the potatoes were served cold and had no seasoning. R52 stated that the lima beans were cold and had no taste to them. R55 stated that the grits were served cold and stiff. R55 stated that the lima beans served on 07/01/24 were cold and had no taste. R27 stated that the food came from the kitchen and sat in the hallways for at least 10 minutes or more before being served by staff, which contributed to the coldness. Review of the ''Resident Council Minutes,'' dated 08/31/23, 09/29/23, 11/30/23, 12/21/23, 03/01/24, 03/29/24, 04/30/24, 05/03/24, and 06/28/24 revealed unidentified ''Dietary concerns.'' Observation of the lunch meal tray line on 07/01/24 at 1:03 PM with Cook1 revealed the following: [NAME] gravy: 150 degrees Fahrenheit (F), Dijon gravy: 166 degrees F, Pork Loin: 182 degrees F, Lima beans: 191 degrees F, Fried potatoes and onions: 185 degrees F, Pureed meet: 157 degrees F, Ground meet: 160 degrees F, Pureed beans: 176 degrees F, Mashed potatoes: 196 degrees F, Salisbury Steaks: 122 degrees F. The dietary manager put the Salisbury steaks back in the oven to reheat and then retested the Salisbury steaks which were now when retested 173 degrees F. The last 200-hall residents' meal cart left the kitchen for the hallway on 07/01/24 at 1:25 PM. The last resident's tray was served at 1:33 PM. The Dietary Manager (DM) took the temperatures of the test tray at 1:34 PM. The following were the temperatures of the test tray: -Pork loin with Dijon gravy: 138.8 degrees F, -Fried potatoes and onions: 122.3 degrees F, and -Lima beans: 111.8 degrees F. Review of the test tray alongside the Certified Nursing Assistant (CNA) 7 revealed: The pork loin with Dijon gravy had a good taste but was at room temperature. Lima beans were at room temperature and had no seasoning and/or moisture, which made them hard to eat. Fried potatoes and onions were at room temperature and had no seasoning. CNA7 confirmed the findings. The DM confirmed the food temperatures were low.

Based on observations, record review, interviews, and facility policy review, the facility failed to provide resident care in a manner that prevented cross-contamination for one of one resident (Resident (R) 42) reviewed for catheter care of 23 sampled residents. In addition, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for three of three residents (R65, R36, and R12) when providing care to residents on enhanced barrier precautions (EBP). This failure could promote the spread of multi drug resistant organisms throughout the facility. Findings include: Review of facility policy titled, ''PPE-Gloves,'' revised 07/09, revealed, '' .8. Wash your hands after removing gloves.'' Review of facility policy titled, ''Handwashing/Hand Hygiene,'' revised 10/23, revealed '' .Indications for hand hygiene .d. after touching a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Review of facility policy titled, ''Catheter Care, Urinary,'' revised 08/22, revealed, '' .Steps in the Procedure: Routine Perineal Hygiene .14. For a male resident: a. Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus, b. Cleanse the glans using circular strokes from the meatus outward, c. Change the position of the washcloth (or wipe) with each cleansing stroke.'' Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, revised 09/22, indicated under the section Contact Precautions that, These strategies may differ depending on the prevalence or incidence of the MDRO [multidrug-resistant bacteria] in the facility and region. For example, additional usage of PPE (enhanced barrier precautions) may be used for residents who do not meet criteria for contact precautions but are infected or colonized with MDROs (or have risk factors for MDRO acquisition). There was no other reference to enhanced barrier precautions within the policy. 1. Review of R42's undated ''Face Sheet,'' located under the ''Profile'' tab in the electronic medical record (EMR), revealed that R42 was readmitted to the facility on [DATE] with a diagnosis including neuromuscular dysfunction of the bladder. Review of R42's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/08/24 indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15 revealed R42 was cognitively intact. During catheter care with Certified Nursing Assistant (CNA) 2 on 07/02/24 at 12:32 PM, she gathered all her belongings and donned (put on) her PPE prior to entering R42's room. She placed a clean barrier on the over bed table, then placed two clear plastic bags on the barrier. CNA2 had her gloves on, she was observed adjusting the bedside table. With the same