Every finding on record at Avondale Estates of Elgin

Based on interview and record review, the facility failed to follow an Antibiotic Stewardship Program for residents receiving antibiotics. This applies to 5 of 5 residents (R216, R217, R167, R23, R24) reviewed for Antibiotic Stewardship in a sample of 20. The findings include: On June 25, 2025 at 2:03 PM, V2 (ADON/Assistant Director of Nursing) went over the Antibiotic Stewardship Program. V2 said the McGeers tool was used to determine whether the resident meets the requirement for the use of antibiotics. V2 said the tool should be used before the resident has started on the antibiotic. V2 said residents admitted from the hospital with antibiotics should also have the McGeers tool completed to ensure the antibiotics were appropriate to continue in the facility. 1. R23's face sheet showed he was admitted to the facility with diagnoses including sepsis and urinary tract infections. R23's POS showed an order for Macrobid Oral 100 MG for UTI starting June 20, 2025 ending June 25, 2025. R23's McGeers Urinary Tract Infection (UTI) Surveillance Definitions tool dated June 20, 2025 showed R23 did not meet urinary tract infection criteria. R23's EMR showed she was still given antibiotics. At 2:03 PM, V2 said he filled out the McGeers tool on June 20, 2025 because that was when he was made aware of the symptoms. V2 said he filled out the form based on the resident's symptoms at the time. 2. R24's face sheet showed he was admitted to the facility with diagnoses including follicular disorder. R24's POS showed orders for Cephalexin Oral 500 MG two times a day related to follicular disorder starting June 20, 2025 and ending June 27, 2025. At 2:03 PM, V2 said R24 had wounds on her head and the Nurse Practitioner ordered Cephalexin. V2 said he was notified of the use of antibiotics after R24 had been started on the antibiotic. V2 said the McGeers tool should have been done before the resident was started on the antibiotic. V2 said he filled out R24's McGeers tool incorrectly. R23's McGeers tool dated June 20, 2025 showed Skin and Soft Tissue Infection Criteria not met. 1. R216's face sheet showed he was admitted to the facility with diagnoses including diverticulitis, bacteremia, and elevated white blood cell count. R216's POS (Physician Order Sheet) showed an order dated June 18, 2025 for Meropenem Intravenous 1 gram intravenously two times a day for bacteremia until June 29, 2025 11:59 PM. 3. At 2:03 PM, V2 said R216 came from the hospital with an order for IV (Intravenous) antibiotic. V2 said neither the McGeers tool nor any standardized tool was used when R216 was admitted to the facility from the hospital. V2 said the facility just followed the orders the resident was sent with from the hospital. V2 said he completed an antibiotic time out tool. R216's EMR (Electronic Medical Record) showed an Antibiotic Time Out form dated June 20, 2025 showed the doctor ordered to continue with current antibiotic therapy. 4. R217's face sheet showed she was admitted to the facility with diagnoses including cellulitis of the right and left lower limbs. R217's POS showed orders for metronidazole oral tablet 500 MG (Milligrams) three times a day for BLE (Bilateral Lower Extremity) wounds for 10 days, which started April 25, 2025 and ended May 5, 2025, Cefdinir 300 MG, two times a day for BLE wounds for 10 days, which started April 25, 2025 and ended May 5, 2025, Bactrim 800-160 MG for UTI (Urinary Tract Infection) for 7 days, started June 15, 2025 and ending June 22, 2025, Ceftazidime 500 MG IV for UTI for 7 days, started June 15, 2025 through June 23, 2025, Fosfomycin Tromethamine 3 Grams for UTI for three administrations, starting June 15, 2025 through June 22, 2025, Meropenem 1 Gram IV for UTI, starting June 3, 2025 through June 6, 2025. At 2:03 PM, V2 said R217 was admitted from the hospital with oral Cefdinir 300 MG and oral Flagyl 500 MG. V2 said he reviewed the hospital records when she was admitted , which showed to continue the antibiotics. V2 said he did not have a McGeers tool completed for R217 for the antibiotics she was admitted with. V2 said R217 was also prescribed Meropenem 1 Gram IV on June 3, 2025 and Ceftazidime 500 MG IV on June 16, 2025 because R217 had acquired ESBL (Extended-spectrum beta-lactamases) of the urine in the facility. V2 said he did not complete the McGeers tool because he was not made aware of the infections until after R217 was already started on antibiotics. V2 said he did not fill out the McGeers tool for the Ceftazidime 500 MG because they were treating the same infection. V2 said if there was another antibiotic ordered, he should have also filled out the Antibiotic Time Out form. 5. R167's face sheet showed he was admitted to the facility with diagnoses including cellulitis of right lower limb, bacteremia, and sepsis. R167's POS showed orders for Cefazolin Sodium 2 Grams IV for wounds starting June 17, 2025 with no end date, Cefazolin Sodium 2 Grams for wounds starting June 17, 2025 and ending July 23, 2025, and a third order for Cefazolin Sodium 2 Grams for wounds starting June 16, 2025 with no end date. The facility was unable to provide the McGeers tools or Antibiotic Time Out completed for any of the antibiotics ordered and administered for R167.

Based on observation, interview, and record review the facility failed to secure medications. This applies to 5 out of 5 ( R28, R49, R56, R269, R369) reviewed for medications in a sample size of 20. The findings include: 1. On 6/24/25 at 1:09 PM, R369 was sitting on the bed. Alert and well oriented. R369 stated that he was on Norco 1-2 pills every six hours as needed and that he had his own bottle of Norco with him. R369 stated he had a pill box full of his pills in his drawer. A weekly pill box with medications for three times a day dosing filled with pills was in R369's drawer. Also in his drawer was one bottle of acetaminophen (500 mg/325 caplets) almost full, and two boxes containing 15 patches of 4% Lidocaine gel. The drawer with medications was not locked. R369's progress notes dated 6/23/25 at 22:59 showed R369 had his own medications with him. On 6/24/25 at 10:44 AM, V15 (RN-Registered Nurse) stated on 6/24/25, she took away a bottle of Norco from R369 after V16's (Physician) rounded in the morning. V15 stated from the time R369 was admitted on [DATE] at 6:00 PM until the doctor rounded on 6/24/25 morning, R369 had the bottle of Norco with him. V15 stated she gave that bottle of Norco to V3 (ADON-Assistant Director of Nursing). V15 stated around 2:00 PM on 6/24/25, R369 was moved to another room and his pill box filled with medications, the bottle of acetaminophen, and the lidocaine patches were also sent with him to his new room and left in his drawer. On 6/26/25 at 10:50 AM, V3 stated, R369 had these medications at his bedside from 6/23/25 at 6:00 PM till 6/24/25 afternoon. On 6/26/25 at 10:44 AM, V2 (DON) stated, there were no Physician orders and no assessment done for R369 to keep his medications at his bedside. 2. 6/26/25 at 09:57 AM, a bottle of TUMS antacid was noted on R56's bedside table. She said she brought it from home and takes 2 tablets every night for indigestion. R56's POS (Physician Order Sheet) was reviewed, no order for TUMS was included, and no order for medication to stay at the bedside. 3. On 6/24/2025 at 9:59 AM, an unlabeled Albuterol Sulfate HFA was noted on R49's bed side table. He said he brought it from home and self-administers it once daily in the morning. R49's POS was reviewed, there is an order for Albuterol Sulfate but no order to keep any medication at bedside. 4. On 6/24/2025 at 10:13 AM R28 had a bottle of TUMS antacid on her bed side table. She said she uses it for heartburn and the medication was brought in by family. R28 also had a tube of Ketoconazole cream 2%, and Hydrocortisone cream 2.5% on top of her bedside table. She said she brought both creams from home and puts it on her left forehead. R28's POS included no orders for any medications found by bed side, and she had no order for medications to stay by bedside. 5. On 06/24/25 at 10:22 AM, unlabeled Symbicort inhaler was seen on R269's bedside table. He said he uses it when he has shortness of breath and he brought it from home. R269's POS included no order for the medication and no order for medication to stay at bedside. On 6/26/2025 at 11:09 AM, V2 (ADON) said there are no residents with orders for medication to stay at the bedside. V2 stated if medications are kept at bedside, they should be kept in a drawer that has a lock so nobody can have access to it aside from the resident for safety reasons. On 6/25/25 at 11:45 AM V6 (LPN-Licensed Practical Nurse) stated, if a resident's mental capacity is normal and if they want to have medications with them, then facility need to do assessment and get Physician orders for those medications to be kept at bedside. If all this not applicable, they cannot have their medications at bedside. Facility's Policy on Storage of Medications revised on March 2020 stated the following: Policy Statement: The facility shall store all drugs and biologicals safely, securely and orderly.

