Every finding on record at Autumn Lake Healthcare at Glen Hill

Based on observations of kitchen, facility policy and interview, the facility failed to ensure food was served in safe and sanitary conditions. The findings include: An observation of the noon meal plating service in the kitchen on 6/6/25 at 11:40AM identified an open industrial garbage can with trash filled to the top; opened with no lid to cover the garbage can while food was being plated from the steam table. The garbage can was to the right of the steam table and 15 feet (ft.) away. The garbage can was opened by steam table for a half hour of the serving time of food from the steam table until 12:10PM. An interview with the Dietary Manager on 6/6/25 at 12:00PM identified the garbage can should have been covered and not in proximity to the steam table while food was being plated. The Dietary Manager further indicated that all kitchen staff is responsibility for ensuring garbage cans are removed and covered during meal service. After surveyor inquiry, the Dietary Manger had a dietary aide cover and move the garbage can from the serving area. A review of the Environment Policy directed, in part, all food preparation and food service areas will be maintained in safe and sanitary conditions. All trash containers will be covered in leak proof containers to prevent cross contamination.

Based on clinical record review, observation, facility policy and interviews for the only sampled resident (Resident #46) reviewed for Respiratory care, the facility failed to ensure oxygen physician's order were current. The findings include: Resident #46's diagnoses included acute respiratory failure with hypoxia, pneumonia, unspecified organism and insomnia, unspecified. The admission Minimum Data Set assessment dated [DATE] identified Resident #46 was cognitively intact and independent for eating, touching assistance for oral hygiene and personal hygiene. Review of Resident #46 care plan did not include interventions for respiratory care. The Resident care plan did not identify any behaviors of refusal of care. A physician's order dated 5/16/25 directed, Oxygen at 1 Liter per minute via Nasal Cannula continuously. The nurse's note from 5/28/25 through 6/5/25 did not indicate any refusal of treatment. Observation on 6/03/25 at 11:31 AM of Resident # 46 being assisted back to his/her room identified no oxygen attached. Additional observation of the oxygen machine in residents' rooms identified no oxygen in use. Interview with Resident#46 indicated she has not received oxygen today. Person #1 indicated he/she was not sure why Resident #46 has oxygen in the room. Observation on 6/04/ 25 at 10:31AM of Resident #46 in the room with no oxygen on. Resident #46 identified although the oxygen machine is in the room she has not been on it for some time. Interview with LPN #1 on 6/4/25 at 10:33 AM indicated the resident was titrated off his/her oxygen last week and she/he is unsure why the physician's orders have not been updated. LPN #1 further indicated the nursing staff is responsible for ensuring physician's orders are accurate and given as ordered. The interview with DNS on 6/5/25 at 11:22 AM indicated if there are changes to resident's physicians ordered the expectation is that physician's orders are updated right away to reflect changes. The DNS could not explain why Resident #46 was not receiving oxygen as ordered or why the physician's orders were not updated to reflect current orders. After inquiry, a physician's order dated 6/4/25 directed Oxygen at 0-2 Liter per minute via Nasal Cannula as needed for oxygen saturation of less than 90.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #48) reviewed for foley catheters, the facility failed to ensure the foley catheter drainage bag was not touching the floor when in wheelchair. The findings included: Resident #48's diagnoses included congenital stricture of urethra, obstructive and reflex uropathy and urinary retention. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #48 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident required moderate assistance for personal hygiene, dressing, transfers, utilizing a wheelchair for mobility and had an indwelling suprapubic urinary catheter (empties urine directly from the bladder from an opening in the abdomen). The Resident Care Plan dated 3/7/25 identified suprapubic catheter related to urinary retention as an area of concern. Interventions included: to change catheter per urology orders, check tubing for kinks every shift, position tubing and bag below the level of the bladder and away from entrance room door and change the indwelling catheter if exhibiting urinary drainage obstruction, signs and symptoms of infection and when the closed system is compromised. A physician's order dated 5/21/25 directed to change suprapubic tube monthly and as needed if occluded or leakage, empty suprapubic bag at least once a shift and enhance barrier precaution related to suprapubic catheter. Observations on 6/3/25 at 1:00PM identified the foley catheter drainage bag attached to the back of Resident #48's wheelchair (w/c) and was dragging on the floor when his/her wheelchair was being pushed from bedroom into the lounging area on the unit. On 6/4/25 at 10:05AM and 2:00PM, and 6/5/25 at 12:00PM, Resident #48's foley catheter drainage bag was attached to the back of his/her wheelchair. The foley drainage bag was not suspended and was touching the floor. Interview with RN #4, the Infection Control Preventionist on 6/6/25 at 10:56AM identified foley catheter drainage bags should be covered and not dragging or touching the floor. RN #4 was unsure if the policy on urinary catheters addresses foley catheter drainage bags touching the floor but indicated it was an infection control standard of practice. Furthermore, RN #4 indicated whoever provides care to a resident with a urinary catheter drainage bag is responsible for ensuring the drainage bag is not touching or dragging on the floor and the nurse should be periodically checking throughout the shift. RN #4 indicated after this concern was brought to her attention, she observed Resident #48's foley drainage bag touching the floor when he/she was in the wheelchair. After the surveyor inquiry, RN #4 made a referral to therapy regarding Resident #48's wheelchair. Therapy applied zip ties to back of wheelchair to ensure drainage bag is off the floor and RN #4 replaced the drainage bag with one that was short in length. In addition, RN #4 updated Resident #48's care plan with the above interventions. The facility Catheter Care, Urinary policy, directed, in part, maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on clinical record review, review of policy and staff interviews for 1 of 2 residents (Resident # 13) reviewed for ADL, the facility failed to ensure a resident received incontinence care promptly. The findings include: Resident #13 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease and heart disease. The admission MDS assessment dated [DATE] identified Resident #13 was cognitively intact, required partial/moderate assistance for toileting hygiene, and was frequently incontinent of the bladder. On 6/3/2025 at 1:49 PM, an interview with Resident #13 identified two weeks prior, the resident had to wait about 2 hours to get changed after an incontinence episode. Resident #13 indicated that although there were two male aides available, the resident preferred a female to help him/her with incontinence care. Resident #13 indicated she/he spoke to a female nurse and a female supervisor but was told to wait for the female aide to become available. On 6/4/2025 at 2:33 PM, an interview with NA #2 identified Resident #13 preferred females to provide toileting care. NA #2 indicated that if the resident were assigned a male aide, then an adjustment in the assignment would be made to accommodate the resident's preferences. On 6/5/2025 at 10:57 AM, an interview with NA# 3 identified on 5/23/2025, in the evening shift, he was assigned to take care of Resident #13. NA#13 indicated he answered the resident's call bell, and the resident requested to be changed. NA #3 indicated he offered to help Resident #13 get cleaned, but Resident #13 indicated she/he preferred a female for help with toileting. NA #13 indicated that he told Resident #13 that she/he would have to wait for the female aide on the floor (NA #4) to be free since she had to finish her assignment first and then notified LPN #1. NA #3 further indicated Resident #13 was eventually provided incontinence care by NA #4 about 1 hour or 1 hour and 15 minutes after the resident initially rang for help. On 6/5/2025 at 11:30 AM, an interview with LPN #1 identified on 5/23/2025, there were two male aides and one female aide working on the unit, and she indicated that she notified the nursing supervisor (RN #2) that the floor had several female residents that preferred a female aide and having two male aides would make the assignments challenging. LPN #1 indicated that she did not have an opportunity to offer toileting to Resident #13 because she was busy administering medications, helping another resident who was falling from their chair, answering phone calls, and speaking to providers. LPN #2 indicated that she informed Resident #13 that a female aide would be provided to help with their toileting care. LPN #2 also indicated there was another female nurse on the floor and that nurse was busy with her assignment and could not offer help. LPN #1 further indicated that NA #4 eventually provided incontinence care to Resident #13, and assignments were changed so that NA #4 would be Resident #13's NA for the rest of the shift. LPN #1 indicated Resident # 13 waited about an hour for care. An attempt to interview NA #4 and RN #2 was unsuccessful. On 6/5/2025 at 12:52 PM, an interview with the DNS indicated she was not aware Resident #13 had to wait an hour for care on 5/23/2025 and further indicated LPN #1 was hands-on and helped the NAs with resident care. The DNS indicated that she was aware Resident #13 preferred a female for toileting and has care planned the preference in the resident's medical record. A care plan revised on 5/29/2025 indicated that Resident #13 had functional performance limitations related to recent hospitalization and illness. Interventions included providing one-person physical assistance for personal hygiene and no male caregivers.