gloves, she removed R42's incontinent brief and tucked it under R42's buttocks .CNA2 obtained several wipes and wiped in an upward and downward motion several times on the left side of the genital area. CNA2 then wiped, with the same gloves, in a downwards motion at first on R42's catheter tubing, then wiped up and down the tubing while wiping around R42's penis, several times. After that, CNA2, did not remove her gloves. CNA2 pushed the overbed table to the other side of R42's bed. She assisted R42 in rolling over to his left side, and finished removing his incontinent brief, and the drawl sheet. CNA2 obtained several wipes and started in an upward motion on R42's bottom at first, and then obtained new wipes where she wiped in an up and down motion several times. At this point, when CNA2 was wiping the surveyor observed a lightly brown color on the wipes after CNA2 wiped R42's anus area. CNA2 disposed of these wipes and placed a new incontinent brief on R42 without removing her gloves. After she placed R42's incontinent brief on him, CNA2 adjusted the drawl sheet, tucking it under R42. CNA2 moved from the right side of R42's bed, to the left side, and assisted R42 to roll over to his right side. CNA2 then finished untucking the drawl sheet from under R42 and adjusted his brief. She adjusted R42's blanket, and placed a pillow under his feet, along with a flat sheet covering the resident. Currently, she removed her gloves, and PPE, but did not wash her hands. She gathered her two plastic bags and exited R42's room. After exiting the room, CNA2 placed the bags inside a dirty bin in the spa room next door to R42's bedroom. After she disposed of these bags, CNA2 did not wash her hands and/or use hand sanitizer. Review of ''Physician Orders,'' dated 02/02/23 located under the ''Orders'' tab in the EMR, revealed ''Foley catheter care every shift and when needed (PRN).'' Review of R42's ''Urinalysis Culture,'' dated 02/08/24, located under the ''Result'' tab in the EMR, revealed ''Escherichia coli (E. Coli) and Extended spectrum beta lactamase (ESBL). During an interview on 07/02/24 at 1:55 PM, the Infection Preventionist (IP) confirmed that staff were to change gloves when going from a dirty area to a clean area, and stated that staff were trained to wipe downwards, and change the direction of the wipes. At 2:22 PM, she stated that the staff had a skills fair last week. During an interview on 07/02/24 at 2:10 PM, the CNA2 stated did not realize what she had done incorrect during the catheter care and stated that when she wiped, she changed the direction of her wipe. When the surveyor asked about changing gloves and/or sanitizing hands, she stated that she had not completed an observation with a surveyor from this state before. 2. a. Review of R65's Admission Record in the Profile tab of the EMR revealed an admitted [DATE]. The Admission Record also revealed diagnoses of breakdown (mechanical) of internal fixation device of bone of left lower leg and infection and inflammatory reaction due to internal fixation device. Review of R65's admission MDS with an ARD of 05/09/24 and located in the MDS tab, revealed a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. During observation of R65 in her room on 06/30/24 at 9:43 AM, the resident had a STOP EBP Precaution signage on the door frame revealing staff must wear gloves and a gown and with an isolation cart outside doorway. CNA4 rearranged the top sheet on patient lying in bed. CNA4 was wearing gloves, but no gown. During an interview on 06/30/24 at 9:46 AM, CNA4 stated, We don't have to gown up for her [R65]. The isolation carts are at different spots in the building for the residents. One isolation cart is for multiple residents on the same hallway. The nurse will know who is in isolation. The supplies in the cart are for everyone. During an interview on 06/30/24 at 9:51 AM, Licensed Practical Nurse (LPN) 3 stated, She[(R65] has a surgical wound. It's not infected now, so we don't wear gowns. When it was infected, then we would wear a gown when providing care to her. During an interview on 06/30/24 at 3:34 PM, R65 stated, Staff use hand sanitizer and wear their gloves, but not gowns. b. Review of R36's Admission Record in the Profile tab of the EMR revealed and admitted [DATE]. The Admission Record also revealed diagnosis of acute kidney failure and end stage renal disease. Review of R36's admission MDS with an ARD of 06/10/24 and located in the MDS tab revealed a BIMS score of one out of 15 which indicated the resident was severely cognitively impaired. During observation of