Based on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions (EBP) when caring for residents needing those precautions. This applies to 4 of 4 (R2, R27, R56 and R369) residents reviewed for infection control in a sample of 20. Findings include: 1. On 6/23/25 at 1:41 PM, R2 exited the washroom in her room and V18 (CNA-Certified Nursing Assistant) was still in the washroom tying up the garbage. V18 stated she helped R2 to clean up after using the toilet. V18 did not wear a gown. A sign outside R2's room door showed EBP and there was a bin with PPE (Personal Protective Equipment) outside R2's room. R2's Physician Order Sheet (POS) dated 6/10/25 showed EBP related to wound 2. On 6/24/25 at 11:40 AM, observed V19 (OT-Occupational Therapist) and V20 (Physical Therapist) provide therapy to R369 in his room, including transfers from & to bed. R369 had a PICC (intravenous) line with a dressing on it on R369's right upper arm. Neither V19 or V20 wore a gown, and there was no sign outside the door indicating EBP was required. On 6/26/25 at 9:30 AM, there was still no EBP outside R369's door. R369's Physician order dated 6/26/25 (during the survey) showed EBP related to intravenous access. 3. On 6/26/25 at 9:46 AM, observed V21 (CNA) provided a bed bath to R27 without wearing a gown. R27 had a urinary catheter. R27 had a sign indicating EBP outside the door. R27's Physician order dated 4/18/25 showed EBP related to urinary catheter. On 6/26/25 at 9:52 AM, V22 (RN-Registered Nurse) stated R27 was on EBP for use of a urinary catheter and V21 should have worn gown and gloves while giving him a bath for infection control reasons. 4. On 6/23/2025 at 2:45 PM, V7 (RN-Registered Nurse) administered R56's IV (intravenous) medication. V7 wore gloves and was not wearing a gown. On 6/26/2025 at 9:50 AM, V2 (ADON- Assistant Director of Nursing) said nurses should wear a gown and gloves when giving injections and IV medication. V2 stated nurses should wear proper PPE to prevent contamination. R56's POS documents R56 is on EBP for PICC (Peripherally Inserted Central Catheter) line. R56 has an order for Cefazolin Sodium 2 grams intravenously three times a day for infection. On 6/26/25 at 10:20 AM, V2 (ADON-Assistant Director of Nursing) stated, V18 and V21 should have worn gown while providing care to R2 and R27, respectively, as both residents were on EBP. V2 stated the nursing staff should have put EBP signage outside the door of R369 so that therapists and other staff would know to follow the EBP precautions. V2 stated, any staff caring for residents on EBP must wear gown and gloves as per facility policy. Facility's Policy/Guidelines on Enhanced Barrier Protection (EBP) dated 9/23/2022 documents the following: 5. c) Use of PPE: ii.Enhanced Barrier Protection (EBP) require the use of a gown and gloves when performing high-contact resident care activities. 6. What are High-Contact Resident Care Activities: g. Device care or use (urinary catheters, feeding tubes, tracheostomy/ventilator, central lines.

Based on observation, interview, and record review, the facility failed to ensure resident's pain was managed. This applies to 1 resident (R369) reviewed for pain management in a sample of 20. Findings include: On 6/24/25 at 1:09 PM, R369 was sitting in the bed. Alert and well oriented. R369 stated when he was admitted the day before in the evening, his pain was at 8-9 out of 10. He stated that he was on Norco 1-2 pills every six hours as needed and that he had his own bottle of Norco with him. R369 stated that he did not sleep the whole night because of pain. R369 stated facility nurse would not give him anything for pain and so he took two pills of Norco from his own bottle around midnight and again two pills of Norco around 5:30 AM on 6/24/25. R369 stated that then the pain reduced. On 6/26/24 at 10:17 AM, V2 (ADON) stated R369 was admitted on [DATE] at 6:00 PM. V2 stated R369 did not receive any medication for pain from the facility since admission until 9:00 AM on 6/24/25 and R369's pain should have been managed better. V2 stated R369 should have received acetaminophen or norco as the orders were to be given for pain as needed. V2 stated the facility had these medications available in the facility for emergency use. R369's face-sheet showed that he was admitted to the facility on [DATE] with diagnoses of B-cell lymphoma and pain in left hip. R369's POS (Physician Order Sheet) for June 2025 included an order dated 6/23/25 for two tablets of Tylenol 500 mg by mouth every six hours as needed for pain. The same POS showed an admission order on 6/23/25 for Norco 5-325 mg, give 1 tablet by mouth every six hours as needed for pain. R369's MAR (Medication Administration Record) for June 2025 showed he did not receive any medication for pain since admission on [DATE] at 6:00 PM, until 6/24/25 at 9:00 AM. R369's Vital Signs included pain score of 7 on 6/23/24 at 10:38 PM, and pain of 8 on 6/24/25 at 8:53 AM, both on a 1-10 scale. R369's progress notes dated 6/23/25 at 10:52 PM showed Pain intensity: 10 and that it was very severe and horrible. The note showed that the indicator for the pain was vocal complaints of pain at 7 out of 10 in the left knee, which was aching. Facility Pain Management policy (revised March 2021) showed 1. The pain management program is to provide comfort to the patient. 5. Resident's pain level should be assessed at least every shift and interventions implemented as appropriate .

Based on observation, interview, and record review, the facility failed to provide timely incontinence care to a resident resulting in resident acquiring MASD (Moisture Associated Skin Damage) to his left and right buttock. This applies to 1 of 3 residents (R368) reviewed for incontinence care in a sample of 20. The findings include: On 6/25/2025 at 9:10 AM during incontinence care with V4 (RN-Registered Nurse/Wound Care Nurse) and V5 (CNA- Certified Nurse Assistant), redness was noted on R368's left and right buttocks. R368 said during midnight shift on 6/25/2025, V8 (CNA- Certified Nurse Assistant) did not dry him well after incontinence care. He said first, he waited for 45 minutes for his call light to be answered while observing V8 walking up and down the hallway and ignoring his call light. R368 said that when V8 finally provided incontinence care, she did not wipe and dry him well. He said he even had to request for V8 to change his bed pad because it was soaked with urine and sweat. R368 verbalized pain when reddened area was touched during assessment by V4 (RN). R368 said he is sure his skin issue is due to being left soaked for a long period of time. V4 assessed the reddened areas during incontinence care and said it was MASD because the skin felt moist to touch. During incontinence care at 9:10 AM, V5 said this was the first time she provided incontinence care to R368 since she started the shift at 6:00 AM. On 6/25/2025 at 9:40 AM, V6 (LPN-Licensed Practical Nurse) said she has no knowledge of R368's skin issue and the previous shift did not mention anything about R368's skin issue. On 6/26/2025 at 11:09 AM, V2 (ADON-Assistant Director of Nursing) said he expects staff to provide incontinence care every two hours and as needed. He said when providing incontinence care, he expects staff to make sure resident is dry to prevent skin breakdown. He said he expects staff to report to nurses if skin issues are discovered. R368's MDS (Minimum Data sheet) dated 6/20/2025 shows he needs substantial/maximal assistance for toileting hygiene and lower body dressing, and he needs partial/moderate assist with upper body dressing. It is documented that R368 is occasionally incontinent of bladder and always incontinent of bowel. R368's Braden Scale done 6/18/2025 documents R368 is at risk for pressure ulcer. R368's admission skin check done 6/18/2025 documents there were no skin issue to left and right buttock. On 6/25/2025, R368's POS Physician Order Sheet) did not show an order for any moisture barrier cream. Facility's Policy on Incontinent - Peri Care (revised on March 2020) showed the following: Purpose: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Procedure: 8. After providing incontinent/peri-care, rinse the area thoroughly and pat dry after rinsing .

Based on observation, interview and record review, the facility failed to attempt to remove an indwelling urinary catheter that was placed after recent surgery, failed to ensure the drainage bag did not touch the floor and failed to have a baseline care plan for indwelling catheter care. This applies to 1 of 3 residents (R47) reviewed for urinary catheter care in the sample of 17. Findings include: R47's EMR (Electronic Medical Record) showed R47 was admitted to the facility on [DATE], with multiple diagnoses including, presence of left hip artificial joint aftercare, chronic diastolic congestive heart failure, type 2 diabetes mellitus with other diabetic kidney complications, essential hypertension, chronic obstructive pulmonary disease, and leukocytosis. R47's MDS (Minimum Data Set) dated April 26, 2024, showed R47 was moderately cognitively impaired and required assistance with ADLs (Activities of Daily Living) including partial staff assistance with eating, oral and personal hygiene, dependent on staff for assistance with toileting, and substantial assistance required with bathing, dressing, bed mobility, and transfer. On May 22, 2024, at 1:00 PM, V2 (IP Nurse) stated when a resident is admitted to the facility with an indwelling urinary catheter, the facility should be sure there is a follow up appointment with urology and a voiding trial should be attempted to remove the catheter if possible. V2 stated the facility did not do a voiding trial for R47. V2 also stated he spoke with R47's NP (Nurse Practitioner) today who ordered a voiding trial for R47. R47's EMR showed R47's Incontinence/Indwelling Foley Catheter Observation dated April 24, 2024, showed .7. Has a trial of a toileting program (e.g., . scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? .answer No . 8.What was the resident's response to the trial program? .answer, not assessed .9. Current toileting program or trial? answer .not assessed/no information. There was no additional catheter assessment completed. On May 22, 2024, at 10:50 AM, V4 (MDS/Care Plan Nurse) showed a baseline care plan dated April 24, 2024, that did not have a plan for indwelling urinary catheter. V4 stated the care plan had no goal and no interventions listed for catheter care and maintenance. V4 stated the care plan for indwelling catheter care should include to maintain the drainage bag in a privacy bag, be sure there were no kinks in the tubing and be sure the drainage bag was not on the floor. The care plan for indwelling urinary catheter was initiated on May 22, 2024. On May 20, 2024, at 10:49 AM, R47 was in bed, receiving care from V8 (Wound Care Nurse) at the end of the bed, the urinary drainage bag was lying on the floor, next to the privacy bag on the left side visible from the doorway. On May 22, 2024, at 10:45 AM, V6 (LPN) stated R47's indwelling urinary catheter was inserted in the hospital on April 21, 2024. R47's hospital assessment and plan dated April 19, 2024, showed R47 had acute urinary retention most likely due to recent anesthesia effect, does have recurrent urinary retention s/p (status post) indwelling urinary catheter placement. The facility's policy titled Catheter Care, Urinary, dated November 2017, showed Infection Control .c. Be sure the catheter tubing and drainage bag are below the resident's bladder and kept off the floor .e. Cover the urinary bag to provide privacy.