Based on observations, review of clinical records, facility policy and interviews for 2 of 2 residents reviewed for dignity (Resident # 41 and Resident # 71). The facility failed to ensure the residents were served lunch at the same time. The findings include: 1. Resident # 71 diagnoses included Alzheimer's disease, dysphagia and type 2 diabetes mellitus. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 as severally cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 and was independent with eating. The Resident Care Plan (RCP) dated 4/10/25 identified potential nutritional risk as an area of concern. Interventions included: to provide a ground diet as ordered, encourage fluids, honor food preferences for meals, monitor intake of all meals and offer alternatives as needed, and report any declines and inability to self-feed. The physician's orders dated 6/1/25 directed to provide regular diet with ground texture, allow ice cream, soft breads, cakes, cookies and soft salad sandwiches upon requests, extra sauce, eat in view of staff. Allow regular food when brought in from home by family with supervision. Provided house supplement with breakfast, lunch and supper. Observations on 6/4/25 Resident #71 was sitting in the lounge area on Nature Way at 11:30AM waiting for lunch to be served. Resident #24 who usually eats in the main dining room was eating in the lounge area. Resident #24 received his/her tray at 11:45AM. Resident #71 along with Resident #41 sat at the dining table watching Resident #24 eat his/her meal. Resident # 71's meal was bought at 1:05PM (1 hour and 50 minutes after Resident #24). 2. Resident #41's diagnoses included dementia, dysphagia and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #41 as moderately cognitively impaired with a Brief Interview for Mental Status score of 9 and was independent with eating. The Resident Care Plan dated 4/30/25 identified nutritional risk as an area of concern. Interventions included supplements as ordered, fortified pudding with lunch and dinner, provide proper consistency of diet solids as ordered by speech therapy-may give pureed fruits, honor food preferences with no fish and eggs and offer alternative food choices as needed. The physician's orders dated 6/1/25 directed to provide ground texture with regular consistency, provide pureed fruit, no fish, no eggs, no carrots, no rice, no watermelon, allow bananas and regular snacks with no nuts or hard candy. Provide potatoes with gravy, provide cup of gravy with sauce on the side, reserve drinks for the end of the meal and magic cup with all three meals. Administer Lantus Solostar insulin 10 units subcutaneously (under the skin) once a day, Metformin 500 milligrams (mg) 2 tabs twice a day and blood sugar monitoring once a day in the morning. Observations on 6/4/25 Resident #41 was sitting in the lounge area on Nature Way at 12:00AM waiting for lunch to be served. Resident #24 who usually eats in the main dining room was eating in the lounge area. Resident #24 received his/her tray at 11:45AM. Resident #41 along with Resident #71 sat at the dining table watching Resident #24 eat his/her meal. Resident # 41 made a comment to Resident #24 stating I am going to eat your watermelon while you're gone. Resident # 41's meal was brought at 1:05PM (1 hour and 5 minutes after (Resident #24). Interview with the DNS on 6/4/25 at 2:00PM indicated that residents at the same table should be served their meal at the same time. The DNS indicated that the NA or nurse should have obtained the meals for the two residents in order for all three residents to have their meal at the same time. Interview with Nurse Aide ( NA #6) on 6/5/25 at 10:30AM indicated Resident #24 recently returned from the hospital and he/she normally eats in the main dining area but had been eating on the unit since his/her return. NA #6 stated that kitchen staff brought Resident #24's tray at 11:30 to the unit as this is the time the main dining room serves lunch. NA #6 indicated that all residents at a table should be served their meal at the same time and it was not normal practice for residents to watch others eat for that length of time. NA #6 stated she should have obtained Resident #71 and #41 a snack or went and got their trays. NA #6 indicated she let the kitchen staff know at 1:00PM that Residents #71 and #41 still did not have lunch at 1:00PM. NA #6 was informed that the trays were being brought to the unit and the trays arrived at 1:05PM. Review of Resident Rights policy directed, in part that all residents have the right to be treated with dignity and respect and to have a safe and homelike environment. Although requested, a facility policy on dining was not provided.

