Every finding on record at Berrien Oaks Nursing and Rehab Center

Based on record review, and staff interviews, the facility failed to develop a care plan for an indwelling Foley catheter for one of three sampled residents (R) (R2), who were observed for perineal care. The deficient practice increased the risk that care would be omitted for R2. Findings includeReview of the admission record revealed R2 was admitted to the facility on [DATE], with the following diagnoses that included, but were not limited to, type 2 diabetes mellitus, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypothyroidism, and right below the knee (BKA).Review of the care plan dated 02/05/2019 and revised on 08/04/2025 revealed, R2 was incontinent of bowel and bladder. Interventions documented that resident was dependent for toileting hygiene; observe for incontinent episodes and assist with incontinence care as needed after each episode. There was no evidence of a care plan for the indwelling Foley catheter.During an interview on 08/25/2026 at 2:30 PM, the Minimum Data Set (MDS) Coordinator revealed that she had not developed a care plan for the indwelling Foley catheter. She stated that when the resident returned from the hospital, she thought that the indwelling catheter had been removed.

Based on observations, staff interviews, and review of the facility policies titled, Catheter Care, and Bowel and Bladder Incontinence, the facility failed to ensure one of three sampled residents (R) (R2), who received perineal care was thoroughly cleaned and free of feces. The deficient practice increased the risk of urinary tract infections for R2.Findings includeReview of the facility policy, Catheter Care revised 03/09/2005, documented, STANDARD: Urinary meatus needs to be cleaned and free of secretions.Review of the facility policy, Bowel and Bladder Incontinence revised 08/2026, documented Policy: To provide guidance in the preventive measure for controlling common infections for incontinent residents as part of the overall infection control program. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections.Review of the admission Record revealed R2 was admitted to the facility on [DATE], with the following diagnoses that included, but were not limited to, type 2 diabetes mellitus, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypothyroidism, and right BKA {below knee amputation}.An observation on 08/20/2026 at 11:30 AM revealed R2 had a right amputation above the knee (AKA) instead of a below the knee amputation (BKA), and an indwelling Foley catheter. Certified Nursing Aide (CNA) UU was on the left side of the bed and removed the brief. CNA UU stated she came to check the resident. R2's Foley catheter was observed with dried black feces on the tubing and there were black flakes on the sheet. CNA UU had a package of wipes in her hand, however there was only one wipe in the package. She then went back to the bedside drawer and located another package and turned to clean the bowel movement off the resident. CNA UU stated she had finished cleaning the resident, but forgot to get a brief, so she left the room. When CNA UU returned to the room with a brief, she placed it on the resident and before securing the brief she turned the resident for inspection of skin, secured the brief and stated that she was finished with perineal care.An observation on 08/20/2026 at 11:40 AM Registered Nurse (RN) FF Supervisor and Infection Preventionist (IP) RN VV were asked to check R2 for cleanliness. RN FF and RN VV stated that there were black flakes on the sheet and a dried black substance remained on the Foley catheter tubing. When RN VV wiped the area near the Foley catheter insertion, there were feces on the wipe. RN VV removed the feces that were left on R2 by CNA UU.Review of Task documentation dated August 2026 revealed R2 was receiving daily perineal care.Review of the hospital discharge documentation dated 04/21/2026 and 05/10/2026 revealed R2 was admitted to the hospital with the following diagnoses that included, but were not limited to, hyponatremia, heart failure with reduced ejection fraction, severe sepsis and urinary tract infection.Review of an Inservice Summary dated 08/05/2026 and 08/06/2026 revealed CNA UU attended the inservice that covered perineal care and Foley catheter care.During an interview on 08/20/2026 at 11:30 AM, CNA UU revealed that the resident was cooperative today so she should have turned R2 over and cleaned the Foley catheter by holding the catheter tubing and then wiping downward.During an interview on 08/25/2026 at 2:24 PM, RN FF revealed that there were dried feces on the Foley catheter tubing and specks of feces on the sheet and when R2 was wiped with a clean wipe, there were feces in the vagina area. RN FF confirmed R2 was not thoroughly cleaned.