R36 in his room on 07/01/24 at 12:13 PM, LPN5 used a glucometer device to check blood glucose. LPN5 performed hand hygiene and donned gloves but did not wear a gown during resident care. c. Review of R12's Admission Record in the Profile tab of the EMR revealed an admitted [DATE]. The Admission Record also revealed diagnoses of dysphagia (difficulty swallowing) following cerebral infarction, requiring the use of a gastrostomy tube (G-tube). A G-tube is a tube inserted through the abdomen that brings nutrition directly to the stomach. Review of R12's admission MDS with an ARD of 06/14/24 and located in the MDS tab revealed a BIMS score of 99 out of 15 which indicated the resident was unable to complete interview. During an observation of R12 in his room on 07/01/24 at 1:19 PM, LPN5 administering medications and tube feeding via gastrostomy tube. LPN5 performed hand hygiene and donned gloves but did not wear a gown during resident care. During an interview on 07/01/24 at 1:30 PM, LPN5 stated, We have a protocol to monitor infection with foley, wound, G-tube, colostomy, and COVID. We take precautionary measures and do handwashing and follow these guidelines (pointing to the STOP EBP based sign) wearing a gown with those residents with infection. We only wear gowns when we do ADLs [activities of daily living] for more than, like two or three minutes. During an interview on 07/02/24 at 12:11 PM, CNA5 stated, We had training on infection control within the last three weeks. We do it for everyone. I don't know what EBP is. During an interview on 07/02/24 at 12:37 PM, IP stated, EBP was implemented longer than a month ago, I believe it was April. I don't know why that CNA [CNA5] would say I don't know what (EBP) is. I've trained on EBP twice recently in this last month and a couple times a month since we started it. I did a one-on-one training with them all this morning and they signed off on it. We even did a skills fair with them as recently as last week. I don't know why that nurse [LPN5] would go in a room without gowning up. She told me about it, and I wrote her up for it . Anytime they provide direct care they need to wear a gown and gloves. They all know to look at the EBP signs on the door as a reminder of when they need to wear them. 43353

Based on interviews, document review, and review of facility policy, the facility failed to respond to resident grievances in a timely manner for one of one resident (Resident (R) 75) reviewed for grievances out of 23 sampled residents. This had the potential to affect resolution of resident concerns. Findings include: Review of the facility policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, showed: Policy Interpretation and Implementation .5. The Resident Grievance/Complaint Investigation Report Form will be filed with the administrator within five (5) working days of the incident. 6. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ___ working days of the filing of the grievance or complaint . During an interview on 06/30/24 at 4:27 PM, R75 stated she had $40.00 stolen from me. When asked where it had been, R75 indicated In cabinet like this [pointed to a bedside table with a lockable top drawer], but the key didn't work; they did not replace it; and a clothes hamper that was stolen in laundry. During an interview on 07/02/24 at 6:35 PM, the Social Services Director (SSD) provided two grievance forms; one dated 05/31/24 regarding the missing money that showed a resolution date of 07/01/24; the second regarding the missing hamper dated 07/01/24 with a resolution date of 07/01/24, the SSD stated they were unaware of the missing hamper. The SSD stated that when she interviewed the resident on 05/31/24, she asked R75 where she got the money and R75 stated she got the money from her daughter; So I asked her if I call her daughter would she tell me she gave you the money? I tried calling the daughter and she didn't call me back. So, I called the POA [Power of Attorney] and the POA said the daughter had been known for taking her money. So, I called the daughter again and she didn't call back. So, the Administrator went to look for the blue hamper in the laundry and found the money there. The SSD confirmed that the grievance was put in on 05/31/24 and not resolved until 07/01/24. During an interview on 07/02/24 at 7:13 PM, the Administrator stated an expectation that grievances would be resolved promptly, 72 hours if I can. When queried at 7:15 PM if over 30 days was too long, the Regional Nurse stated, Well, it depends on what it is and if it is still being investigated.