Based on observation, interview, and record review, the facility failed to ensure three resident's central venous catheter dressings were changed within 48 hours as per the facility policy. This applies to 3 of 3 residents (R44, R23, and R357) reviewed for central venous catheters in the sample of 17. The findings include: 1. R44 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Aftercare Following Joint Replacement Surgery, and Infection and Inflammatory Reaction Due to Other Internal Joint Prosthesis. On May 20, 2024 at 11:38 AM, R44 had a right upper arm central venous catheter with gauze covering the insertion site, and a transparent dressing was on top. The dressing was dated May 19, 2024. R44 stated they changed his central line venous dressing yesterday. On May 22, 2024 at 9:05 AM with V7 (RN), R44's right upper arm central venous catheter dressing was still dated May 19, 2024, and the insertion site was still covered with the same gauze and transparent dressing. 2. R23 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Bacteremia and Effusion of Left Knee. On May 20, 2024 at 3:06 PM, R23 had a left upper arm central venous catheter with gauze covering the insertion site, and the transparent dressing on top was dated May 19, 2024. On May 22, 2024 at 9:07 AM with V7, R23's left upper arm central venous catheter dressing was still dated May 19, 2024, and the insertion site was still covered with the same gauze and transparent dressing. 3. R357 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Osteomyelitis, Inflammatory Conditions of Jaws, and Cutaneous Abscess of Face. On May 20, 2024 at 3:08 PM R357's had a right upper arm central venous catheter with gauze covering the insertion site, and the transparent dressing on top was dated May 19, 2024. On May 22, 2024 at 9:11 AM with V7, R357's right upper arm central venous catheter dressing was still dated May 19, 2024, and the insertion site was still covered with the same gauze and transparent dressing. V7 stated that she is not aware what the policy is in regards to changing the central venous catheter dressings. V7 stated V2 (Infection Preventionist) would know. On May 22, 2024 at 1:58 PM, V2 (Infection Preventionist) stated that peripherally inserted central catheter (PICC) lines or midline catheter insertion site dressing changes should be completed every 5-7 days. However, if gauze is used on the dressing the dressing should be changed every 48 hours. On May 23, 2024 at 10:28 AM, V2 stated that the reason for changing central venous line dressing with gauze is to prevent infection and to monitor the insertion site and integrity of the dressing. R44, R23, and R357's Treatment Administration Records showed that their central venous line dressings were all last changed on May 19, 2024. The facility's Midline Dressing Policy dated September 2, 2016 showed the following: Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 4. Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with a TSM dressing and change the dressing every 48 hours.