Based on review of the clinical record, facility documentation, interviews and facility policy for 1 of 3 residents (Resident #25) reviewed for abuse, the facility failed to conduct a thorough investigation regarding an allegation of injury of unknown origin. The findings include: Resident #25's diagnoses included dementia, involuntary movements and age-related osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 as severely cognitively impaired and unable to participate in Brief Interview for Mental Status (BIMS) and noted totally dependent on staff for personal hygiene, transfers, toileting and bed mobility. The Resident Care Plan dated 1/25/24 identified Resident #25 as being dependent for activities of daily living as an area on concerns. Interventions included: to provide assist of 2 staff members for bed mobility, ¼ siderails to assist with bed mobility and positioning, provide cueing for safety and sequencing to maximize current level of functioning and monitor for fatigue and adjust ADL tasks accordingly. The physician's orders dated 2/1/25 directed to administer valium (muscle relaxer) 2 Milligrams(MG) two times a day via feeding tube for jerky movements, [NAME] Calcium 500 mg one tab once a day via feeding tube for fractures, Cholacalferol 1000 unit tab once a day via feeding tube for fractures, padded ¼ siderails used for positioning and enabler for turning, and splint to left arm every shift, remove daily when providing care. A Reportable Event submitted to the state agency indicated Resident #25 sustained an injury of unknown origin to his/her left thumb. At 7:00AM on 3/29/24 Resident #25 was noted with a slightly swollen red left thumb. The physician and responsible party were notified, and an order was obtained for an x-ray to Resident #25's left thumb at the facility. The x-ray to left thumb was completed at the facility at 9:20AM on 3/29/25 which revealed 1st left proximal phalanx fracture with mild displacement with soft tissue swelling. Resident #25 remained at the facility per responsible party request with stabilization utilizing a left thumb splint. The Director of Nursing Services (DNS) initiated an investigation on 3/29/25 to determine the possible cause of the fracture left thumb and rule out abuse. The statements obtained from nurse aides and licensed staff failed to identify the 2 nurse aides that provided care to Resident #25 on 3/28/25 on the 7-3 PM, 3-11 PM, and 11-7 AM shift. In addition, the statement obtained from Nurse Aide (NA #8) who provided care to Resident #25 on the 7-3 PM shift on 3/26/25 and 3/27/25 failed to identify who the 2nd staff member that helped with Resident #25's care. All the statements lacked any information regarding how care was provided to Resident #25 or if there was any unusual occurrence during care. A phone interview with Registered (RN #6) on 6/9/25 at 9:59AM identified she was the RN in the facility on 3/28/24 on the 3-11 PM shift. RN #6 indicated that she did not notice any injury to Resident #25's left thumb that evening. Additionally, RN #6 could not recall who provided care to Resident #25 on 3-11 PM shift on 3/28/25 or if 2 staff members helped Resident #25 per plan of care. RN #6 stated that she wrote a statement for the DNS but no one from the facility spoke to her directly regarding the investigation or requested any clarifications regarding her written statement. An interview and review of the investigation with the DNS on 6/5/25 at 10:30AM identified she was unable to identify who provided care for the resident on 3/28/24. The DNS stated that she was responsible for conducting the investigation and ensuring the investigation was complete. Furthermore, the DNS stated that the investigation for abuse/injury of unknown origin was incomplete, and she was new at the time and just learning. The DNS stated that the investigation was lacking on the cause of injury. A review of Resident Care flowsheets on 6/5/25 identified that NA #9 provided care for Resident #25 on the 3-11 PM shift on 3/28/24 and NA #10 provided care for Resident #25 on the 11-7 AM shift. An attempt to contact NA #10 who is no longer an employee of the facility, on 6/6/25 at 10:30AM, was unsuccessful. An interview with NA # 9 on 6/6/25 at 2:00PM identified she worked on 3/28/24 on the 3-11 PM shift and worked on a split assignment but she could not recall if she provided care for Resident #25 that evening. A second interview with the DNS on 6/9/25 at 11:55AM identified she concluded that 2 people did not help Resident #25 on 3/28/25 because she had witnessed NA #8 providing care to Resident #25 alone on 3/29/24 in the morning. The DNS indicated that verbal and written education was immediately initiated on 3/29/24 with the nurse aides to ensure Resident #25 is in proper body alignment and the plan of care is followed for 2-person assistance. An interview with Advanced Practice Registered Nurse (APRN #1) on 6/9/25 at 12:15PM indicated Resident #25 fractured thumb was most likely pathological in nature. APRN #1 also indicated Resident #25 has jerky movements of his/her extremities which may have contributed to the injury to his/her thumb. A review of Resident #25's clinical record on 6/9/25 identified that APRN #1 had given Resident #25 a diagnosis of age-related osteoporosis with current pathological fracture on 4/2/24. An interview with the Medical Director on 6/11/25 at 9:00AM identified the diagnosis of pathological fracture for Resident #25 was incorrect and he would need to speak to APRN #1 regarding incorrect diagnosis. He stated that Resident #25 had an osteopenia fracture which can result from minor trauma. He indicated Resident #25 had previous fractures related to mild trauma due to osteopenia. In addition, Resident #25 has diagnosis of involuntary movements. A re-read of Resident #25's x-ray on 6/13/25 was conducted by a second radiologist from the same vendor. The x-ray results for Resident #25's left thumb revealed there was a fracture of the proximal phalanx, as reported. Diffuse bone demineralization is noted. There is no evidence that this is a pathological fracture. A review of the facility Abuse policy, directed, in part, notes the facility is to provide protection for the health, welfare and rights of all residents with written policies and procedures that prohibit and prevent abuse. A possible indicator of abuse is physical injury of a resident of an unknown source. An immediate investigation is warranted when there is suspicion of abuse. Identifying and interviewing all involved people, including alleged victims, alleged perpetrators, witnesses and others who might have knowledge, focusing on determining if abuse has occurred. Providing complete and thorough documentation of the investigation.

Based on review of the clinical record reviews, facility policy and interviews for 1 of 3 residents (Resident #25) reviewed for abuse, the facility failed to ensure the plan of care for assistance of 2 staff members for all care provided was followed and for the only sampled resident ( Resident #46), the facility failed to develop a comprehensive plan of care to address the residents respiratory and sensory needs. The findings included: 1.Resident #25's diagnoses included dementia, involuntary movements and age-related osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 as severely cognitively impaired and unable to participate in Brief Interview for Mental Status (BIMS) and was totally dependent on staff for personal hygiene, transfers, toileting and bed mobility. The Resident Care Plan dated 1/25/24 identified Resident #25 as being dependent for activities of daily living as an area on concerns. Interventions included: to provide assist of 2 staff members for bed mobility, ¼ siderails to assist with bed mobility and positioning, provide cueing for safety and sequencing to maximize current level of functioning and monitor for fatigue and adjust ADL tasks accordingly. The physician's orders dated 2/1/25 directed to administer valium (muscle relaxer) 2 milligrams (mg) two times a day via feeding tube for jerky movements, [NAME] Calcium 500 mg one tab once a day via feeding tube for fractures, Cholacalferol 1000 unit tab once a day via feeding tube for fractures, padded ¼ siderails used for positioning and enabler for turning, and splint to left arm every shift, remove for daily when providing care. A review of Resident #25's care card on 6/9/25 (directs NA to provide care) revealed Resident #25 required assistance of 2 staff for bed mobility. An interview with the DNS on 6/9/25 at 11:55AM identified she was investigating injury of unknown origin of a fractured left thumb to Resident #25 left hand. DNS indicated she was in the initial stages of her investigation. She proceeded to observe and assess Resident # 25's left thumb in the AM on 3/29/25. The DNS stated upon entering the room she witnessed NA #8 providing care to Resident #25 in bed without the assistance of another staff member per individualized plan of care. She further indicated based on this observation Resident #25 may have sustained the injury to his/her thumb prior because assistance of 2 staff members may not have been providing care. The DNS indicated that education was immediately initiated with NA #8 and the rest of NA staff regarding assistance of 2 staff members for care for Resident #25. An interview with NA #8 on 6/9/25 at 2:00PM identified NA #8 was providing care to Resident #25 in bed without the assistance of another staff member on 3/29/24. NA #8 indicated that she was the primary NA for Resident #25 during the day. She was aware that Resident #25 required the assistance of 2 staff members for care. She also stated that she thought she would be able to provide care to Resident #25 alone but realizes now that she should have obtained assistance by the plan of care plan. NA #8 indicated she was made aware in the AM of 3/29/25t Resident #25 had an injury to his/her thumb but still proceeded to provide care without assistance. NA #8 stated that the DNS observed her providing care on 3/29/25 to Resident #25 alone and she was immediately educated that Resident #25 required assistance of 2 staff members. NA #8 stated that assistance of 2 staff members was present on Resident #25's care card. A review of the Care Plan policy directed, in part, a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial needs is developed and maintained for each resident. The residents receive the services and/or items in the care plan to maintain the residents' well-being. Although a policy was requested related to resident care cards, the facility was unable to provide a policy. 2. Resident #46's diagnoses included acute respiratory failure with hypoxia, pneumonia, unspecified organism and insomnia, unspecified. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was cognitively intact and independent for eating, touching assistance for oral hygiene and personal hygiene. a. Review of Resident #46 care plan did not include interventions to address the residents' respiratory care. The Resident care plan failed to identify any behaviors of refusal of care. An interview with the DNS and RN #1 on 6/5/25 at 11:22 AM indicated residents who are on oxygen should have a care plan. The DNS reported that all nursing staff are responsible for ensuring there is a care plan. RN#1 identified this was an oversight that the resident had no interventions for respiratory care. The facility policy labeled Care Plans Comprehensive Person-Centered, not dated, indicated in part; care plan interventions are chosen only after data gathering, proper sequencing of events and consideration of the relationship between the resident's problem areas and their causes. The policy further indicated that the care plan is ongoing and revised as information about the residents and their condition changes. b. Observation on 6/03/25 at 11:31 AM identified Resident #46 with hearing aids. Review of Resident #46 care plan failed to identify interventions for hearing aids. Interview with the DNS and RN #1 on 6/5/25 at 11:22 AM indicated the facility is responsible for the care/ maintenance of the hearing aid therefore a care plan would be implemented. DNS reported that the admission assessment did include the residents who have hearing aids. Interview with Resident #46 on 6/5/25 at 11:38AM indicated he/she had his/her hearing aid since arriving to the facility. Interview with LPN #3 on 6/6/25 10:33 AM indicated information for the MDS is collected through discharge paperwork from the hospital and/or admission assessment. LPN#3 reported I don't usually go up to talk with residents, however, I double checks notes. LPN #3 further indicated she/he believed the notes will help her get information that might be missing from admission assessment. The facility policy labeled Care Plans Comprehensive Person-Centered, not dated, indicated in part; care plan interventions are chosen only after data gathering, proper sequencing of events and consideration of the relationship between the resident's problem areas and their causes. The policy further indicated that the care plan is ongoing and revised as information about the residents and their condition changes.