Based on observation, record review, interview, and facility policy review, the facility failed to prevent accidents for one of one resident (Resident (R) 32) when they failed to implement an intervention listed on the care plan of 23 sample residents. This failure had the potential to cause the resident harm from a fall out of bed. Findings include: Review of the facility's policy titled, Falls and Fall Risk, Managing, dated March 2018, indicated, 1. Resident centered fall prevention plans should be reviewed and revised as appropriate. 2. Several possible interventions may be identified considering resident fall risk, and the staff may prioritize certain interventions [NAME] on circumstances . Record review of R32's undated Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, muscle weakness, and unsteadiness on feet. Review of the significant change Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/13/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the Physician Order, dated 06/30/24, indicated, Change to scoop mattress. Review of R32's Care Plan, located under the Care Plan tab of the EMR, indicated Falls: Resident is at risk for falls with or without injury related to history of falls, weakness, incontinence, diuretic use, psychotropic drug use Intervention included, 03/01/24 Fall mat to right side of bed . 05/24/24-Fall mat to left side of bed . There was no documentation of the scoop mattress on the care plan. Review of the Initial Falls Assessment located under the Assessment tab of the EMR, dated 01/25/24, coded the resident as a high risk for falls. There were no interventions documented in the assessment. The monthly Fall Assessment assessed the resident as high risk. During an interview and observation on 07/02/24 at 1:50 PM, the Restorative Certified Nursing Assistant (CNA) stated the scoop mattress was to prevent the resident from scooting down and getting out of bed. Observation at time of interview revealed the resident had a fall mat on the left side but not the right side of the bed. The resident was not oriented but could answer basic questions. During an interview on 07/02/24 at 1:55 PM, CNA8 stated R32 had a fall on Sunday because she felt as though she could get out of bed herself. She stated that she was known to have two fall mats and confirmed there was only one in the room. During an interview on 07/02/24 at 2:03 PM the Regional Nurse stated they just changed her bed to a scoop mattress as an intervention for her falls. The Regional Nurse stated the resident previously had an air mattress, but they swapped it out for a scoop mattress to try and reduce the falls. During an interview on 07/02/24 at 2:23 PM Licensed Practical Nurse (LPN) 2 stated she was usually on the 400-hall. LPN2 confirmed there was no fall mat on the right side of the mattress. During an observation and interview on 07/02/24 at 6:07 PM, the Assistant Director of Nursing (ADON) stated the resident should have had floor mats on both sides of the bed. The ADON searched the room and revealed there was no additional fall mat in the room. At 6:30 PM, the ADON returned and reported the reason the fall mat was missing was because it was getting cleaned.

Based on observation, record review, interviews, and facility policy review, the facility failed to assess a resident for self-administration of medication for one of one resident (Resident (R) 27) reviewed for self-administration of medication of 23 sample residents. This had the potential to affect resident medication safety at the facility. Findings include: Review of the facility's policy titled, Self-Administration of Meds, revised in 02/21, indicated, under the section Policy Interpretation and Implementation that, lf it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Review of R27's Admission Record in the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE]. The Admission Record also revealed a diagnosis of hemiplegia and hemiparesis following cerebral infarction, affecting left dominant side. Review of R27's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/24 and located in the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an observation and interview on 06/30/24 at 8:10 PM, observation revealed three bottles of eye drops on R27's bedside table. Licensed Practical Nurse (LPN)6 stated, Yes ma'am we always leave them in her room at bedside. I will check to see if she has order to keep at bedside for the eye drops. LPN6 checked orders and stated, I don't see one to keep eyedrops at bedside. During an observation and interview on 06/30/24 at 8:39 PM, R27 stated, I've kept my eye drops here ever since I've been here. I've been here six and a half years. If I could get the lids off I could do them myself. I used to do them twice a day myself, but that was six and a half years ago. The facility has done them for me the entire time I've been here. I never asked the doctor if I could keep them at bedside. I think the nurses leave them here, because they used to come in and forget them. Then they would have to leave, go get them, and give them to me. It's easier to just keep them in here.

Based on interviews, record review, and facility policy review, the facility failed to report staff to resident abuse when they failed to report the allegation of abuse to the State Survey Agency (SSA) for one of two residents (Resident (R) 254) reviewed for abuse of 23 sample residents. These failures had the potential to contribute to further verbal abuse and possible psychosocial harm. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation, revised September 2022, indicated All reports of resident abuse, neglect exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (As required by current regulations) and thoroughly investigated by facility management. Review of the undated Face sheet found in the electronic medical record (EMR) under the Profile tab, revealed R254 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of the R254's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/19/24 revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During a family interview on 06/30/24 at 1:52 PM, when asked had the resident ever been abused, made to feel afraid or humiliated/degraded, R254's Family Member (F) 254 stated a week ago, Certified Nursing Assistant (CNA) 1 came into the resident's room and told R254 to stop pressing the call bell and that the CNA1 had other residents who were dying and needed her care. The next day the resident reported to F254 that CNA1 told her, We will not have a repeat of yesterday. F254 stated she then came to the facility to speak to CNA1. F254 stated she spoke to CNA1 about how she spoke to R254 and asked that CNA1 not provide care for R254. CNA1 has not provided care for R254 since then. F254 stated she reported it to Licensed Practical Nurse (LPN) 1. Review of the facility's Grievance Log, provided by the facility during the entrance conference, revealed the log did not have any concerns logged by R254 and/or F254. During an interview on 06/30/24 at 2:39 PM, Social Services Director (SSD) stated they did not have any staff to resident abuse concerns reported to them. During an interview on 06/30/24 at 2:45 PM the Administrator and Assistant Director of Nursing (ADON) stated they had not received a complaint about staff to resident verbal abuse. During an interview on 06/30/24 at 6:58 PM, LPN1 stated she reported to the Assistant Director of Nursing (ADON) that CNA1 was rude to R254, and the family asked for CNA1 to be removed from caring for R254. When asked what the facility's expectation for reporting abuse was, LPN1 stated she reported the allegation of abuse to ADON via text message. LPN1 stated in regard to abuse they would have reported it to their supervisor. Review of the Concern/Grievance Report, submitted 06/30/24 at 10:30 PM by the ADON, stated, Date initiated 06/23/24 . Subject- Last Wednesday CNA was removed from assignment due to resident thinking CNA was talking Loudly. Comments- CNA removed from assignment. Concerns Party Response- CNA Removed from assignment family stated they were okay with interventions. During an interview on 06/30/24 at 10:30 PM, when asked Was the incident reported to the SSA, the ADON and Regional Nurse Responded no. The Regional Nurse stated she felt as though the concerns went through nursing as a customer service issue and therefore stayed within nursing.

Based on interviews, record review, and facility policy review, the facility failed to ensure a thorough investigation was conducted for an allegation of abuse for one of two residents (Resident (R) 254) reviewed for abuse of 23 sample residents. These failures had the potential to contribute to further abuse and possible psychosocial harm. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation revised September 2022, indicated, All allegations are thoroughly investigated. The administrator initiates the investigations . 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is completed. The individual conducting the investigation as a minimum: a. Reviews the documentation and evidence b. reviews the residents medical record to determine the resident physical and cognitive status at the time of the incident and since the incident. C. observes the alleged victim, including his or interaction with staff and other residents. D. interview the person reporting the incident. E. interview any witnesses to the incident . Review of the undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R254 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of R254's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/19/24 revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During a family interview on 06/30/24 at 1:52 PM, when asked has the resident ever been abused, made to feel afraid or humiliated/degraded, R254's Family Member (F) 254 stated a week ago Certified Nursing Assistant (CNA) 1 came into the resident's room and told R254 to stop pressing the call bell and that the CNA1 had other residents who were dying and needed her care. The next day the resident reported to F254 that CNA1 told her that we will not have a repeat of yesterday. F254 stated she then came to the facility to speak to CNA1. F254 stated she spoke to CNA1 about how she speaks to R254 and asked CNA1 not to care for R254. CNA1 had not cared for R254 since then. F254 stated she reported it to Licensed Practical Nurse (LPN) 1. Review of the facility's Grievance Log, provided by the facility during the entrance conference, revealed the log did not have any concerns logged by R254 and/or F254. During an interview on 06/30/24 at 2:39 PM, the Social Services Director (SSD) stated they did not have any staff to resident abuse concerns reported to them. During an interview on 06/30/24 at 2:45 PM the Administrator and Assistant Director of Nursing (ADON) stated they had not received a complaint about staff to resident verbal abuse. During an interview on 06/30/24 at 6:58 PM, LPN1 stated she reported to the Assistant Director of Nursing (ADON) that CNA1 was rude to R254, and the family asked for CNA1 to be removed from caring for R254. When asked what the facility's expectation for reporting abuse was, LPN1 stated she reported the allegation of abuse to the ADON via text message. LPN1 stated in regard to abuse they would report it to their supervisor, she would remove the staff member from the resident until the investigation was completed. The LPN stated she did not write a statement or document the incident with R254. LPN1 stated if she witnessed abuse she would have removed the staff member from care pending the investigation. When asked if CNA1 was removed from care, LPN1 stated no she was just swapped out with another CNA to provide care to R254. Review of the Concern/Grievance Report submitted 06/30/24 at 10:30 PM by the ADON, stated, Date initiated 06/23/24 . Subject- Last Wednesday CNA was removed from assignment due to resident thinking CNA was talking Loudly. Comments- CNA removed from assignment. Concerns Party Response- CNA Removed from assignment family stated they were okay with interventions. During an interview on 06/30/24 at 10:30 PM, when asked was the incident reported to the SSA, the ADON and Regional Nurse Responded no. When asked were there any additional residents interviewed to ensure they did not feel as though CNA1 was rude to them, the ADON and Regional Nurse Responded no. The Regional Nurse stated she felt as though the concerns went through nursing as a customer service issue and therefore stayed within nursing.