Based on observations and staff interviews, the facility failed to ensure pureed meals were prepared according to standardized recipes and appropriate consistency requirements for eight of eight residents who received a pureed diet. Specifically, pureed meals were not consistently prepared or served in a manner that maintained appropriate texture, appearance, palatability, and safety for residents with swallowing difficulties. This deficient practice had the potential to affect all residents receiving pureed diets by placing them at risk for choking, aspiration, poor nutritional intake, and decreased quality of life.Findings include:Observation on 05/11/2026 at 11:00 AM of puree preparation revealed that a recipe was not followed. The cook put some chicken salad in the blender, then she added water (did not measure the amount) she then put some chicken bouillon seasoning in a small Styrofoam cup and added it to the blender, she then blended the mixture, then checked it, and it appeared to be to have too much liquid in it because she then got another small Styrofoam cup and dipped some thickener out of a container, and then added it to the mixture, she then blended some more at which time she added more water. Nothing was measured during the process.Interview on 05/11/2026 at 11:15 AM with the [NAME] confirmed that she had been at the facility for eight years, and in those eight years, she had never used a recipe. She stated that she went by the consistency, and since she had been doing this so long, she knew what it should look like. Interview on 05/11/2026 at 11:30 AM with the Dietary Manager confirmed that they did not use recipes when preparing the puree meals.

Based on observations, staff interviews, and review of the facility policy titled, Food Storage: Cold Food Items, the facility failed to ensure that food was properly labeled and dated and in sanitary conditions to prevent foodborne illness. The deficient practice had the potential to affect 94 residents of 95 who received meals from the kitchen.Findings include:Review of the facility policy titled Food Storage: Cold Food Items revealed under Procedure: . 5. Cold foods are to be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination.A tour on 05/11/2026 at 9:45 AM with the Dietary Manager revealed the following concerns: Observation of the walk-in refrigerator revealed a bag of finely diced cabbage with carrots, a package of cooked ham, a piece of open ham, an open pack of what appeared to be sliced turkey, and a block of cheese, all with no label or date.Observation of the walk-in freezer showed a bag of zucchini, a bag of grilled cheese, and a package of green vegetables, all with no label or date.Observation of the dry food storage revealed expired cornmeal and flour in large containers. Interview on 05/11/2026 at 9:45 AM during the tour of the kitchen with the Dietary Manager confirmed all identified concerns. He immediately labeled and dated all items that were not labeled or dated. He confirmed that he was responsible for ensuring all food was labeled with open dates/ expired dates to ensure the safety of residents. Interview on 05/11/2026 at 10:30 AM with the [NAME] revealed that they all staff were responsible for making sure the food was labeled and dated when it came off the truck.

Based on observations, record review, and staff interviews, the facility failed to ensure an indwelling Foley catheter drainage bag was covered to maintain dignity for one of three residents (R) (R57) reviewed for catheter care and dignity. This deficient practice had the potential to compromise the personal dignity of R57 by exposing clinical urinary waste to public view.Findings include:A review of the facility's electronic medical record (EMR) revealed R57's most recent admission to the facility was on 05/01/2026 with diagnoses including, but not limited to, retention of urine and presence of urogenital implants.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] for R57 revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive decline. Section C (Cognitive Patterns) indicated severe cognitive impairment; a status of dependent for personal hygiene, Section GG (Functional Status), no indicators for rejection of care, Section E (Behavior), presence of an indwelling catheter.A review of the care plan for R57 dated 05/08/2026 revealed a focus area stating, I am incontinent of bowel and have a Foley Catheter. The goals with a target date of 08/06/2026 stated that R57 will not have complications from use of catheter such as pain, infection, or obstruction through next review. The interventions stated that staff should anchor catheter tubing to leg, avoid excessive tugging on catheter during delivery of care/transfers, utilize a catheter bag cover, complete catheter care every shift and as needed, check catheter tubing for proper drainage and positioning, and keep the drainage bag below level of the bladder at all times and off the floor.A review of physician orders revealed multiple active urinary retention and precaution orders, including but not limited to: Change 18fr (French) foley catheter with 10ml (milliliter) bulb to BSD (bedside drainage) bag starting on the 15th and ending on the 15th every month for urinary retention; Change foley catheter as needed for pain, blockage; Ensure catheter care completed every shift for urinary retention; Ensure foley catheter privacy bag in place every shift for urinary retention; and Enhanced Barrier Precaution (EBP) every shift for foley catheter.Observation on 05/11/2026 at 11:45 AM revealed R57 lying in bed. The resident's Foley catheter drainage bag was uncovered, leaving urine fully exposed to public view.Observation on 05/12/2026 at 09:45 AM revealed R57 lying in bed. The resident's Foley catheter drainage bag remained uncovered with the urine waste visibly exposed.Observation on 05/13/2026 at 11:05 AM revealed R57 in bed with the covers pulled over his head. The resident's Foley catheter drainage bag remained completely uncovered and visible to anyone entering the room.Observation and interview on 05/13/2026 at 11:23 AM with the Infection Preventionist (IP) revealed upon witnessing the exposed catheter drainage bag, the IP stated it was her expectation that Foley bags must be maintained in privacy bags at all times to preserve resident dignity.Interview on 05/13/2026 at 12:13 PM with the Director of Nursing (DON) revealed it was her direct expectation that catheter bags must be covered for dignity purposes.Interview on 05/14/2026 at 1:30 PM with the Administrator revealed a review of the above findings. The Administrator stated that these findings confirmed deficient practice, confirming that catheter drainage bags should not be left uncovered.