Based on review of the clinical record interview and facility policy and interviews for the only residents (Resident # 50) reviewed for bladder and bowel incontinence, the facility failed to ensure staff revised the care plan to reflect the current resident status. The findings include: Resident #50's diagnosis included overactive bladder, urge incontinence and Congestive Heart Failure (CHF). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated in part Resident #50 was cognitively intact and required substantial assistance with toileting, used a wheelchair and had a functional limitation with range of motion of one lower extremity. The MDS further indicated Resident #50 was frequently incontinent of urine and always incontinent of bowel, no trial of a toileting program (scheduled toileting, prompted voiding or bladder training and no toileting program was being used to manage the bowel incontinence. The care plan initiated 4/3/2024 indicated Resident #50 was incontinent of bowel and bladder and was unable to cognitively or physically participate in a retraining program due to impaired mobility. Interventions included to assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for signs of infection and skin redness and use multi-void disposable briefs. On 4/22/2025 an additional intervention was added to the care plan to check and change Resident #50 and to provide care as needed. A physician order dated 5/22/2024 directed to provide MiraLAX Powder 17 grams mixed in 4-8 ounces of fluid if no bowel movement in the past 72 hours. A physician order dated 7/23/2024 directed to provide Lasix (a diuretic) 60 mg tablet once daily for CHF. A Urology visit note dated 9/10/2024 indicated Resident #50 had a history of bladder cancer and advised timed toileting, limiting nighttime fluids and avoiding other irritants. The quarterly Bowel & Bladder Program Screener dated 10/1/2024 was completed indicating Resident #50 was a Good Candidate for retraining. A physician order dated 12/2/2024 directed to provide MiraLAX Powder 17 grams by mouth for constipation and to hold for loose stools. The quarterly Bowel and Bladder Screener dated 1/1/2025 was completed and indicated Resident #50 was a good candidate for Schedule toileting (timed voiding). The quarterly Bowel and Bladder Screener dated 3/14/202 indicated Resident #50 was a Candidate for Schedule toileting (timed voiding). The urology visit note dated 3/25/2025 directed Resident # 50 to start Myrbetriq extended-release tablet (24 hour) one 50 mg tablet once daily for overactive bladder. The urologist also advised timed toileting, limiting nighttime fluids, avoiding caffeine and other irritants and warned the diuretic would likely exacerbate the frequency of urination and incontinence. Resident #50 started the Myrbetriq per physician's order on 3/27/2025. The quarterly MDS assessment dated [DATE] indicated Resident #50 was cognitively intact and always incontinent of bowel and bladder, required substantial assistance with toileting, dependent for transfer, used a wheelchair and had a functional limitation of range of motion of one lower extremity. The MDS further indicated Resident #50, had no trial of a toileting program (scheduled toileting, prompted voiding or bladder training) and no toileting program was being used to manage the bowel incontinence. The quarterly Bowel and Bladder Screener dated 5/14/202 indicated Resident #50 was a Candidate for Scheduled toileting (timed voiding). On 6/9/2025 at 12:22 PM an interview and record review with the Director of Nursing Services (DNS) indicated Resident #50 had always been cognitively intact although the care plan initiated on 4/03/2024 indicated Resident #50 was unable to cognitively participate in a retraining program due to impaired mobility. The DNS further indicated Resident # 50 had bowel and bladder incontinence, Bowel and Bladder Incontinent Screens had all indicated Resident #50 was a candidate for retraining, the Urologist advised timed toileting on 2 consults and indicated she/he would have expected nursing staff to have informed the team of the results of the Bladder and Bowel Screens so Resident #50 could have trialed a toileting program using the bed pan and Resident #50 interviewed regarding his/her wishes and the care plan updated. The facility policy labeled Care Plans Comprehensive Person-Centered, not dated, indicated in part care plan interventions are chosen only after data gathering, proper sequencing of events and consideration of the relationship between the resident's problem areas and their causes. The policy further indicated the care plan is ongoing and revised as information about the residents and their condition changes as well as with significant change in condition, the desired outcome is not met, when readmitted to the facility from a hospital stay and at least quarterly in conjunction with the MDS.

Based clinical record review, observations, review of the clinical record and interviews for 1 of 6 residents (Resident #42) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall. The findings include: Resident #42's diagnoses included Parkinson's Disease, Cerebral Infarction (stroke) with Hemiplegia (paralysis on one side) and Hemiparesis (weakness on one side) affecting right dominant side, and vascular dementia. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 was severely cognitively impaired and required maximal assistance (helper does more than half the effort) with toileting hygiene, personal hygiene, and toilet transfers. The Resident Care Plan (RCP) dated 6/11/24 identified falls as an area of concern. Interventions included: to provide education to Resident #42's family on fall prevention and to not to leave the resident alone. The RCP was updated on 6/1/25 with a new intervention that aimed at gathering all items needed prior to providing care and to not leave resident alone in the bathroom. A nurse's note dated 6/1/25 at 9:45 AM identified Resident #42 was observed laying on the bathroom floor. Resident #42 was sitting on the toilet when NA #8 stepped away to get a new brief. Resident #42 stood up without assistance and fell forward. Resident #42 bumped his/her head on the doorframe and sustained an abrasion and large bump to the forehead and an abrasion to the left knee. Observations on 6/4/25 at 10:50 AM, identified Resident #42 sitting at a table in the main dining room with a bruise on the forehead. Interview with Nurse Aide (NA #8) on 6/9/25 at 1:33 PM identified she brought Resident #42 to the toilet on the morning of 6/1/25 and left him/her on the toilet alone while she left the room to retrieve an incontinent brief from the supplies cart in the hallway. When NA #8 returned to Resident #42's bathroom the resident was noted on the floor. Interview with the Director of Nursing (DNS) on 6/9/25 at 1:43 PM identified Resident #42 should not have been left alone in the bathroom. NA #8 should have gathered all the necessary supplies with her in the bathroom or should have placed Resident #42 in a wheelchair and wheeled the resident with her to the supplies cart to get a new brief. Review of the Falls and Fall Risk, Managing Policy directed, in part that staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try and minimize complications from falling.