Based on record review, and interviews, the facility failed to ensure three of three residents and/or their representatives (Resident (R) 11, R25 and R101) reviewed for facility initiated emergent hospital transfer, from a total sample of 23 residents, were provided with written transfer/discharge notice that contained the required information. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. During an interview on 06/30/24 at 4:41 PM, R11 stated she had been sent to the hospital about a month ago. Review of R11's electronic medical record (EMR) Census tab, showed R11 had been hospitalized on [DATE]. Review of R11's EMR Progress Notes tab, showed on 06/10/24 at 4:53 PM, R11 was hard to arouse, had slurred speech, and was not at her normal baseline. R11 was sent to the hospital for evaluation. A Progress Note, date 02/25/24 at 7:37 AM, revealed R11 was noted to have an altered mental status and not responding at baseline. Review of R11's Admission Record from the EMR Profile tab, showed a facility admitted [DATE], readmission on 02/27/23, with medical diagnoses that included spinal stenosis, intervertebral disc disorder, rheumatoid arthritis, and pulmonary hypertension. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/24 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of being cognitively intact. Further review of R11's Progress Notes tab, Evaluations tab, and Documents tab, did not show evidence of a written notice of transfer having been provided to R11 or her RR. In response to a request for the evidence of provision of a written notice of transfer, the facility provided two untitled forms- on facility letterhead; the first dated 02/24/24 stated R11 was her own 'self' and the form was provided to her that stated she was being sent to the hospital for altered mental status. The form did not include any information regarding the Ombudsman contact or appeal rights. The second form was dated 06/10/24 and was addressed to the R11's RR, did not include the reason for transfer (a canned line of related to a change in medical status), Ombudsman mailing address, or information regarding an appeal of the transfer. During a follow-up interview on 07/02/24 at 11:27 AM regarding the receipt of the written notice of transfer, R11 reviewed the papers and responded, First time I seen this paper. They never gave me this paper. My daughter never got one either - you can call her. Three unsuccessful attempts were made to contact R11's RR. 2. Review of R25's Census tab showed he had been sent to the hospital on 04/10/24 and 04/19/24. Review of R25's Admission Record from the EMR Profile tab, showed a facility admitted [DATE], with readmissions on 05/05/21 and 11/19/21; with medical diagnoses that included hypertensive heart disease with heart failure, stage IV pressure injury, diabetes type II, chronic obstructive pulmonary disease (COPD), acute respiratory failure, and ventricular tachycardia. Review of R25's significant change of status MDS with an ARD of 06/13/24 showed a BIMS score of 15 out of 15, indicative of being cognitively intact. Review of R25's Progress Notes tab, revealed on 04/10/24 at 8:03 AM, he was experiencing blood pooling from around his catheter with no urine output and was sent to the emergency room . On 04/19/24 at 3:33 PM a Progress Note revealed R25 was experiencing a change in mental status with respiratory distress and was again sent to the emergency room . In response to a request for evidence of provision of the written notices of transfers, the facility provided two untitled forms. The first, dated 04/10/24, addressed to R25's RR showed R25 was sent to the hospital for a change in medical status, but did not include the Ombudsman mailing address or how to appeal the transfer. Review of the second form, dated 04/19/24, addressed to R25's RR, showed R25 was sent to the hospital for a change in medical status, but did not include the Ombudsman mailing address or information to appeal the transfer if desired. During an interview on 07/02/24 at 11:17 AM regarding receipt of the two forms, R25 reviewed the forms and responded, No, not ever received anything like this. During a telephone interview, regarding receipt of written notices of transfers, on 07/02/24 at 1:33 PM, R25's Representative (RR25) stated, No, I never received anything in writing, they called. 3. Review of R101's Admission Record from the EMR Profile tab, showed a facility admitted [DATE], readmissions on 04/03/23 and 05/02/23; with medical diagnoses that included chronic kidney disease, emphysema, diabetes type II, pleural effusion, and heart failure. R101 was reviewed as a hospitalization closed record. Review of R101's EMR Census tab, showed a hospital leave status as of 04/11/24. Review of R101's EMR Progress Notes tab, showed on 04/11/24 at 6:06 PM, the resident experienced a low blood pressure and was sent to the emergency room . Further review of R101's Progress Notes tab, Evaluations tab, and Documents tab, did not show evidence of a written notice of transfer provision to the Resident or RR. In response to a request for evidence of the provision of a written notice of transfer, the facility provided an untitled form for R101, stating he was transferred for altered conditions, but did not include any information regarding Ombudsman contact or appeal rights. During an interview on 07/02/24 at 9:15 AM, the Assistant Director of Nursing (ADON) reviewed the regulation and confirmed the two different forms provided did not contain all the required information. As evidence of the notices being provided to the Resident and RR, the ADON printed out the full months of April and June (no print date of the report was found) and a check mark was placed next to the resident name which indicated the form was mailed out. During an interview on 07/02/24 at 5:12 PM, the Director of Nursing (DON) stated, I expect they would get it [written notice] the day they transfer. A request was made for an emergent transfer policy on 07/02/24 at 1:57 PM, but no policy was received.