Based on observations, record review, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to assess for and obtain a physician order for the ability to self-administer medications for one of 58 sampled residents (R) (R3). The deficient practice had the potential for residents and visitors to access medications and experience adverse effects.Findings include:A Review of the facility's Medication Storage policy dated 12/08/2023 indicated under Policy: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. A review of the facility's electronic medical record (EMR) revealed R3's most recent readmission to the facility was on 03/09/2026 with diagnoses including, but not limited to, pressure ulcer of left heel (unstageable), pressure ulcer of the right heel (stage 4), type 2 diabetes mellitus, history of cardiovascular accident (CVA) with functional quadriplegia, and benign prostatic hyperplasia with lower urinary tract symptoms including ESBL (extended-spectrum beta-lactamase) positive Klebsiella/E. coli.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R3 revealed a Brief Interview for Mental Status (BIMS) score of 15 in Section C (Cognitive Patterns), indicating intact cognition; a status of dependent for all Activities of Daily Living (ADLs) in Section GG (Functional Status); the presence of an indwelling catheter in Section H (Bowel and Bladder); and the presence of active treatment for pressure ulcers in Section M (Skin Conditions).A review of the care plan for R3 dated 11/02/2022 and revised on 03/17/2026 revealed no documentation or assessment for self-administration of medications.A review of physician orders revealed no orders for self-administration of medications for R3.Observation on 05/11/2026 at 11:51 AM revealed R3 lying in bed with several topical medications left unsecured and unattended on the overbed table, the bedside dresser and at the sink. These findings included triple antibiotic ointment, hydrophilic wound dressing, antifungal cream, and Nystatin powder. Dermal wound cleanser was further observed on the overbed table immediately adjacent to the resident's breakfast tray.Observation on 05/12/2026 at 11:23 AM, immediately upon entering the room for wound care, revealed that all wound care medications remained unsecured on the bedside dresser and at the sink. During concurrent interviews, the Infection Preventionist (IP) and Wound Care Nurse acknowledged the safety risk of these findings, prompting the IP to immediately confiscate and discard the unsecured topical medications.Interview on 05/13/2026 at 12:13 PM with the Director of Nursing (DON) stated it was her expectation that all wound care supplies and medications remain secured on the medication and treatment carts. She further noted that leaving them at the bedside deviated from both the medication storage policy and her expectations for staff compliance.On 05/14/2026 at 1:30 PM, an interview with the Administrator stated that these findings were unacceptable practices, confirming that medications should not be accessible to residents or visitors as it constitutes an accident hazard.

Based on observations, record review, staff and family interviews, and review of the facility's policy titled, Elopement and Wandering Policy, the facility failed to ensure safety for one of 48 sampled residents (R106). Specifically, the facility failed to provide adequate supervision and monitoring for R106 related to wandering and elopement. This deficient practice had the potential to place R106 at risk for safety concerns including but not limited to physical and/or mental distress.Findings include:Review of the facility's policy titled Elopement and Wandering Policy with an effective date of 07/09/2018 documented under Policy:This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Under Policy Explanation and Compliance Guidelines revealed: . 2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. d. Adequate supervision will be provided to help prevent accidents or elopements. 7. d. DON (Director of Nursing) or designee shall notify the physician and family member or legal representative. f. Once the resident is located all parties will be notified of the outcome. g. Appropriate reporting requirements to the State Agency shall be conducted. 8. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. f. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. g. Documentation, physician/family notification, care plan discussions, and consultant notes as applicable. Tips for Prevention of Elopements: Consider use of a Chain of Custody for High Risk Residents; develop a schedule for periodic checks on the resident; never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff and whoever is involved in the resident's care even for a short period of time. R106 was admitted to the facility on [DATE] with diagnoses that include, but not limited to, Alzheimer's disease and unspecified dementia, unspecified severity, with other behavioral disturbance.Review of the 04/20/2025 Comprehensive Minimum Data set (MDS) assessment for R106 revealed a Brief Interview for Mental Status (BIMS) score of 3. indicating severe cognitive impairment. Section GG, Functional Abilities and Goals revealed: Has not exhibited the behavior of wandering. Walking not attempted due to medical condition or safety concerns. Section H, Bladder and Bowel revealed: Occasional urinary incontinence (7 episodes of incontinence) and occasionally incontinent of