The facility failed to implement acceptable standard of infection control practices regarding the following: (due to two failures noted under this regulation, there are two deficient practice statements). A. Based on observation, interview, and record review, the facility failed to identify and ensure a resident (R362) with diagnosis of Candida Auris (highly contagious fungal rash infection) and with drainage from a non-contained open wound rash was placed on contact precautions, failed to prevent cross contamination during wound dressing change and while removing contaminated medications from the isolation room, failed to utilize dedicated medical equipment in an isolation room, and failed to educate staff and family regarding necessary contact precautions and use of protective equipment. This failure resulted in Immediate Jeopardy when R362 was admitted to the facility on [DATE] and was not placed on contact isolation precautions. This applies to 30 of 30 residents (R1, R18, R20, R28, R39, R40, R47, R48, R50, R53, R54, R57, R117, R118, R119, R120, R121, R122, R123, R124, R125, R126, R127, R128, R129, R141, R361, R362, R363 and R354) reviewed for infection control. The Immediate Jeopardy began on 6/19/23 at 8:00 PM when R362 was admitted to the facility. V1 (Administrator) and V2 (Director of Nursing) was notified of the immediate jeopardy on 6/28/23 at 11:58 AM. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on 6/29/2023 at 9:51 A.M., but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan, including in-service training of staff on infection control. The findings include: The EMR (Electronic Medical Record) showed that R362, a [AGE] year-old, was admitted to the facility on [DATE]. R362's diagnoses included Candida Auris (Per the Centers for Disease Control and Prevention dated December 27, 2022: a fungal infection that presents a serious global health threat, often a multi drug resistant infection that can cause an outbreak in a facility settings), syncope and collapse, epilepsy, congestive heart disease, chronic embolism, diabetes, atrial fibrillation, non-pressure chronic ulcer of the right calf, transient ischemic attack, protein calorie malnutrition, and thrombosis. The MDS (Minimum Data Sheet), dated 5/23/23, shows R362's cognition was moderately impaired, and R362 required limited to extensive assistance from staff for ADLs (Activities of Daily Living) including hygiene, transfers, toileting, dressing and bed mobility. The transfer order dated 6/19/23, shows that R362 was transferred to the facility with a physician order, dated 6/18/23, for contact precautions due to Candida Auris to the right axilla. On 6/27/23 at 3:01 PM, V6 (Registered Nurse- Admission Nurse) stated that R362 was admitted to the facility with an order of contact precautions due to Candida Auris to the right axilla. V6 stated he overlooked the order of contact precautions and failed to transcribe it into R362's admission orders to the facility. This resulted in R362 not being placed in contact isolation precautions. V6 further said that no one screened resident' clinical needs prior to admission except when the resident was already in the facility, and this had delayed placing R362 on contact isolation precautions. V6 also said it was 3 days that R362 was not on contact isolation precautions, and it was only when V16 ([NAME] County Health Department) had called and informed the facility that R362 was positive for Candida Auris and was on their surveillance list. V6 stated V16's call had prompted the facility to place R362 on contact isolation precautions. V6 stated he should have looked at the transfer records thoroughly and it would help if referral documentation was screened by clinician prior to resident' admission so the appropriate infection control would be timely implemented. V6 stated no one at the facility screened the admission referral except the admitting nurse which was V6 who stated he overlooked the resident's infection control precautions order. V6 stated if he had identified R362 as needing to be placed on contact precautions, he would have referred R362 to V7 (Infection Control Preventionist Nurse) to ensure correct management of the infection control precautions. On 6/27/23 at 1:05 PM, V16 ([NAME] County Public Health) stated she informed the facility that R362 was on their list for surveillance/tracking due to positive diagnosis of Candida Auris of the right axilla. On 6/28/23 at 11:40 AM, V9 (Attending Physician/ Medical Director) stated that a resident's transfer order should be carried out and be continued when transferred to the admitting facility which includes any orders for transmission-based precautions. V9 also stated he was made aware of R362's contact isolation precautions due to Candida Auris recently on 6/22/2023 when [NAME] County Public Health had called the facility for tracking. V9 stated if R362 has drainage and flaky substances from the axilla, then R362 is considered contagious and able to transmit Candida Auris and therefore strict contact precautions should be continued. V9 stated the facility required guidance to manage this highly contagious disease. On 6/26/23, at 10:00 AM, during the initial tour with V10 (Registered Nurse), it was observed at the entrance of R362's door that there was a sign which showed Contact Isolation. V10 stated, The contact isolation sign was a mistake. V10 stated (R362) is only on Enhanced Barrier Precautions due to a wound on her buttocks related to Moisture Associated Skin Damage (MASD). V10 stated only gloves were required to enter the room. V10 and the surveyor entered R362's room wearing only gloves. Inside room of R362, there was no dedicated medical equipment such as stethoscope, sphygmomanometer, and thermometer. V10 said that the medical equipment used for R362 is the same medical equipment used and shared with other residents on the third floor. R362 was lying in bed, awake, confused. There was an open box of Debrox eardrop medication on the bed, on R362's left side near her left hand and left thigh. V10 took the open eardrop medication and stated, (R362) cannot administer this because she is confused. V10 picked up the medication, removed her gloves, and took the mediation out of R362's room. V10 continued to hold the Debrox medication with her bare hands and walked in and out several resident rooms including R361, R47, R118, R39 and placed it on top of their beds, overbed tables, and nightstands. V10 then took the medication to the nursing station, placed it on the nursing station countertop, and called a physician for orders. V10 then proceeded to place the medication on top of the [NAME] Unit medication cart. V13 (R362's daughter) and V12 (R362's son) were in R362's room and they were not wearing any PPE (Personal Protective Equipment). V13 stated she had not been provided any education regarding R362's infection, was not aware she needed to wear any PPE in the room, and V13 only understood R362 has rashes on the axilla. V13 also said no one provided education regarding handling R362's soiled laundry as V13 does R362's personal laundry. On 6/26/23 at 3:00 PM, the EMR was reviewed. During the review, the surveyor had identified that R362's current POS (Physician Order Sheet) for the month of June 2023 showed a physician order dated 6/22/2023 for contact isolation precautions due to Candida Auris of the right axilla. On 6/26/23 at 3:45 PM, surveyor verified with V10 regarding R362' current isolation precaution. V10 said she made a mistake and thought that R362 was on Enhance Barrier Precaution. In addition, V10 was not observed providing education to V12 and V13 regarding use of PPE, and V12 and V13 were seen going in and out of R362's room. On 6/26/2023 at 3:45 P.M., V18 (CNA/Certified Nurse Assistant) said she does not know what kind of precaution that R362 was on. On 6/27/23 at 4:30 PM, V7 (Infection Control Preventionist) stated he did not receive information from V6 regarding R362 being admitted with orders for isolation precautions. V7 stated if he had received notice R362 had a diagnosis of Candida Auris he would have placed R362 on isolation precautions and would have referred R362 to the Infectious Disease specialist for proper management. V7 stated R362's infection was not a contained wound due to the blood that was oozing from the infected area, right axilla, and that the axilla still has a flaky substances from the rash. V7 stated that (R362) has symptoms of oozing blood and flaky substances from the infected side (right axilla and under breasts), this indicates the presence of an active infection is still ongoing and strict contact isolation precautions should be maintained. V7 stated R362 was placed on strict contact isolation precautions as of 6/27/23 at 3:33 PM. V7 explained that strict contact precautions meant that R362 was not to be removed from the room for therapies and all services should be performed inside her room. V7 further said that there should be dedicated medical equipment such as a thermometer, stethoscope, and sphygmomanometer, and they should be kept inside R362's room to ensure no occurrence of cross contamination. The skin admission assessment dated [DATE]: -right axilla with erythema moisture associated skin damage with dressing of less than 25% saturation. -6/20/2023: - right axilla fungal rash, and bilateral breasts fold with rashes. The assessment also shows that right axilla skin was macerated, fungal rash noted under bilateral breasts folds. -6/22/2023: fungal rash under right axilla noted with erythema and drainage. -6/26/2023: right axilla Candida Auris, right axilla noted with decreased erythema (skin persistent redness irritation), papule (a raised area of skin tissue that is an inflamed bumps in the skin that might suggest skin condition that possible signs of undelaying skin condition/infection). On 6/26/23 at 5:11 PM, V12, and V13 were in R362's room with V18. They were not wearing gloves and gowns. V18 was leaning against R362's bed with no PPE talking with the family. V18 exited the room and stated she was aware that she should have worn PPE. V12, V13 and V18 stated they had not been provided information about Candida Auris, and how they should handle R362's personal laundry. On 6/26/2023 at 3:52 P.M., V19 (LPN/License Practical Nurse) said R362's family goes in and out of R362's room and does not wear PPE. V19 also said that R362's is on contact precaution and that anyone entering R362's room should wear PPE. On 6/27/2023 at 4:45 P.M., V8 (Housekeeping/Laundry Department) said that R362's linens are washed at the facility. V8 also said that R362's personal clothing is handled by the family. V8 added that she did not provide education to R362's family on how to properly disinfect soiled clothing to prevent cross contamination. V8 said it is up to nursing to do that. On 6/27/2023 at 11:43 A.M. R362 was observed for wound dressing change and skin observation. V3 (LPN/Wound Care Nurse) and V10 (CNA) did the wound dressing change. R362 was lying in bed, awake and alert with bouts of confusion. R362 said It is itchy around my breasts, under my breast and my armpits and I sometimes scratch it. V12 was present in R362's room, wearing a pair of gloves. V12 said he was informed by V13 as of 6/26/2023 to wear gloves only when entering R362's room. Prior to start of dressing change, V5 (CNA) was asked when was the last time R362 was provided skin care. V5 said that this morning at 7:00 A.M. I gave her a bed bath. I noticed a lump of dried blood on the creases of (R362's) right axilla and accumulation of flaky substance around her axilla and underneath her breasts. The wound dressing change observation were as follows: -V3 said that R362 has a rash under breasts, right axilla, left hip skin tear and MASD to the left buttock and sacrum. V3 gathered the following treatment supplies: Gathered supplies: -Nystatin powder -Hydrocolloid x2 -Xerofoam dressing -Bordered gauze dressing -Skin prep pads (times 2) At 11:43 AM, V3, V10 and surveyors entered R362's room with PPE on. R362 was lying in bed. R362 said she complains of itchiness to her right axilla from warm clothes. -V10 used disinfectant wipe to clean the over the bed tray table, and bath towel was placed on table, then the dressing supplies were put on the table. V10 had pulled down R362's blanket towards feet and upper shirt was pulled up exposing R362's upper chest to feet. R362's right breast was observed with 4 raised, fluid filled skin papules that were yellowish in color. The size was approximately 0.5 cm x 0.5 cm in diameter. V3 said the raised skin are pimples and with yellowish fluid blisters. The raised skin was surrounded with flaky yellow substances. V3 said the largest papule near the skin fold like a pimple with a white head. R362's right forearm was slightly pulled away by V10 to expose R362's right axilla. The right axilla has an open area and creases and fresh red blood combined with serosanguinous drainage coming out of the right axilla. V3 measured R362's right axilla and measurement showed 5.5 cm x 7 cm (L x W) with an open area measuring 1.5 cm x 1.0 cm. R362's left breast- one area close to the medial chest measuring 1/4 inch raised area that is red and appears to be scabbed. Red rash area under breast described as flaky per V3. V3 changed gloves after lifting breast to arm to look at axilla areas. Placed the box of gloves on R362's bed to grab new gloves to put on. There was no hand hygiene after removing gloves and putting on new gloves. After both staff removed new gloves from the box, the box was removed from the bed to the dresser in the room. R362's right shin has a dry flaky rash. R362's left rash on anterior right shin extends from the ankle to below the knee and extends to the posterior calf. R362 was turned onto her right side to make left hip visible. Left hip showed a skin tear measuring 1.1 cm x 0.5 cm. Left hip was cleaned with saline by V3, she then removed gloves, no hand hygiene, new gloves, dressing applied. After done applying dressing, V3 had removed gloves, washed hands with soap and water, put on new gloves. R362's incontinence brief was opened by V3 and V10. R362 was turned to her right side, two dressings were noted to the resident's left buttock and sacral area. R362's incontinence brief was noted to be wet and there was a small smear of stool. V3 said there was no stool, and surveyor pointed out the stool that was noted in between buttocks. V3 had removed the two dressings (sacral and left buttock) before providing incontinence care. There were two open wounds that were exposed to contaminant (urine and stool). V10 went to bathroom and filled 2 basins, one with water and body wash and other basin with plain warm water. V3 followed V10 into the bathroom and was heard talking Spanish to the V10, when V10 came from bathroom and went to the right side of bed with R362 facing her. V10 took a washcloth with water and body wash, V10 leaned over R362, V10's thighs, upper legs and abdomen were in direct contact with R362's when she leaned over the resident. V10 was wiping R362's stool from the rectal area, from front to back towards the open sores which were exposed, and this had open to cross contamination of the open wounds. Surveyor asked V10 to come around the bed to the side where she would be able to see what she was doing. V3 measured R362's wound on left buttock and the measurement were 1.0 cm x 0.5 cm x 0.0. Wound on sacral area 1.5 cm x 1.0 cm, x 0.0. V3 continued to clean R362's left buttock was cleaned with saline and applied skin prep and hydrocolloid dressing. V3 then proceeded with R362's sacral wound, cleaned with saline, skin prep applied, and hydrocolloid dressing. During this wound dressing observation, hand hygiene was not consistently implemented, only one time V3 was observed with hand hygiene despite multiple changing of gloves after removing contaminated dressings. V10 never did hand hygiene during the process. On 6/29/2023 at 11:30 A.M., V20 (Wound Care Physician) said that regarding Candida Auris, a group of specialists including epidemiologist guidance should be sought to ensure proper care and management of the infection. On 6/28/2023 at 1:25 P.M., V1 (Administrator) and V2 (Director of Nursing) said that staffing on the third floor were scheduled and assigned permanently as possible on the third floor. R362 resides currently on the third floor. V1 and V2 said that third floor currently housed 30 residents including R362. There were multiple facility's policies that were reviewed with V2 on 6/29/2023 at 1:30 P.M. 1. The facility's admission policy dated January 2011 shows: Before or at time of admission, the resident's attending physician must provide facility with information needed for immediate care of the resident .Acceptance of residents with certain conditions or needs may require authorization or approval by Medical director Administrator and DON . The Administrator through the admission department shall assure that the resident and facility follow applicable admission policies. 2. The undated facility's admission check list showed that it included checking to ensure any isolation was needed. 3. The facility's Physician Orders-Medication & Treatment policy dated 11/2027 shows that 1. The physician's orders shall be entered or transcribed in the resident's medical records. 2. Medications and Treatments shall be transcribed in the resident's medical records when ordered upon admission . 4. The facility's Admission Policy of Residents of Communicable Disease shows ensure to provide appropriate medical and nursing care Prior to or upon admission the infection control nurse will assess the following infection risk for each admission .A resident who is transferred to an acute facility with infection . should be reviewed prior to admission the facility. 5. The facility's policy dated 6/21/2023 regarding Transmission Based Precautions policy showed that the purpose of this policy is to summarize best practices for the use of transmission-based precaution to assist with decision making regarding the placement of residents with organisms of concern.XDRO (Extensively Drug Resistant Organisms) refers to organisms that being entered into the XDRO registry and conditions of these infections included but not limited to [NAME] Auris . Transmission based precautions are for patients known or suspected to be infected or colonized with infectious agents including will require additional control measures to effectively prevent transmission. When implementing TBP (Transmission Based Precautions) XDRO, contact precautions should be implemented with drainage that cannot be contained. 6. The facility's policy dated 1/2023 for Candida Auris shows that facility will implement the procedures for infection prevention and control for Candida Auris .Have healthcare personnel and visitor who enter the isolation room should have PPE donned prior to entering room including gown, gloves, and facial mask in case of unexpected contamination from the source of infection. When leaving the isolation room, removed PPE, dispose to appropriate receptacle, wash hands thoroughly. The soiled should be handled with the use of recommended disinfectant to prevent cross contamination. If family does laundry of the infected residents, should be given education how to handle soiled clothing using appropriate disinfectant. 7. The facility's wound care policy dated 11/2025 showed that staff should wash hands thoroughly before the dressing change, maintained clean barrier field, wash hands/hand hygiene after removing gloves. Do not cross contaminate by exposing open wound with no dressing with contaminants such as bowl, urine and bodily fluids. The Immediate Jeopardy that began on 6/19/2023 at 8:00 P.M., was removed on 6/29/2023 at 9:51 A.M. when the facility took the following actions to remove the immediacy: a. On 6-27-23, R362 was placed on strict contact precautions for C. Auris at 15:33pm (See attachment A) b. On 6-27-23, R362's care plan was also updated indicating strict contact isolation (cannot leave the room for therapy/dining/activities all services are provided in the room) versus previous contact isolation (can leave the room for therapy/dining/activities/services) (See Attachment B) c. On 6-22-23 the order for contact precautions was entered and implemented into the patients record. On 6/27/23 strict contact precautions were entered and implemented into the patient's chart (See Attachment C) d. On 6-26-23 the object which was the Debrox that was removed from the patient's room was discarded and a new medication was purchased. a. Contact tracing was conducted of all patients that were assigned to V10. Body assessments were completed, vitals monitored with no acute findings. (No redness, rashes or new skin alterations noted and no complaints of pruritus) (See Attachment D) b. Housekeeping immediately deep cleaned all resident rooms and patient areas including nurses station using an EPA approved cleanser for candida Arius. 2. All residents on the third floor were identified as having the potential to be affected by this alleged deficient practice. a. See attached census of residents on the third floor on 6/26 (total of 30 patients) (See Attachment E) b. On 6/26/23 skin assessments were completed for all resident on the third floor with no abnormal findings (no redness, rashes or new skin alterations noted and no complaints of pruritus) and will continue to be monitored and will notify physician for any changes of condition and immediately placed on strict contact isolation. c. Vitals were taken for all residents on the third floor with all patients remaining afebrile and will continue to be monitored and will notify physician for any changes of condition. d. All affected residents will be monitored for 30 days from potential exposure per the guidance of the [NAME] County health department. Facility has left messages with the IDPH communicable disease department to determine their guidelines. Will follow [NAME] County recommendations until able to speak with IDPH. 3. Measures, systems, and changes taken to prevent a recurrence of this alleged deficiency include but are not limited to: a. On 6-26-23, the Administrator, Director of Nursing, and Infection Preventionist reviewed the policy on the use of Transmission Based Precautions for XDROs and implemented the policy accordingly. (See Attachment F) b. In services will be completed by a total of 75% or greater at time of abatement 6/28/23 using in person and phone inservice (See attachment G) c. On 6-28-23, the Administrator, Director of Nursing, or designee in-serviced the nurses on the following topics: i. Upon admission physician orders will be entered into the medical records and implemented appropriately, especially with those requiring isolation precautions such as Candida Auris. ii. Upon admission, place the patient on appropriate precautions based on ongoing infection symptoms or ongoing infection. iii. When providing wound care prevent cross contamination especially during wound dressing change and peri care. iv. Any objects that are in a resident's room that is under contact precautions should be contained in the resident's environment. v. The staff shall not be allowed to work until they are in service on the topics stated above. vi. The administrator in serviced the infection preventionist and housekeeping director on educating the family. a. Type of isolation/precaution that needs to be practiced reducing potential for spread including but not limited to proper handling of laundry and other personal belongings vii. The Administrator in service the admissions team and clinical management staff to ensure that they are aware of the facilities clinical capabilities and are notifying the Administrator and DON of isolation status of a potential admission prior to admission. 4. How the facility will monitor its corrective actions to ensure that the deficient practice is abated, corrected, and will not recur: a. The Administrator, Director of Nursing, and or designee will conduct an audit using a QA tool on all admissions to check: (Attachment H) i. The admission order from the hospital or other SNF for contact, droplet, or enhanced barrier precautions was carried out and entered in the order section of the resident's medical record by the admitting nurse, then audited by the overnight nurse by using the admission checklist and then audited by the Director of Nursing or designee within 24 hours of admission. ii. If there is a care plan initiated indicating the type of precaution that needs to be implemented for the resident upon admission iii. If there is a bin outside the resident's door for PPE and appropriate signage placed outside the resident's door; iv. If there is dedicated medical equipment such as a BP cuff, stethoscope, and blood glucose machine (if indicated) inside the resident's room. v. If the resident and family education was provided on the type of infection control precaution and the use of PPE while inside the resident's room as well as education on how to handle laundry and personal belongings. vi. Staff compliance with the use of PPE when entering and exiting the room. b. The Administrator and/or designee will conduct an audit of all new admissions to ensure that isolation orders are followed and carried out as outlined above until the facility has achieved resolution c. The findings of the QA audit shall be submitted to the QAPI Committee which meets monthly. d. The QAPI Committee will review to determine the level of compliance and the need for additional training, corrective actions, and follow-up. 5. The QAPI Committee met on 6/28/23 to review the abatement plan and all members including the Medical Director agree with the implementation of the plan. 41855 B. Based on interview and record the facility failed to follow their Water Management Program and test yearly for the Legionella bacteria. This applies to all 77 (Census on form 672) residents residing in the facility. The findings include: The facility provided their Water Management binder. Review of the binder showed the facility water had been tested for the Legionella bacteria in September 2018. On June 29, 2023 at 12:46 PM V28 (Maintenance Director) and V29 (Assistant Maintenance Director) said they test the water temperatures in the building, but they are not testing the water for Legionella and do not think there is a company coming in to do it. On June 29, 2023 at 1:02 PM, V1 (Administrator) said they do not have a company coming to do annual testing. Facility provided policy dated October 2018, titled Water Management Program Policy and Procedure showed Policy: The facility will implement the Water Management Program to reduce the risk for Legionnaire's disease associated with the building water system and devices, reduce the growth and spread of Legionella bacteria in the facility, and to identify areas or devices in the facility where Legionella might grow or spread to people so the facility can reduce that risk 4. Control measures and Corrective Actions: .C. The following but not limited to are the areas that will be routinely checked: Quality of Water: On a quarterly basis a culture sampling and analysis shall be performed during the first year of the program and annually thereafter (and PRN (as needed) basis).