Based on interviews, record review, and review of the facility's policy, the facility failed to ensure one of three residents (Resident (R) 254) reviewed for abuse were free from abuse of 23 sample residents. Specifically, R254 reported that she was afraid to push her call light due to two instances of intimidation and verbal abuse by Certified Nursing Assistant (CNA)1. This had the potential to affect resident safety at the facility. Findings include: Review of the facility's policy titled, Abuse and Neglect- Clinical Protocol, revised March 2018, indicated, 1. Abuse is defined . the willful inflection of . intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any, mental or condition, cause physical harm, pain and mental anguish. Record review R254's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of the R254's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/19/24 revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During a family interview on 06/30/24 at 1:52 PM, when asked had the resident ever been abused, made to feel afraid or humiliated/degraded, R254's Family Member (F) 254 stated a week ago, CNA1 came into the resident's room and told R254 to stop pressing the call bell and that the CNA1 had other residents who were dying and needed her care. The next day the resident reported to F254 that CNA1 told her We will not have a repeat of yesterday. F254 stated she then came to the facility to speak to CNA1. F254 stated she spoke to CNA1 about how she spoke to R254 and asked that CNA1 not provide care for R254. CNA1 has not provided care for R254 since then. F254 stated she reported it to Licensed Practical Nurse (LPN) 1. During an interview on 07/01/24 at 3:50 PM, R254 stated When I was first admitted to the facility the staff told me if I needed help to press the call bell so that's what I did. Then [CNA1] came in and told me to stop pressing the call bell so much and that I was playing with the call bell. I asked her how I would get care if I don't press my call bell and that I was not playing with it, I actually needed help. R254 then stated the next day CNA1 came into the room and told her We are not doing this today in regard to pressing the call bell. The resident stated that she asked CNA1 what she meant by that, and the CNA replied playing with the call bell. The resident stated to the CNA that she wasn't playing with the call bell and that she needed help. R254 stated that her granddaughter then came to the facility and asked CNA1 how would R254 get care if she did not press the call bell. When asked if she was scared to press the call bell, the resident responded, yes but it's not like they were going to come. Review of the facility's Grievance Log, provided by the facility during the entrance conference, revealed the log did not have any concerns logged by R254 and/or F254. During an interview on 06/30/24 at 2:39 PM, the Social Services Director (SSD) stated they did not have any staff to resident abuse concerns reported to them. During an interview on 06/30/24 at 2:45 PM, the Administrator and Assistant Director of Nursing (ADON) stated they had not received a complaint about staff to resident verbal abuse. During an interview on 06/30/24 at 6:58 PM, LPN1 stated she reported to the Assistant Director of Nursing (ADON) that CNA1 was rude to R254 (06/22/24), and the family asked for CNA1 to be removed from caring for R254. The LPN stated while she was doing medication pass, she heard loud yelling coming from R254's room (the yelling was between CNA1 and F254- 06/23/24). When she entered R254's room, LPN1 stated CNA1 was explaining to F254 that she was just loud and not being rude. LPN1 said F254 reported to her that CNA1 was rude and loud and wanted CNA1 removed from grandmother's care. LPN1 then stated, I reported this allegation of abuse to [ADON]. When asked what the facility's expectation for reporting abuse was, LPN1 stated she reported it to ADON via text message. LPN1 stated in regard to abuse we would report it to our supervisor, they would remove the staff member from the resident until the investigation was completed. The LPN1 stated she did not write a statement or document the incident with R254. LPN1 stated if she witnessed abuse she would remove the staff member from the care pending the investigation. When asked was CNA1 removed from care, LPN1 stated no she was just swapped out with another CNA to provide care to R254. During an interview on 06/30/24 at 7:54 PM, LPN1, the Director of Nursing (DON) and ADON revealed R254 called her family and stated that CNA1 was loud, so the facility took the concern as CNA1 