bowel (one episode of bowel incontinence). Section N, Medications revealed: Takes an antipsychotic, antidepressant, and a diuretic 7 out of 7 days. Section P, Restraints revealed: No physical or electronic alarm devices used to monitor the movement of R106. Care Area Assessment (CAA) results include, but not limited to, cognitive loss/dementia, visual function, communication, urinary incontinence, and falls. No behavioral symptoms assessed. Review of the care plan for R106 initiated 07/05/2023 and revised 05/14/2025 revealed a focus that R106 has the potential for altered thought process, impaired cognition, and/or altered psychosocial well-being related to Alzheimer's disease, psychotic disorder, depression, and dementia as evidenced by confusion at times, impaired decision making, memory problems, disorganized thinking, wandering, delusions, will frequently remove hard cervical collar or decline to wear it. Goal is R106 will have optimal quality of life by socializing with others, attending activities, and involvement with care with a target date of 1/13/2026. Interventions include, but is not limited to, if R106 is wandering, ask if you can help her find something, observe for and document behavioral disturbances, observe ability to follow directions and assist with decision making as needed.There was no specific care plan in place for wandering / elopement for R106Review of physician orders for R106 revealed an order dated 06/27/2023 to chart observed behavior: 0. None, 1. Continuous crying/yelling, 2. Continuous pacing, 3. Hitting, 4. Kicking, 5. Head banging, 6. Scratching, 7. Biting, 8. Hallucination, 9. Paranoia, 10. Delusions, 11. Other.Review of the electronic medical record (EMR) for R109 revealed a progress note dated 10/13/2025 that stated, At approximately 00:15 am (12:15 AM) CNA (Certified Nursing Assistant) came to this nurse & (and) stated that she went in to check on resident & that she could not find her. This nurse, another floor nurse & (and) all CNAs looked all throughout building trying to locate resident (R106). Several staff members went outside in front & behind building to look for resident. Hospital security guard helped look also. 911 was called. This nurse notified DON (Director of Nursing). As police arrived, a CNA came up to front door & stated resident had been found. Resident was located in a bathroom that had light burned out, lying on back in bathtub. Resident was assessed for injuries; no injuries notified. Several staff members assisted resident from bathtub to W/C (wheelchair). Resident further assessed for injuries; none noted. Resident took to her room & assisted to bed. Resident kept stating that her husband had left her for another woman. V/S (Vital Signs) Temperature 97.5, pulse 78, respirations 18, BP (Blood Pressure) 130/72, O2 (Oxygen) saturation 98% on room air.Review of a progress note dated 10/05/2025 stated, Nurse from east wing noticed that someone passed by door near room [ROOM NUMBER]-160 and told her CNA someone was outside. She sent CNA down to look. This writer was down hallway at room [ROOM NUMBER] when resident came walking up sidewalk ramp pushing her wheelchair to come into the door. Resident never left the sidewalk from going around the buliding [sic]. Resident was brought back into the building and assessed. Resident had only been outside approximately 10 minutes because she was beside this writers [sic] medication cart when I was down by room [ROOM NUMBER] checking blood sugars and she was sitting there with me. She had just returned to the facility from spending the day with her family.Review of a progress note dated 09/10/2025 stated, Local hospital housekeeping staff notified this nurse that a resident was wandering the halls at the hospital in a w/c. Immediately went over to hospital and found resident propelling self down hallway with c-collar (cervical collar) in lap. C-collar reapplied and resident brought back to facility via w/c. Assessed locked doorway to and doorway locks without difficulty. Spouse, notified of incident. No s/s (signs and symptoms) of injury noted.Further review of the EMR revealed that R106 had no assessments completed for risk of elopement and unsafe wandering since admission to the facility on [DATE].Review of the Facility Reported Incidents (FRIs) since the last standard survey on 04/17/2025 revealed no FRIs related to R106's elopement on 10/05/2025.Review of care plan meetings for R106 revealed the last documented care plan meeting for the year 2025 was dated 01/07/2025 and there was no documentation in the notes for the meeting that related to concerns of wandering and elopement. Further review of the medical record revealed invites to the care plan meetings for the Resident Representative (RP) dated 01/08/2025, 03/27/2025, and 11/13/2025, but there were no documented notes for these meetings in the medical record.During a telephone interview on 05/11/2026 at 2:45 PM with a family member of R106, they confirmed being notified back in September 2025 when R106 went missing and was found in the hospital that attached to the facility. R106's family member stated that the facility notified them when R106 had a fall but was never made aware of any other time that she was missing from the facility or that she had gotten outside the building.During an interview on 05/12/2026 at 10:33 AM with Nurse Supervisor, she reviewed the medical record of R106 and confirmed there were no wandering or