Based on review of the clinical record interview and facility policy and interviews for the only residents (Resident # 50) reviewed for bladder and bowel incontinence, the facility failed to ensure attempts were made to restore the residents bladder. The findings include: Resident #50's diagnosis included overactive bladder, urge incontinence and Congestive Heart Failure (CHF). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated in part Resident #50 was cognitively intact and required substantial assistance with toileting, used a wheelchair and had a functional limitation with range of motion of one lower extremity. The MDS further indicated Resident #50 was frequently incontinent of urine and always incontinent of bowel, no trial of a toileting program (scheduled toileting, prompted voiding or bladder training and no toileting program was being used to manage the bowel incontinence. The care plan initiated 4/3/2024 indicated Resident #50 was incontinent of bowel and bladder and was unable to cognitively or physically participate in a retraining program due to impaired mobility. Interventions included to assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for signs of infection and skin redness and use multi-void disposable briefs. On 4/22/2025 an additional intervention was added to the care plan to check and change Resident #50 and to provide care as needed. A physician order dated 5/22/2024 directed to provide MiraLAX Powder 17 grams mixed in 4-8 ounces of fluid if no bowel movement in the past 72 hours. A physician order dated 7/23/2024 directed to provide Lasix (a diuretic) 60 mg tablet once daily for CHF. A Urology visit note dated 9/10/2024 indicated Resident #50 had a history of bladder cancer and advised timed toileting, limiting nighttime fluids and avoiding other irritants. The quarterly Bowel & Bladder Program Screener dated 10/1/2024 was completed indicating Resident #50 was a Good Candidate for retraining. A physician order dated 12/2/2024 directed to provide MiraLAX Powder 17 grams by mouth for constipation and to hold for loose stools. The quarterly Bowel and Bladder Screener dated 1/1/2025 was completed and indicated Resident #50 was a good candidate for Schedule toileting (timed voiding). The quarterly Bowel and Bladder Screener dated 3/14/202 indicated Resident #50 was a Candidate for Schedule toileting (timed voiding). The urology visit note dated 3/25/2025 directed Resident # 50 to start Myrbetriq extended-release tablet (24 hour) one 50 mg tablet once daily for overactive bladder. The urologist also advised timed toileting, limiting nighttime fluids, avoiding caffeine and other irritants and warned the diuretic would likely exacerbate the frequency of urination and incontinence. Resident #50 started the Myrbetriq per physician's order on 3/27/2025. The quarterly MDS assessment dated [DATE] indicated Resident #50 was cognitively intact and always incontinent of bowel and bladder, required substantial assistance with toileting, dependent for transfer, used a wheelchair and had a functional limitation of range of motion of one lower extremity. The MDS further indicated Resident #50, had no trial of a toileting program (scheduled toileting, prompted voiding or bladder training) and no toileting program was being used to manage the bowel incontinence. The quarterly Bowel and Bladder Screener dated 5/14/202 indicated Resident #50 was a Candidate for Scheduled toileting (timed voiding). On 6/9/2025 at 12:22 PM an interview and record review with the Director of Nursing Services (DNS) indicated Resident # 50 had bowel and bladder incontinence, Bowel and Bladder Incontinent Screens had all indicated Resident #50 was a candidate for retraining, the Urologist advised timed toileting on 2 consults and indicated she/he would have expected nursing staff to have informed the team of the results of the Bladder and Bowel Screens so Resident #50 could have trialed a toileting program using the bed pan. The facility policy labeled Bowel and Bladder Policy indicated in part, a bowel and bladder assessment should be completed admission, readmission, quarterly and with any change in condition that may affect bowel and bladder continence. Assessment of a resident's appropriateness to participate in bowel and bladder continence maintenance include nursing staff therapy and physician services, the resident must possess the ability to comprehend educational efforts and follow through to identify the urge to void.

Based on observation, review of facility policy and interviews, the facility failed to ensure Grievance forms were readily available to residents, family members and visitors and the location of the forms. The facility failed to ensure the residents were made aware of the process for filing a grievance. The findings include: On 6/05/2025 at 9:58 AM a meeting with 12 residents who regularly attend the resident council meetings all agreed they were unaware of the grievance process and where the forms were located. An interview and observation on 6/05/25 at 10:38 AM with charge nurse RN #3 indicated the unit does not have any grievance forms. An observation and interview on 6/05/25 at 11:00 AM with Social Worker #1 while walking through the facility, identified no grievance forms located on the units only an empty folder in a file drawer. A policy regarding grievances and complaints was posted high above the State Ombudsman contact form and difficult for those in a wheelchair to see and read. The policy did not provide directions of how to obtain a form or who to contact. SW#1 indicated the policy would be lowered for ease of readability. SW#1 indicated she/he reviewed how to file a grievance with the residents but was unable to provide evidence of such. On 6/09/25 at 1:18 PM SW #1 indicated the posting on the bulletin boards were added and lowered for ease of access and grievance forms were placed in the lobby on a tabletop form holder for all to access if needed. A facility policy labeled Resident and Family Grievances with no date, indicated in part it was the policy of the facility to support each resident's and family's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.

Based on review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to maintain comprehensive antibiotic stewardship logs for antibiotics prescribed in the facility. The findings include: Review of the facility documentation for antibiotic stewardship on 5/22/23 at 12:33 PM with the Infection Preventionist (RN #1), identified the Infection Control Monthly Line Listing dated [DATE] - May 2023 did not include the stop date for the antibiotics prescribed, a time out to determine the effectiveness of the antibiotic during the midpoint of the prescribed drug, clear documentation of the resolution of the initial problem identified, or if subsequent medication and or treatment was ordered to fully resolve the initial identified concern. The facility policy for antibiotic stewardship identified to monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions.

Based on review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to maintain water treatment protocols to prevent the growth of opportunistic water pathogens. The findings include: Review of the facility documentation for antibiotic stewardship on 5/22/23 at 12:33 PM identified the water treatment protocols were delegated to the Maintenance Director. Interview and facility record review with the Maintenance Director on 5/23/23 at 2:15 PM indicated the water was tested [DATE] for Legionella, however the monthly safety meeting minutes from 1/2023 - 4/2023 identified only the amount of facility drinking water on hand and a commitment from a supplier to provide more drinking water on demand as needed. The facility's safety meeting minutes failed to identify an assessment of the building's water system, measures to prevent the growth of opportunistic waterborne pathogens such as visible inspections, disinfectant use, temperature controls, or in house testing. He also identified he was new to the position and unaware of water surveillance requirements. The facility policy for water management identified to conduct routine, regular maintenance of water systems.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to maintain a home-like environment in the resident's dining room. The findings include: Observations on 5/21/23 at 7:00 AM identified the following in the resident's dining room: a multi-iPad charging station, 2 medication carts, and a resident weight scale. Interview with the DNS on 5/22/23 at 2:20 PM noted it is her expectation that the dining area is home like for the residents and the items should not be stored there. Although requested, a facility policy was not provided.