being loud and not rude. The ADON did not ask exactly what CNA1 said to R254. The ADON stated I spoke to CNA1, and she said she wasn't rude, she was just loud. The family stated they did not want CNA1 working with their grandmother. We swapped CNA1 out and she had not worked with her again. On the day of the incident, LPN1 stated she was four doors down completing a medication pass when she heard the commotion in R254's room and went to see what was happening. When she entered, CNA1 was explaining to F254 that she was not being rude. LPN1 confirmed CNA1 was not removed from care but instead swapped to the care for other residents. Review of the Concern/Grievance Report, submitted 06/30/24 at 10:30 PM by the ADON, stated, Date initiated 06/23/24 . Subject- Last Wednesday CNA was removed from assignment due to resident thinking CNA was talking Loudly. Comments- CNA removed from assignment. Concerns Party Response- CNA Removed from assignment family stated they were okay with interventions. When asked were there any additional residents interviewed to ensure they did not feel as though CNA1 was rude to them, the ADON and Regional Nurse Responded no.

Based on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 6) had a gradual dose reduction (GDR) conducted according to the physician approved recommendation from the pharmacist in a timely manner of 23 sample residents. This had the potential for the resident to receive unnecessary antipsychotic medications. Findings include: Review of the facility policy titled Behavior Management, effective date 12/31/15, showed: .Provision for Psychotropic Medication Use .5. Dosage reduction or re-evaluations are provided according to CMS [Centers for Medicare and Medicaid Services] and OBRA [Omnibus Budget Reconciliation Act] regulatory guidance: -Anti-psychotropic medications: every 6 months of continuous use. Twice within the first year .6. The Consultant Pharmacist reviews the appropriateness of the psychotropic medication order as part of the monthly drug regimen, at a minimum . Review of the facility policy titled Physician Services, revised February 2021, showed: Policy Statement The medical care of each resident is supervised by a licensed physician. Policy Interpretation and Implementation .3. Supervising the medical care of the residents includes (but is not limited to) .d. prescribing medications and therapy .5. The attending physician will determine the relevance of any recommended interventions for other disciplines .6. Physician orders and progress notes are maintained in accordance with current OBRA regulations and facility policy. Review R6's undated Admission Record from the facility electronic medical record (EMR) Profile tab, showed a facility admitted [DATE] and readmission on 07/07/23 with medical diagnoses that included psychosis, Wernicke's encephalopathy, and dementia. Review of R6's EMR Orders tab, showed an order for the atypical antipsychotic medication Seroquel (generic name quetiapine) 25 milligrams (mg) at bedtime for agitation, ordered 06/29/24. Review of R6's monthly Pharmacist Medication Reviews showed on 04/08/24 a gradual dose recommendation was made for the Seroquel, then at 50 mg per day; the recommendation was signed for reduction to 25mg on 04/11/24. The Pharmacist made a recommendation on 06/11/24 that the GDR was ordered but the Medication Administration Record (MAR) did not show the reduction. During an interview on 07/02/24 at 2:33 PM, regarding the reason the GDR took over 60 days to be instituted, the Assistant Director of Nursing (ADON) responded, The doctor signed it but did not put the order in. When asked to clarify, the ADON stated, the doctors put their own orders in [EMR name]. When queried about what happened to the signed pharmacy recommendations, ADON stated they went to Medical Records to be scanned into the record. When asked if anyone reviewed the signed recommendations, the ADON stated someone would be from now on.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was in the building and available for resident care and needs for 4 days during a staffing review for the months of September and October 2022. Findings include: Record review on 10/24/22 at 3:00 PM of the daily staffing as posted from September through October, 2022 revealed no Registered Nurse in the facility on the following dates: 9/18/22, 10/10/22, 10/16/22, and 10/18/22. An interview with the Director of Nursing (DON) on 10/24/22 at 3:30 PM confirmed that the facility was without RN coverage on 9/18/22, 10/10/22, 10/16/22, and 10/18/22. There was no staffing policy provided at the time of the survey.