Based on observation, interview and record review, the facility failed to utilize chemical sanitizing solution at concentrations per manufacturer's instructions to sanitize food contact surfaces and sanitize equipment in the three compartment sink. This applies to all 77 residents residing in the facility. The findings include: Resident Census and Conditions of Residents form, dated 6/26/23, shows the facility census was 77 residents. Facility document, undated, shows there were two residents residing in the facility with physician orders that included NPO (nothing by mouth). On 6/26/23 at 10:20 AM during initial tour of the kitchen with V17 (Food Service Director), V23 (Cook) was swabbing his cook work station with a cloth from his chemical sanitizing solution bucket at his station. V17 stated the sanitizing chemical utilized in the sanitation buckets and in the three compartment sinks was quaternary ammonium and the concentration of the sanitizing solution was expected to measure between 150-400 ppm (parts per million). V17 stated kitchen staff fill their sanitizing buckets from the sanitizing solution prepared in the three compartment sink. V23 measured the concentration of the sanitizing solution in his sanitizing bucket and the concentration measured 100 ppm of quaternary ammonium. Above the three compartment sink, manufacturer's instructions for preparation of the chemical sanitizer utilized in the three compartment sink was posted above the sink. The instructions showed the final chemical sanitizing solution of the three compartment sink was expected to measure 150-400 parts per million. V17 measured the concentration of the chemical sanitizer in the third compartment which measured only 100 ppm. There were pots/pans and utensils soaking in the sanitizing/third compartment of the three compartment sink. Review of the HACCP (Hazard Analysis Critical Control Point) Sanitation Bucket PPM Log posted next to the three compartment sink showed staff measured the concentration of four sanitation buckets on both the AM shifts and PM shifts between 6/1/23 and 6/25/23 and recorded the results on the log. The log showed the concentrations of the sanitizing buckets only measured 100 ppm in all sanitizing buckets measured for the month. The log showed the concentration of quaternary ammonium was expected to measure 150-400 ppm or 200-400 ppm. Facility Manual Sanitizing In Three-Compartment Sink policy/procedure, dated 2001, shows, After washing and rinsing utensils and equipment are sanitized in the third sink by immersion in either: * Hot water . * Chemical sanitizing solution used according to manufacturer's instructions. Facility Sanitation Buckets/Wiping Cloths Food Contact Surfaces and Equipment Too Large To Immerse In The Sink policy/procedure, dated 2021, shows the concentration of quaternary sanitizing solution in the sanitation buckets was expected to measure 150-400 or 200-400 ppm per manufacturer's directions.

Based on interview and record review the facility failed to follow their Pneumococcal Vaccine Policy. This applies to 4 of 5 (R11, R27, R362, R364) residents reviewed in the sample of 19. The findings include: The resident's face sheet showed the following residents were greater than [AGE] years old and: 1. R11 was admitted to the facility on [DATE]. Consent dated May 21, 2023 showed family checked No, I do not want [R11] to receive the Pneumococcal Prevnar 23 vaccine because:_______. The form was not completed to show a reason for refusal or if any education had been done. R11's record did not indicate if she had previously received PCV13 (Pneumococcal Conjugate Vaccine). 2. R27 was admitted to the facility on [DATE] with a readmitted [DATE]. Consent dated August 10, 2022, prior to admission showed yes [R27] had received PCV 23 on October 1, 2021. Facility documented PCV23, full name Pneumococcal Polysaccharide PPV23 was given October 1, 2021. There was no clarification which vaccine the resident received PCV13 of PPSV23. 3.R362 was admitted to the facility on [DATE] Consent dated June 19, 2023 showed unable to recall date 2012. There was no documentation or follow up to identify which pneumonia vaccine R362 received in 2012. No documentation to show if education had been provided. 4. R364 was admitted to the facility on [DATE]. There was no documentation to show if [R364] had received any version of the pneumococcal vaccine, if facility offered the pneumococcal vaccine, or if any education was provided. On June 29, 2023 at 10:12 AM, V7 (Infection Prevention Nurse) said the facility will schedule vaccine clinics and the pharmacy will come into the facility to administer the vaccines. V7 said they offer PCV13 (Pneumococcal Conjugate Vaccine), Prevnar 23, and also PVC20. When a resident is admitted to the facility, the admission nurse will ask the resident or their representative if the resident has had any form of the pneumonia vaccine (PCV13, PPSV23, PCV20). If the resident or the resident representative are not sure of dates or which specific vaccine the resident received, V7 said he will notify the PCP (Primary Care Physician) the resident sees in the community. If we still are unable to figure it out, we will offer PCV20. Consent form was reviewed with V7. The form showed the pneumonia vaccine was referred to as pneumococcal or pneumococcal Prevnar 23 vaccine. Consent does not identify PCV13, PPSV23, or PCV20. V7 said he will write on the form what vaccine was given (PCV13, PPSV23, or PCV20). Facility provided policy titled, Pneumococcal Vaccine dated November 2017, showed Policy Statement Residents in the facility will be offered pneumococcal vaccine to aid in preventing pneumococcal infections .Policy Interpretation and Implementation .1. The staff of the facility should provide each resident or resident's representative education regarding benefits and potential side effects of the immunization. 2. Residents in the facility will be offered the vaccine unless medically contraindicated or if the resident has already had the vaccine 4 If refused, appropriate entries will be documented in each resident's medical record indicating the refusal of the pneumococcal vaccine.