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and failed to ensure cold food items were stored at appropriate temperatures, and failed to ensure dietary staff used hair nets and beard guards while in the kitchen, and failed to ensure food items were handled and distributed in a safe and sanitary manner, and failed to ensure kitchen preparation equipment was clean, and failed to ensure ice machines were maintained and in good working order, and failed to ensure food items in resident nourishment refrigerators were labeled and dated. The findings include: 1. During an initial tour of the facility kitchen on 5/21/23 at 7:20AM with Dietary Cook #1, the following was identified. a. Dietary Cook #1 was observed without a beard guard to cover his facial hair prior to the start of the kitchen tour. Dietary Cook #1 was observed to have a beard guard on, however positioned below the level of his face and [NAME] and positioned at the level of his mid neck. Subsequent to surveyor inquiry, Dietary Cook #1 repositioned the beard guard on his face to cover his facial hair. b. The kitchen was observed to have multiple areas of debris, darkened areas of what appeared to be dried fluids throughout all the kitchen floors. Approximately 5 food trucks used to transport residents' trays in the facility were observed placed in dirty dishwashing area with unused unopened packets of various sweeteners which included individual sugar and sweetener packets in plastic rectangular trays on top of each truck. The dishwasher was not in use during this observation. c. Food items were observed on the floor inside of the walk-in refrigerator and walk in freezer. Inside of the walk-in refrigerator, a total of 21 whole red potatoes and 7 green leaf vegetable pieces that appeared to be lettuce were observed laying directly on the floor at the rear center of the refrigerator. Inside of the walk-in freezer, a large unopened bag of frozen green beans was observed laying directly on the floor at the rear right corner of the freezer. Interview directly following the observations with Dietary Cook #1 identified that the items had recently fallen and he had not had enough time remove the items prior the survey team's arrival to the facility or prior to the initial tour of the kitchen. 2. A follow up observation on 5/21/23 at 9:19 AM identified Dietary Cook #1 without a beard guard positioned to cover his facial hair, with the beard guard pulled down below the level of his face and [NAME] and at the level of his mid neck. Dietary Cook #1 failed to identify why his beard guard was not positioned on his face and repositioned it subsequent to surveyor inquiry. Interview immediately following this observation with the Dietary Manager identified that Dietary Cook #1 should have a beard guard positioned correctly, and all kitchen staff should have appropriate beard and hair coverings in place when working in the kitchen. The Dietary Manager also identified that the kitchen staff did not have time to clean items off the kitchen floor, walk-in refrigerator or freezer floors. The Dietary Manager identified that the kitchen staff had daily cleaning tasks assigned daily, and deep cleaning items were assigned to be done each Wednesday. 3. Observations during a follow-up visit to the kitchen and breakfast plating on 5/22/23 at 7:22 AM identified the following. a. Dietary Cook #1 was observed with a hair net in place, however the hair net was observed to be partially covering a portion of his head. Dietary Cook #1 was observed to have a braided hair style and approximately 20 braids were observed to be pulled to the back and side of his head, but not inside of the hairnet. b. A large metal tray with cut up raw pieces of green bell pepper and onion was observed next to the Dietary Manager on entrance to kitchen at 7:22 AM. The tray was observed to have no covering and open to air. A large box of vinyl gloves was positioned at the far end of the metal tray. During observation of the breakfast plating, the Dietary Manager was observed reaching over open tray 10 times over a one hour period to the glove box, which was partially resting on top of a portion of metal tray containing the cut peppers and onions. c. Dietary Aide #1 was observed assisting with assembling breakfast meal trays by adding fruit, pudding and yogurt cups to the meal trays which were all uncovered throughout the duration of the breakfast meal plating. The cups were placed on each dining tray, and then into a food truck which was delivered to each resident unit. d. A small reach in refrigerator with shelves of apple juice and cups observed to be uncovered and containing items identified by the Dietary Manager as puddings, yogurt, milk and fruit, were observed with the door left open for the duration of the breakfast meal plating during a constant observation by this surveyor. During the observation, the temperature readings observed on the external digital refrigerator temperature monitor display were: 7:30 AM - 41F; 7:49 AM 44F; 7:54 AM 46F; 8:05 AM 47F; 8:07AM 48F; 8:09 AM 50F; 8:12 AM 51F; 8:14 AM 53F; 8:16 AM 55F. e. Two large trays of orange juice cups with lids on were observed on a counter in the kitchen next to Dietary Aide #1, and an open but nearly full half gallon of 2% milk was observed on a metal counter directly next to reach in refrigerator for the duration during the breakfast meal plating. Immediately following a review of the observations with the Dietary Manager at 8:17AM, a request was made to provide current temperatures for the cold items which were observed to be stored improperly. The Dietary Manager was observed obtaining the following food item temperatures utilizing a facility food thermometer: Orange juice cups from the tray on counter 45.4F; half gallon 2% milk observed sitting on counter 51.2F; one cup of yogurt from the open reach in refrigerator (cup positioned closest to open door opening) 56.7F; one cup of pudding from the open reach in refrigerator (cup positioned closest to open door opening) 53.2F. The Dietary Manager identified he did not believe that there were any issues with any of the observations identified. Following the request by this surveyor for cold food item temperatures, the Dietary Manager identified that the cold items should not be above 40F and that he would keep the reach in refrigerator door closed and milk on ice going forward. 4. During observations of the ice machines and resident nourishment rooms on 5/22/23 at 12:25 PM the following was identified. An ice machine used for residents of the facility, located in a locked area of the staff break room directly next to the kitchen, was observed to be functioning improperly. The ice machine storage compartment (approximately 75% full) was observed to be a mix of water and ice. Observations of both facility resident nourishment refrigerators identified multiple open food items without any labels or dates on the items. Interview with the DNS on 5/22/23 at 1:15 PM identified that maintenance was responsible for ensuring the ice machines were functioning properly and that the ice compartments should not have water mixed with ice and she would notify the Maintenance Director of the issue. The DNS further identified that all food items in resident nourishment areas should be labeled with the resident's name, room number and date, and any items in the refrigerators that were not labeled properly should be thrown out. The DNS further identified nursing staff was responsible for ensuring food items in nourishment refrigerators were labeled properly. Interview with the Maintenance Director on 5/23/23 at 9:19 AM identified he had a technician working on the ice machine in the staff break room identified to be functioning properly, and that that maintenance staff completed a visual daily rounding on the facility ice machines but did not keep any logs or maintenance schedules for the ice machines. The Maintenance Director identified that he believed that someone checked the ice machine in the staff break room on 5/22/23 but was unsure who and it was not reported to him that the machine had any issues. The facility policy regarding cold food storage directed all frozen and refrigerated foods would be stored appropriately at least 6 inches above the floor. The policy further directed that all perishable foods would be maintained at a temperature of 41F or below, and all foods would be wrapped or in covered containers, labeled and dated, and in a manner to prevent cross contamination. Although requested, the facility failed to provide policies regarding cleaning and sanitation of the kitchen and equipment, use of hair nets and beard coverings for dietary staff; maintenance of ice machines, or labeling items in resident nourishment refrigerators.