Based on observation, interview and record review the facility failed to assess for food preferences and failed to provide nutritional interventions to maintain weight and prevent a significant weight loss. This applies to 1 of 2 (R11) residents reviewed for nutrition in a sample of 19. The findings include: R11's admission record shows her diagnoses included heart failure, pneumonia, and a fracture of the right femur with surgical repair. R11 was admitted for rehabilitation on May 21, 2023 with a plan to return to assisted living. R11's MDS (minimum data set) dated May 24, 2023 shows R11 is cognitively intact and requires only set up assistance for eating. R11's POS (physician order summary) of June 2023 shows her diet order to be regular consistency, thin liquids and NAS (no added salt). There was a nutritional supplement drink ordered one can daily on May 31, 2023. R11 also receives a diuretic medication daily, the dose has not changed throughout the month. An additional supplement, frozen nutritional cup was ordered on June 25, 2023. R11 experienced a significant weight loss. R11 weighed 119 lbs. (pounds) on admission and 105.1 lbs on June 25, 2023, an eleven percent weight loss over the month of June 2023. The nutrition progress note of June 25, 2023 shows R11's weight loss is not desired at this time. On June 26, 2023 at 11:25 AM, V15 (MDS Nurse) attributed R11's weight loss to being a picky eater, having edema and use of diuretic medication. R11's progress notes from May 30, 2023 through June 28, 2023, shows R11's HCP (health care provider) documented minimal non- pitting edema in both ankles once on June 19, 2023 and ten entries describing no edema in bilateral lower extremities. On June 26, 2023 at 12:00 noon there was no frozen nutritional cup observed on R11's lunch tray. On June 28, 2023 at 11:40 AM there was no frozen nutritional cup, but there was an unopened nutritional shake container on R11's lunch tray and R11 stated I'm not going to drink that. V17 (food service supervisor) stated on June 28, 2023 at 12:42 PM that there is no frozen nutritional cup in the facility as they are unable to obtain it from the food vendor for several months and it should not have been ordered for R11. A review of R11's June MAR (medication administration record) shows nurses initials for three times a day administration of magic cup from June 25 through June 28, 2023. On June 29, 2023 at 08:43 AM R11 stated she is being served too much food at mealtime. R11 further stated at home she usually eats smaller meals more frequently. R11 stated she usually eats dry cereal with milk and coffee and fruit juice for breakfast, has a mid -morning snack, and at lunch she eats a sandwich. If she goes out to eat, she likes a waffle with fruit and whipped cream. R11 described an eating pattern of six smaller meals during the day and at bedtime a snack of short bread cookies. R11 stated she also enjoys ice cream, pudding and cottage cheese with fruit. R11 had an unopened container of nutritional drink at the bedside and stated she prefers the drink to be cold or served over ice. There was no documentation of R11's food preferences in the EHR. On June 29, 2023 at 11:22 AM, V17 (food service supervisor) stated that there was no documentation of resident food preferences that they rely upon the select menu to obtain what residents prefer to eat. V17 further stated there is a spread sheet and menu available for six small meals per day and there is a select menu for that meal pattern. V17 was not aware of R11's prior eating pattern of six small meals a day or food preferences including cottage cheese and fruit, ice cream and pudding. The facility's policy Weight Assessment and Interventions, dated November 2015, shows Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents Interventions: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences .

Based on observation, interview and record review the facility failed to ensure a black mold like substance did not grow on the sides of the ice machine in the kitchen for 11 residents on the first floor (R20,R24,R30,R31,R44,R55,R58,R211,R212,R213,R214) reviewed for food serice safety. The findings include: On 09/19/22 at 8:46 AM, the ice machine in the kitchen had black mold like debris on the inside of the left and right walls of the ice machine. On 09/19/22 at 8:46 AM, V15-Dietary Manager said, maintenance cleans the ice machine. I will ask maintenance how often the cleaning is performed. On 09/21/22 at 11:15 AM, V1-Administrator said, the ice machine in the kitchen is used for the first floor residents. The facility provided a resident roster with the first floor residents on 09/19/22,showing R20, R24, R30, R31, R44, R55, R58, R211, R212, R213, R214 residing on the first floor. The facility's Ice Dispensing policy dated 2017 shows, the ice machine is cleaned at a frequency necessary to preclude accumulation of soil or mold.

Based on observation, interview and record review the facility failed to obtain a physician order for self-administration of medication for 3 of 18 residents (R24,R58,R211) reviewed for pharmacy services in the sample of 18. The findings include: On 09/19/22 at 9:14 AM, R211 had a bottle of aluminum hydroxide, magnesium hydroxide [MEDICATION(S)] suspension at the bedside. R211 said, at the hospital they screwed up my stomach, I must take an aluminum hydroxide, magnesium hydroxide, [MEDICATION(S)] solution in suspension before I eat. I take it three times a day before meals. On 09/19/22 at 12:24 PM, R58 had an [MEDICATION(S)] metered dose inhaler on the bedside table. R58 stated, that is my rescue inhaler. I use it when I need it. On 09/20/22 at 9:00 AM, R24 had oxymetazoline HCL 0.05% nasal spray, dextran polyethylene [MEDICATION(S)] tetrahydrozoline eye drops and two bottles of [MEDICATION(S)] [MEDICATION(S)] solution on the bedside table. R24 said, am I not supposed to have my medication there? None of the staff have said anything to me about it. On 09/20/22 at 9:00 AM, V13 RN-Registered Nurse said, I do not see physicians order for R24's [MEDICATION(S)] [MEDICATION(S)], R24 does not have an order to self-administer medication. R211 does not have a physician's order for self-administration of aluminum hydroxide, magnesium hydroxide [MEDICATION(S)] suspension. R58 does not have a physician's order for self-administration of the [MEDICATION(S)] inhaler. The facility's Self-Administration of Medications policy dated 10/25/2014 shows, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.

Based on observation, interview and record review the facility failed to ensure urinary catheter drainage bags and tubing were kept off the floor, and failed to ensure urinary catheter drainage bags and tubing were kept below the level of the bladder at all times for 2 of 6 residents (R36 and R58) reviewed for catheters in the sample of 18. The findings include: 1. R36's face sheet shows she was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's care plan shows she has an indwelling urinary catheter and the catheter bag and tubing should be kept below the level of R36's bladder. R36's Electronic Medical Record shows she has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/19/22 at 10:25 AM, R36's urinary catheter bag was lying flat on the floor next to her bed. On 9/20/22 at 10:03 AM, V11 and V12 (Certified Nursing Assistants/CNAs) were using a mechanical lift to get R36 up out of bed. Once the lift sling was underneath R36 and hooked up to the mechanical lift, V11 picked up R36's urinary catheter bag and raised it up above the level of R36's bladder. There was a small amount of urine in the tubing at this time. V11 then hooked R36's urinary drainage bag to the hook on the arm of the mechanical lift. As a result R36's catheter bag and tubing were above the level of her bladder during the entire transfer. On 9/20/22 at 10:56 AM, (V10) RN said urinary catheter bags should not be raised above the level of the bladder, it should be kept below the bladder, and held by staff down low during the transfer especially with urine in tubing. The facility provided Catheter Care, Urinary with a revised date of 11/17 states, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be held or positioned lower then the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are below the resident's bladder and kept off the floor. 2.On 09/19/22 at 12:15 PM, R58 was sitting in a wheelchair in his room. R58's indwelling urinary catheter's retention device was open. The indwelling urinary catheter was resting on the seat of the wheelchair weighted down by the drainage tube. The urine collection bag was hooked onto the right arm rest of the wheelchair above the level of R58's bladder. On 09/19/22 at 12:15 PM, R58 states, I have an indwelling urinary catheter because of Urinary Tract Infections. I need help getting out of bed. I have three new leg bags in my dresser drawer. The staff will not use them. The indwelling urinary catheter gets pulled out of the retention device when the staff pulls my pants down too quickly. On 09/21/22 at 10:16 AM, V13 RN-Registered Nurse said, urine collection bags should be placed below the bladder in a privacy bag under the wheelchair. It should not be on hung from the arm of the wheelchair. The facility's Catheter Care, Urinary policy dated, November 2017 shows, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review the facility failed to ensure a resident with dysphagia was supervised during meals for 1 of 18 residents (R36) reviewed for safety/supervision in the sample of 18. The findings include: R36's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: dysphagia (difficulty swallowing), urinary tract infection, urinary retention, muscle weakness, lack of coordination, and pneumonia on 8/11/22. R36's 8/26/22 facility assessment shows she has a cognitive impairment and requires extensive staff assistance with her activities of daily living (ADLs) On 9/19/2022 at 12:50 PM, R36 was lying in bed and her lunch tray was sitting in front of her on an overbed table. The tray had pureed food and a thickened glass of juice. R36 was falling asleep while trying to feed herself. There were no staff present in the room. There was sign dated 8/9/22 that was posted on the bulletin board next to R36's bed that showed, R36 is on swallowing precautions she requires a pureed diet with honey thick liquids and 1:1 assistance/supervision with meals. The sign also shows she is supposed to sit upright in a chair during and for 30 minutes after meals, take small bites and sips, alternate bites and sips, eat at a slow rate and not use straws. On 9/20/22 at 8:29 AM, R36 was sitting up in bed with her breakfast tray in front of her. She had her hand resting on the bowl of hot cereal. She had used a spoon to eat some of the ice cream which was leaking out of both sides of her mouth. There were no staff present in R36's room. R36 was asked by the surveyor how she was doing and she stated, terrible look at this, and pointed down at her meal tray. R36 also said she has not been feeling very well lately and needed more help because maybe its my time. On 9/20/22 at 10:56 AM, V10 (Registered Nurse/RN) said that R36 is supposed to be assisted during meals and someone should be in the room with her at all times while she is eating. On 9/20/22 at 10:47 AM, V9 (Speech Therapist) said she was not the person who had completed R36's prior speech therapy evaluations but based on the evaluation R36 is supposed to be a 1:1 level of supervision during meals because she has difficulty swallowing and is at risk for aspiration. R36's 8/8/22, Speech Therapy Evaluation and Plan of Treatment shows, Bedside swallowing assessment revealed a mod(erate) oropharyngeal phase dysphagia, and an observation of coughing with some consistencies. The same evaluation states, meds crushed in applesauce, 1:1 feeding assistance, sit upright for meals, stay upright for 30 minutes following meals, take small/single bites sips, alternate bites/sips and eat at a slow rate. R36's 8/21/22 Speech Therapy Discharge Summary shows that R36 needs maximum verbal and cues for swallowing and a delayed cough was observed with nectar-thick liquids and an occasional cough before and after swallowing food. On 9/21/22 at 11:20 AM, V1 (Administrator) said after the surveyor brought forth concerns about R36 eating alone in her room without assistance, she asked speech therapy to do another evaluation. R36's 9/21/22 Speech Therapy Evaluation and Plan of Treatment states the following: R36 is still requiring aspiration precautions, no straw, tray setup, assistance with feeding as needed d/t (due to) fluctuating alertness. Prior to this assessment R36 required supervision at meal times 91-100% of the time. R36 also needed feeding assistance due to fatigue. 26-49% of the time pt (patient) able to self feed however, recommend tray setup and feeding assistance as needed d/t fluctuating alertness and cognition.

Based on observation, interview and record review the facility failed to ensure protective dressings were in place to pressure injuries to 3 of 5 residents (R14, R53, R36) reviewed for pressure injuries in the sample of 18. The findings include: 1. On 9/19/22 at 9:53 AM, V4 (Certified Nursing Assistant-CNA) and V5 (Registered Nurse) turned R14 to her side. An open area was noted to R14's bottom covered with urine and stool. R14 said there is a hole in my butt, it hurts. V5 (RN) said there should be a dressing in R14's pressure injury. R14's Braden Scale pressure ulcer risk dated 9/10/22 show R14 score at 15-at risk. R14's treatment sheet dated 9/22 shows an order date of 9/11/22- Treatment order: Cleanse site to buttock apply [MEDICATION(S)] and cover with 4x4 dressing daily and PRN. R14's progress notes dated 9/19/22 show open area to right buttocks 1.5 centimeters (cm)-3.0 cm. On 9/21/22 at 1 PM, V2 (DON) and V8 (Wound Nurse) both said R14 has stage 2 pressure injury to her right buttocks. Both said treatments should be done and dressing should be in place to all wounds including pressure injuries per order to promote healing and prevent the wound from being infected. 2. On 9/20/22 at 8:30 AM, R53 was sitting in her wheelchair. R53 was complaining of pain to right heel. V7 (Registered Nurse-RN) removed R53's socks, a deep purplish discoloration noted to R53' right heel with no dressing in place. V7 said R53 has a deep tissue injury. (DTI) R53's Braden Scale pressure ulcer risk dated 9/15/22 show R53 score at 11- high risk. R53's Wound Treatment with order date of 9/16/22 show-Site: Right heel, apply skin prep and cover with foam dressing daily. R53's document entitled- Skin Evaluation dated 9/15/22 show- Resident has current skin issues. Skin Issue: Deep Tissue Injury (DTI) . Skin Issue Location: R HEEL A wound measurement dated 9/20/22 show DTI to right heel 4.5 cm to 7.6 cm. On 9/20/22 at 1 PM, V8 (Wound Nurse) said R53 prefers to have the foam dressing rather than the offloading boots. V8 said R53 should have the foam dressing in place to protect the right heel. R53's careplan dated 9/6/22 show actual skin impairment, right heel DTI with intervention of, monitor and document size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/21/22 at 10 AM, V2 (DON) said the facility is working on a better wound program. All wound treatment dressings should be in place. The facility's policy entitled Wound Prevention Program dated 2/22 show, .Implementation of preventive measures and/ or appropriate treatment modalities for ulcers are put into place according to the standard of care. 3. R36's 8/29/22 Braden Scale for pressure risk assessment shows she is bedfast, her ability to change positions is very limited, her skin is occasionally moist, and she requires maximum assistance moving. Her pressure ulcer risk score is 11 showing she is high risk for pressure ulcer (injury) development. R36's 9/12/22 skin evaluation shows she has a stage 2 pressure injury to her sacrum measuring 1.0 centimeter (cm.) x 1.0 cm. and 0.1 cm deep. R36's September 2022 Treatment Administration Record shows she is supposed to have a dressing on her sacrum and a daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/22 at 9:18 AM, V11 (CNA) was doing incontinence care on R36. She had taken off R36's incontinence brief and R36 had some stool on her buttocks and V11 was cleaning her up. There was a dime size open area to R36's sacrum that had no dressing on it. The area was pink around the edges, white center and a small amount of clear fluid was observed in the wound bed. V11 said she does not typically work that hall and was unaware of how long R36 has had the pressure injury. V11 said she had cleaned up R36 earlier that day and did not notice the wound at that time. V11 said she would tell the nurse immediately that R36 needs a dressing put on. On 9/20/22 at 9:50 AM, V8 (Wound Nurse) came into the room to apply a new dressing to R36's pressure injury. V8 said she has been on vacation for a couple weeks and was not sure how long R36 has had the pressure injury but R36 should have a dressing on it all the time. V11 was assisting V8 and said that she had checked the hospice book and R36 was given a bed bath last evening by hospice so maybe they took the dressing off her and forgot to tell someone. The facility provided wound care policy revised on 1/2019 states, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.14. Dress wound as ordered by physician.

Based on observation, interview and record review the facility failed to provide assistance to residents that need extensive assist with Activities of Daily Living (ADLs) to 2 of 18 residents (R14 and R53) reviewed for ADL's in the sample of 18. The findings include: 1. R14's facility assessment dated [DATE] show R14 needs extensive assist for toileting and bed mobility. The same assessment show R14 is always incontinent of bowel and bladder. On 9/19/22 at 9:53 AM, R14 was in bed. R14 was permeating with strong smell of urine and stool. R14 was turned to her side by V4 (Certified Nursing Assistant-CNA) and V5 (Registered Nurse) R14's incontinent pad was fully saturated with urine and stool. Large amount of stool was all over R14's back area. R14's bed was also soaked with urine. R14 said the last time she was changed was at 4 AM. V4 (CNA) said she has not had a chance to change R14. On 9/21/22 at 8:30 AM V16 (Registered Nurse) said resident should be changed every 2 hours and as needed to keep them clean and dry. 2. R53's facility assessment dated [DATE] show R53 needs 1 person physical assist for eating On 9/19/22 at 9:30 am, R53 was lying sideways trying to get up from bed. R53 stated please pull me, please help me, I want to sit up. I want to eat breakfast. R53 was trying to reach her breakfast tray. R53's breakfast tray was on top of overbed table that was more than an arms length away from R53. R53's breakfast tray was covered, was not set up, and the milk was still unopened. This surveyor went to find a staff for R53. V4 (Certified Nursing Assistant-CNA) said she was the one who served R53's breakfast tray at around 8:00 AM. V4 said she thought R53 did not want to eat so she just put the tray on top of the overbed table. V5 (Registered Nurse) said R53's breakfast tray should be within reach. V5 also said R53 needs assistance when eating. The facility Policy on Activities of Daily Living dated 1/22 show Residents will receive assistance with ADL's every shift, as appropriate.

Based on interview and record review the facility failed to follow R20's physicians orders for one of eighteen residents reviewed for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: On 09/20/22 at 1:59PM, V13 RN-Registered Nurse said, residents are weighed on admission. R20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's Medical Record on 09/20/22 showed, R20 was weighed 08/04/22. No other weight record was available for R20. R20's Physicians Orders dated 08/04/22 shows, weigh resident weekly times four.

Based on observation, interview and record review the facility failed to accommodate a longer bed for a tall resident. This applies to 1 of 18 residents (R111) reviewed for accommodation of needs in the sample of 18. The findings include: R111's electronic medical record show R111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R111's height was documented as 75 inches (6 foot and 3 inches). On 9/19/22 at 10:34 AM, R111 was in bed. R111's legs were bent and R111's both feet were resting directly on the foot board. V14 (POA-Significant other) requested to talk to this surveyor who was at bedside. V14 said R111 has been in the facility since Thursday 9/15/22. V14 said she told the staff that R111 is a tall guy- 6 foot 3 inches and will need a longer bed. V14 said still today (9/19/22) R111 has been placed in this short bed. V14 said R111 does not like his feet resting on the foot board. At 11 AM, this surveyor pointed out to V6 (Registered Nurse) that R111 cannot straighten his legs because the bed was short. V6 (Registered Nurse) confirmed that R111's bed is too short for him. V6 said R111 should have been provided an appropriate bed. On 9/20/22 at 9 AM, V3 (Maintenance Director) said no one informed him that R111 needed a longer bed. V3 said there are beds that can be extended 5 inches. V3 said resident's durable medical equipment (DME) should be provided and appropriate to the residents.