Based on review of facility documentation, facility policy, and interviews, the facility failed to complete nursing competencies related to blood draws from a peripheral inserted central catheter (PICC). The findings include: Interview with the Staff Development Nurse (RN #2), on 5/22/23 at 11:20 AM identified that the facility performs blood draws from PICC lines, and she is responsible to conduct competencies for that function. Review of facility documentation identified that only 1 registered nurse, (RN #2) had been deemed competent to draw blood from a PICC line. Interview with RN #8 on 5/23/23 at 2:20 PM identified she had drawn blood from a PICC line earlier in the day. Facility documentation failed to reflect that RN #8 had been deemed competent to draw blood from a PICC line. The facility policy for specimen collection/peripheral blood indicates peripheral venipuncture to obtain blood specimens is performed with a physician/advanced practice provider order by a licensed nurse or other staff per state regulation who has completed a comprehensive peripheral phlebotomy course, demonstrated competency, and education per state regulations.

Based on observation, review of facility documentation, facility policy and interview the facility failed to ensure that meals provided to the residents of the facility were based on the posted menu and failed to provide reasonable notification to the residents of any menu changes or substitutions. The findings include: Observation on 5/21/23 (Sunday) at 7:15 AM identified that the menus posted for residents in the unit common areas (Recovery, Nature Trail and Deerfield) did not correspond to the current day. The Recovery unit menus posted included Friday's breakfast specials, Saturday's lunch specials and Friday's dinner specials. On the Nature Trail and Deerfield units, the menus identified Friday's breakfast, lunch and dinner specials. No dates were identified on any of the menus posted. Interview with the Dietary Director on 5/21/23 at 9:19 AM identified it was the responsibility of the dietary staff to change the posted menus daily, but he was unsure if the staff had been trained about the menus as most of the dietary staff had started within the last 3 weeks. The Dietary Director identified that if there were issues with food deliveries, such as ordered items being out of stock and not delivered, some food items may be different than what was on the posted menu. The Dietary Director identified if menus were changed, he notifies the Recreation Director to let residents know during morning activities, and if there were residents who did not attend activities, he would put a sticky note next to the menu on each unit with the handwritten changes to the menu for the day. The Dietary Director failed to identify how residents who were unable to physically access the menus on the units were notified of menu changes, or if residents were offered the option to choose from alternatives based on what food selections were available. Interview with the Recreation Director on 5/23/23 at 11:28 AM identified she had been employed by the facility for [AGE] years, and during that time she had never been approached or directed by any staff at the facility, including the Dietary Director, to notify residents of any issues with meals including substitutions or alternatives to meals or menu items. The Recreation Director also identified that her staff also never had been directed to discuss changes or alternatives to the menus of the facility at any time, and she also had never observed any sticky or handwritten notes with menu changes on any of the unit menu boards. Review of the resident rights directed that residents of the facility had the fundamental right to considerate care that safeguarded their personal dignity. The policy further directed that each resident should be treated with respect, the facility incorporated the resident's preferences and choices into care, and the facility recognized each resident's individuality as well as honor and value his/her input. Although requested, the facility failed to provide a policy on resident menus and notice of substitutions or changes.