Based on interview and record review, the facility failed to ensure a resident's safety while in bed when a staff was rendering care, leading to a resident's fall from bed. This applies to 1 of 4 residents (R1) reviewed for safety in the sample of 4. The findings include: R1's progress note dated September 23, 2020 at 9:15 PM showed (V8) CNA (Certified Nurse Assistant) was rendering patient care. While turning on left side, (R1) overturned and fell off the bed. (V8) called for help and two nurses came to assist. Upon entering, noted (R1) lying on his left side. Upon head to toe assessment, (R1) remained alert and oriented X (times) 3. Verbally responsive. Noted minimal bleeding and laceration (2 cm) to occipital area The same progress note shows R1 was sent to the local hospital. R1's progress note dated September 24, 2020 shows R1 returned back to the facility with a one inch laceration. V8 is no longer working at facility. V8's written statement showed I proceeded to clean (R1) up while (R1) turned on his left side,he fell off the bed on his left arm and head. I quickly told the nurses that he had fallen, they came quickly while I stayed with R1. We then got him off the floor using the (mechanical) lift, back in bed. The facility's Post Fall Investigation dated September 24, 2020 under conclusion shows the contributing factor for R1 falling from the bed was staff rendering patient care, while turning on left side, guest (R1) overturned and fell . R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and discharge from facility on October 16, 2020. R1 has multiple diagnoses including multiple [CONDITION(S)], enterocolitis due to [CONDITION(S)] -recurrent, acute pyelonephritis (inflammation of kidney due to bacterial infection), muscle weakness, urinary tract infection, gastrointestinal hemorrhage, chronic embolism and [CONDITION(S)] of deep vein right upper extremity, long term (current) use of anticoagulants, flaccid neuropathic bladder, and unspecified severe protein-calorie malnutrition. On May 20, 2021 at 11:29 AM, V4 (Physical Therapist) stated when repositioning a resident, the staff first needs to explain to the resident what they are going to do. If the resident has good upper body strength, they are asked to help reach over to the side of bed they are turning towards. They can grab onto the mattress to help pull themselves over. The staff needs to make sure the resident is not to close to the edge they are turning towards. If the resident needs to be moved away from the edge of the bed, they will need to pull the resident closer to them before turning. On May 20, 2021 at 11:37 AM, V2 DON (Director of Nursing) stated her expectation when a staff is repositioning a resident is that, they make sure the resident is in center of bed and has enough room to turn. The residents are to always have a draw sheet under them that can be used to pull resident towards the staff and away from edge of bed they are turning towards. Facility provided competency undated and titled Competency on Turning and Repositioning of a Resident. There are a total of 10 steps listed, .#4. The staff lowered the head of the bed to a level appropriate for the person; it is as flat as possible, #5. The staff stood on side of the bed opposite to where the resident will be turned, . #7. The staff placed her/his hand on resident's shoulder and the other hand on the hip area and gently roll the resident to the left or right . Facility provided undated policy title (the name of the facility) Policy and Procedure Turning Patient to Side-Lying Position The purposes of this procedure is to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. Procedure: There are total of 11 steps listed, . #5. Using the draw sheet ensure proper positioning in preparation for turn, #6. Cross the patient's arms over their chest, #7. Bend the leg towards you, #8. Gently pull across the hip and the shoulder so that the patient rolls towards you .

Based on observation, interview and record review, the facility failed to obtain food preferences for a resident who was identified as high risk for weight loss; failed to obtain weekly weights as ordered by the Physician and failed to provide nutritional assessment as per facility's policy and procedure in order to prevent a drastic weight loss. This failure resulted in R143 not eating his meals and having significant weight loss (16%) in two weeks. This applies to 1 of 1 resident (R143) reviewed for weight loss in the sample of 12. The Findings Include: Review of R143's electronic health record (EHR) showed R143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R143's 5 Day Minimum Data Set ((MDS) dated [DATE] showed R143 with Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS also showed R143 requires minimum assistance of one staff member for bed mobility, transfer and hygiene. The MDS also showed R143 requires supervision with meals. The MDS swallowing/nutritional status section showed R143 with no swallowing problems. The nutrition section also showed R143 weighed 198 pounds on admission and his height was 70 inches. The section also showed R143 was on therapeutic diet. On 6/18/18 at 2:55pm, R143 was sitting in a chair in his room with V13 (family member). R143 was noted to have bilateral lower extremity [MEDICAL CONDITION]. R143 was alert and oriented times three. R143 stated he was admitted to the facility about two weeks ago after an abdominal surgery. R143 and family member complained about food choices since admission. R143 stated the menu given to him does not have varieties of food items he could eat. Family member also stated as a result of this R143 has not been eating his meals. R143 stated gravy is added to most facility's meals and he does not like gravy. On R143's bedside table, there was a cup of cold water and a cup of coffee for the family member. There were no snacks or any food items observed in R143's room. On 6/19/18 at 10:35am, V4 (Dietitian) stated she comes to the facility on ce a month for 8 hours. V4 stated she only sees residents that are high risk. When asked to define high risk. V4 stated she sees residents with pressure sores and weight loss. V4 stated her last visit to the facility was on 6/11/18 and she did not see R143 because he was not on her list of residents she had to see. V4 further stated she believed someone in the facility met with R143. On 6/19/18 at 12:01pm, V2 (Director of Nursing) DON stated normally dietitian or someone from the dietary meets with new residents. V2 stated the facility did not have a dietary manager for some time but someone started yesterday (6/18/18). V2 further stated someone should have done the dietary assessment for R143. On 6/19/18 at 12:31pm, V1 (Administrator) stated menus are given to new admits within 24 hours to fill out. V1 stated the facility has been out of a dietary manager for about six weeks. V1 stated V12 (Assistant Dietary Manager) was supposed to fill in the gap but because of the workload the facility acquired outside company to monitor new residents, fill out nutritional assessment. V1 stated the expectation is for the dietary technician or Food service manager to see newly admitted residents within 24 to 48 hours for their food preferences. On 6/19/18 at 2:44pm, V1 stated the facility hired a dietary technician about a month ago. V1 stated apparently the process is broken because the old Food service manager was no longer around and the newly hired dietary technician has not been coming to the facility as scheduled. R143 should have been seen for his food preferences. On 6/19/18 at 2:44pm, V4 also stated R143's record showed R143 eats about 75-100% of his meals. On 6/20/18 at 2:23pm V1 stated, the process fell off with the absence of dietary technician. On 6/20/18 at 2:27pm, V5 (Dietary Technician) stated she was hired by the facility about a month ago. V5 stated she visits once a week but did not on the week of (MONTH) 3 to (MONTH) 8 because of family commitment. V5 stated the dietitian was supposed to visit when she was absent. V5 stated she tried to visit R143 on 6/15/18 but R143 was not in his room. V5 stated she did not see R143 on 6/15/18 but wrote the nutritional assessment notes. V5 stated she wrote the 6/15/18 assessment note based on the information she obtained from Matrixcare. The information included height, weight, gender, appetite, diet, and consumption. When her note was shown to her, V5 stated I wrote the notes but did not see this particular resident. V5 understood her role as to visit new admissions and perform a dietary assessment. On 6/20/18 at 8:40am, V13 (Family Member) stated she stays with R143 most of the day because she currently resides in the hotel across the street from the facility since she and R143 are primarily from out of state. V13 stated she consumes most of R143's meals because he would not eat it and that the girls know about it. V13 stated what is the point wasting the food when (R143) would not eat. V13 did not want the food to be wasted. When asked about obtaining a guest tray, V13 stated she cannot afford to purchase $10 guest tray on a daily basis because she is also paying for her hotel stay. V13 stated the girls would sometime give her a tray when there is an extra one, but they have not done that lately. V13 further stated R143 was served sausage links for breakfast on 6/19/18 which he was not able to eat. On 6/20/18 12:40pm, V11 (Nursing staffing coordinator/reception) stated guest trays are usually $5 and the kitchen needs to be notified two hours prior to lunch. V11 stated there was no guest tray order for (V13) today. Review of R143's Physician order [REDACTED]. On 6/20/18 at 11:30am, V7 (Physician) stated R143's weight loss issues has not been brought to his attention. V7 stated he can only address issues that were brought to his attention. When briefed regarding R143's drastic weight loss, V7 stated R143 should have been seen by a dietitian for his food preferences and the doctor's order for weekly weights should have been followed. On 6/20/18 at 11:45am, V8 (Nurse) stated she is a regular nurse on the second floor and she has cared for R143 many times. V8 stated R143 eats fair amount and not too much. V8 stated R143's wife shares his food with him. V8 further stated Certified Nursing Assistants (CNAs) obtain resident's weights as it appears on their to do list. V8 just realized weight was not done weekly as ordered. On 6/20/18 at 11:55am, V9 (CNA) stated she had served R143 his meal trays many times. V9 stated she thinks R143 eats even though she did not physically see him eat but she collects his trays. V9 stated V13 is always in the room with R143. On 6/20/18 at 12:05pm, V10 (CNA) stated she served R143 a late lunch on 6/19/18 because R143 was down in the therapy room. V10 stated R143 ate about 50% of his lunch meal at that time. V10 stated V13 did not ask for extra lunch tray yesterday when she served R143 but she sometimes gives V13 a tray when there is an extra tray available. Review of R143's weight history showed R143 with an admission (6/5/18) weight of 197.8 pounds. The history also showed no recorded weekly weight as ordered by Physician. The next weight record was obtained on 6/19/18 after being prompted by the surveyor and it was 165.6 pounds. This showed R143 with a 16% significant weight loss. Review of R143's care plan initiated on 6/6/18 showed: R143 has/at a risk for weight gain/loss related to recent abdominal surgery, infection, [MEDICAL CONDITION] with a goal of maintaining adequate nutritional intake to keep body weight +-5pounds on normal body weight. One of the approaches on the care plan showed, Record weights as ordered and report weight loss or gain of 5pounds or more to the Primary Care Physician (PCP). The facility failed to follow this approach. Review of facility's policy and procedure titled, Dietary Department-Organization and Staffing dated 2010 showed, Dietary Manager or designated person will visit newly admitted residents to obtain food preferences, complete a nutrition assessment and participate in care plan conferences. Review of facility's policy and procedure titled, 'Dietary Department-Nutrition Therapy' dated (YEAR), showed, New admissions may be weighed weekly for the first four (4) weeks.