Based on observation, review of facility policy and interview for 8 residents (Residents #1, 6, 14, 22, 24, 48, 56 and 57) reviewed as part of the resident council task, the facility failed to consistently have available and offer an evening snack to all residents. The findings include: Interview with Residents #1, 6, 14, 22, 24, 48, 56 and 57 on 5/22/23 at 11:00 AM identified that evening snacks were not offered to residents. Resident #56 indicated an evening snack would be given upon request. Resident #48 further identified that occasionally facility staff have indicated that they do not have snacks available to offer the residents and facility residents were lucky to get an evening snack. Interview with the DNS on 5/22/23 at 12:50 PM indicated the expectation of facility staff is that a snack cart is wheeled through each unit and all residents would be offered an evening snack. Interview with the Dietitian on 5/22/23 at 4:12 PM identified the facility does not have an efficient program for evening snack distribution in place. The current practice is facility staff will go to the kitchen to obtain evening snack items for the residents and items such as cookies, graham crackers, saltines, applesauce, and pudding should be stocked on the units. The Dietitian indicated she was working with the food service director to improve how evening snack distribution could be better implemented and indicated an interdisciplinary program would need to be put in place to ensure that evening snacks are being appropriately offered, distributed, and monitored. The Dietitian further identified she would collaborate with the interdisciplinary team and Quality Assurance and Performance Improvement committee to create a program for evening snack distribution. Review of the snacks, nourishments, supplements, and pantry stock policy directed nursing or designated staff to offer an evening snack to every resident and an evening snack is planned as part of the menu.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #21) reviewed for advance directive, the facility failed to provide information on advance directive to the residents Conservator of Person (COP) on admission and readmission to ascertain their wishes. The findings include: Review of a probate court document dated [DATE] identified Person #1 was appointed Resident #21's Conservator of Person (COP). Resident #21 was admitted to the facility in [DATE] with diagnoses that included dementia, chronic lymphocytic leukemia, and malignant neoplasm of esophagus. Review of the nursing admission documentation dated [DATE] identified Resident #21's mental status was alert. Review of the resident/patient health care instructions dated [DATE] identified the Resident #21 signed the advance directive form on [DATE] indicating do not attempt Cardiopulmonary Resuscitation (CPR): allow death to occur naturally Do Not Resuscitate (DNR). A facility staff signed the advance directive. The facility failed to provide documentation to reflect Person #1 had been informed of the advance directive. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, Do Not Resuscitate (DNR), Do Not Intubate (DNI), Registered Nurse may pronounce. Review of the consent for treatment and release of information form dated [DATE] identified the facility had Resident #21 sign the form. The care plan dated [DATE] identified Resident #21 has an established advance directive: Do Not Resuscitate. Interventions directed to follow Resident #21's advance directive as indicated. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, Do Not Resuscitate (DNR), Do Not Intubate (DNI), Registered Nurse may pronounce. The nurse's note dated [DATE] at 9:09 AM identified Resident #21's COP was updated Resident #21 was admitted to the hospital with a diagnosis of transient ischemic attack (TIA). The nurse's note dated [DATE] at 9:13 AM identified Resident #21's COP indicated Resident #21 is to be a bed hold. Review of the nursing re-admission documentation dated [DATE] identified Resident #21's mental status was alert, and oriented to person, place, and time. A physician's order dated [DATE] directed to discontinue Do Not Resuscitate (DNR), Do Not Intubate (DNI), Registered Nurse may pronounce. Review of the resident/patient health care instructions dated [DATE] identified the facility had received a verbal consent from Resident #21 indicating yes, attempt (CPR). A facility staff signed the advance directive. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, perform cardiopulmonary resuscitation (CPR). The quarterly MDS dated [DATE] identified Resident #21 had severely impaired cognition and required extensive assistance with personal hygiene. Review of the clinical record failed to reflect Resident #21's code status, and an advance directive had been discussed or addressed with the COP. Interview and review of the clinical record with RN #6 on [DATE] at 11:25 AM identified she was not aware Resident #21 had signed the advance directive form. RN #6 indicated the admission nurse should have contacted the COP and discussed the advance directive with him/her. Interview with Resident #21's Conservator of Person (Person #1) on [DATE] at 2:03 PM identified he/she was not provided or informed of any paperwork for Resident #21's advance directive. Person #1 indicated he/she was not aware the facility had Resident #21 sign the advance directive on [DATE] on admission day, and again via a verbal consent from Resident #21 on [DATE]. Person #1 identified Resident #21 has a diagnosis of dementia and is not competent to sign any forms at the facility. Person #1 indicated he/she was appointed COP of Resident #21 by the court. Person #1 indicated he received a call from the facility on [DATE] indicating Resident #21 was unresponsive and he/she notified the facility that Resident #21 was a Full Code, and he/she is to be transferred to the hospital. Person #1 indicated Resident #21 has a diagnosis of dementia and he/she would have to go to court and a judge is the only person that can make the decision for a DNR. Interview with the DNS on [DATE] at 4:30 PM identified she was not aware Resident #21 signed the advance directive and gave a verbal consent regarding the advance directive. The DNS indicated the facility should have called the COP and reviewed the advance directive with the COP. The DNS indicated the admission nurse is responsible to discuss and notify the resident representative regarding advance directive. Review of the facility code status orders identified all residents require a code status order as soon as possible upon admission/re-admission, a change in resident preference, or a significant change in resident condition. Although requested, a facility advance directive policy was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #30), reviewed for choices, the facility failed to ensure that the resident's meal preferences were honored. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, muscle weakness, and diabetes. A physician's order dated 5/4/23 directed Resident #30 be provided a consistent carbohydrate diet. The care plan dated 5/8/23 identified Resident #30 was at nutritional risk due to diabetes and the need for a therapeutic diet. Interventions included honoring Resident #30's food choices within the meal plan, and to offer and encourage food and fluids of choice with preferences on file. The nutritional assessment dated [DATE] identified Resident #30 enjoyed dietary preferences of diet ginger ale, vanilla yogurt, and cold cereal rather than oatmeal. The admission MDS dated [DATE] identified Resident #30 had intact cognition and required staff assistance to set up meals. Interview with Resident #30's on 5/21/23 at 8:18 AM identified that while the meal tickets that comes with the meals reflects the resident choices, the actual food items served often do not match the meal tickets. Resident #30's breakfast tray was also observed at that time, and the items on the meal ticket did not reflect what was provided on the tray. Resident #30's breakfast ticket identified Consistent Carbohydrate order with his/her selected food items which included 2 slices of bacon, one slice of white toast, and vanilla yogurt; however, the breakfast tray delivered was observed to have one slice of bacon, strawberry yogurt (instead of vanilla), and no toast. Resident #30 identified that the discrepancies in his/her selections for meals versus what is provided on the meal trays had been an ongoing issue since his/her admission to the facility. Resident #30 also provided his/her meal tickets from dinner on 5/11/23 and lunch on 5/13/23 and identified on 5/11/23 there were missing items from his/her tray which included croutons for a salad, a dinner roll, and a slice of cake; and on 5/13/23, a brownie was missing from the meal, and a chicken sandwich was delivered instead of a philly cheese steak sandwich, which was Resident #30's preferred meal. Resident #30 identified that he/she did not want a chicken sandwich on 5/13/23, but the meal was just delivered and no one from the facility had ever discussed substitutions or changes, and he/she had never been asked about alternative choices. Interview with the Dietary Director on 5/21/23 at 9:19 AM identified that each resident's meal tray was checked against the meal ticket by dietary staff prior to leaving the kitchen, and he was unsure why there were missing or different items on Resident #30's breakfast tray. The Dietary Director identified that the resident may have received a chicken sandwich instead of a philly cheesesteak sandwich because if there were issues with food deliveries, such as items being out of stock and not delivered, some food items on the residents' trays may be different than what was reflected on the meal ticket. The Dietary Director further identified that he was responsible for reviewing changes to the menus with residents. The Dietary Director was not sure if he had ever reviewed menu changes or substitutions with Resident #30, or if the resident had been given the option to choose an alternative meal. The facility policy on nutrition care and services directed that facility staff would provide a therapeutic diet for each resident that accounts for the resident's clinical condition and preferences. The facility policy on resident rights directed that residents of the facility had the fundamental right to considerate care that safeguarded their personal dignity. The policy further directed that each resident should be treated with respect, the facility incorporates the resident's preferences and choices into care, and the facility recognizes each resident's individuality as well as honor and value his/her input.

Based on a clinical record review, staff interviews, and a review of the facility documentation for one sampled resident reviewed for significant medications errors (Resident #65), the facility failed to ensure medications were administered per the physician's orders [REDACTED]. Review of the clinical record identified Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 was cognitively intact, required total dependence on staff for bed mobility transfers and personal hygiene, was independent with eating after set up, and received daily insulin injections. The Resident Care Plan (RCP) dated 10/11/18 identified a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the nurse's note dated 12/6/18 at 4:22 AM identified Resident #65 was found unresponsive at 1:25 AM. Resident #65 was diaphoretic and cool to touch. A blood sugar was completed at 1:25 AM and was 29 mg/dl. (Normal blood sugar is 70-99 mg/dl). [MEDICATION NAME] 1 milligram (mg) was administered intramuscular (IM). At 1:40 AM the residents blood sugar was 46 mg/dl. A subsequent dose of [MEDICATION NAME] 1 mg IM was administered. At 1:50 AM the residents blood sugar was 71 mg/dl. At 2:00 AM Resident #65's blood sugar was 84 mg/dl. At 2:15 AM the blood sugar was 92 mg/dl. Orange juice was given and the resident was able to swallow and responded well. Review of the Reportable Event dated 12/6/18 at 11:00 AM identified Resident #65 was administered long acting insulin in the morning (Basaglar Kwikpen 30 units). A new order was given for a different dose (Basaglar Kwikpen 24 units) starting at night. Both doses were administered on 12/5/18 in error. Resident #65 had an episode of [DIAGNOSES REDACTED] managed with [MEDICATION NAME] injections. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with LPN # 2 on 2/5/19 at 12:05 PM indicated on 12/5/18 he/she had administered Basaglar insulin 30 units to Resident #65 at approximately 9:00 AM. The physician came in on 12/5/18 and changed the orders to Basaglar insulin 24 units daily. LPN #2 identified he/she transcribed the order, but did not double check the order as well as he/she should have. LPN #2 indicated he/she transcribed the physician's orders [REDACTED]. Interview with LPN #1 on 2/5/19 at 2:19 PM identified he/she gave the Basaglar insulin as ordered at approximately 10:00 PM on 12/5/18. LPN #1 identified on the 11:00 PM to 7:00 AM shift a nurses aide had come to him/her after first rounds and reported that Resident #65 was diaphoric. LPN #1 indicated he/she went to see Resident #65 and then summoned the nurse supervisor. LPN #1 identified he/she had discovered two does of Insulin were transcribed for the same day when performing chart checks on the 11:00 PM to 7:00 AM shift.