elopement assessments completed for R106. She confirmed there were invites to the care plan meetings for the Resident Representative (RP) dated 01/08/2025, 03/27/2025, and 11/13/2025, but there were no documented notes for these meetings in the medical record for R106.During an interview on 05/12/2026 at 11:00 AM with the Administrator, he confirmed there were no wandering or elopement assessments done for R106. He stated that he knew the nurse who documented the note about the resident who was outside the building but that he had a document written by a staff member about the incident that showed staff had their eyes on the resident the whole time and that the note in the chart was incorrect. Administrator stated that he did not report the elopement to the State Agency because staff had their eyes on the resident the whole time. He stated he would find the documentation and provide it to the survey team. The Administrator stated that the staff involved no longer worked in the facility.During an interview on 05/12/2026 at 2:00 PM with the Administrator, he stated that he was unable to locate additional documentation related to the elopement of R106 on 10/05/2025.During a telephone interview on 05/11/2026 at 3:49 PM with the Director of Nursing (DON) of the local hospital, she stated that one of her nurses worked PRN (as needed) at the nursing home adjacent to the hospital and was familiar with the residents there. She stated that the nurse identified R106 as she was near the entrance to the facility. The DON stated that the resident came through the door connecting the nursing home and the hospital and added that she (R106) was propelling in a wheelchair and it would have taken her at least 10 to 15 minutes to get to where she was located by staff in the hospital from the nursing home side of the building.During an interview on 05/13/2026 at 12:13 PM with the DON for the facility, she stated that they do not do hourly checks on residents who wander but ii was something that should be put into place and should be documented in the medical record of the resident who wanders.During an interview on 05/13/2026 at 3:45 PM with the Administrator, he stated that the facility no longer had alarms on the doors because they could be considered restraints. He stated they could not put belts on residents in wheelchairs as that was also a restraint. The Administrator stated that residents had the right to fall and he did not have enough staff to do one on one.

Based on observation, staff interview, record review, and review of the facility policy and procedure titled Medication Administration Policy- General, the facility failed to ensure that the medication error rate was less than five percent. A total of 30 opportunities were observed with six errors, for one of four residents (R) (R7) by one of three nurses, for a medication error rate of 16.6 percent.Findings include:Review of the facility policy and procedure titled Medication Administration Policy- General, dated 8/7/2023, documented to verify that the medication name and dose are correct when compared to the medication order on the medication administration record. Review of the Clinical Physician's Orders and the October 2025 Medication Administration Record (MAR) for R7 revealed the following physician's orders: ciprofloxacin HCL (hydrochloride) otic solution, instill four drops in the right ear once a day for otitis (inflammation of the ear) for seven days, cetirizine HCL 10 milligrams (mg) one tablet by mouth once a day, fluticasone propionate suspension 50 micrograms one spray in each nostril once a day, magnesium oxide supplement 400 two tablets by mouth once a day, docusate sodium 100 mg one capsule by mouth two times a day, and Refresh ophthalmic solution 1.4-0.6 percent instill one drop in both eyes two times a day.Review of the MAR for R7 revealed that the cetirizine, fluticasone, magnesium oxide, docusate sodium, Refresh ophthalmic solution, and ciprofloxacin otic solution were scheduled to be administered at 8:00 am.Observation of medication pass with the Director of Nursing (DON) on 10/7/2025 at 10:00 am revealed she administered 8:00 am medications to R7 to include sertraline, omeprazole, nortriptyline, Eliquis, Baclofen, and gabapentin that had been prepackaged by the pharmacy. The surveyor instructed the DON to inform the surveyor if there would be any medications not given that were ordered to be given at that time. The DON voiced understanding and continued to administer the prepackaged medications. The DON failed to administer the over-the-counter medications of cetirizine, fluticasone, magnesium oxide, docusate sodium, and Refresh ophthalmic solution, and the ciprofloxacin otic solution.During an interview with the DON on 10/7/2025 at 11:57 am, she stated she was unable to locate the ciprofloxacin otic drops. She stated she called the pharmacy and was told the medication was delivered on the evening of 10/6/2025. When the surveyor inquired about the omitted over-the-counter medications, the DON asked another nurse working on that unit to come and show her where they were located. Those medications were located in the top drawer of the medication cart. She stated that this was the first time she had to work on the medication cart.During an interview with the Administrator on 10/7/2025, he stated that if he had known the DON was working the medication cart, he would have told her to assign the cart to another nurse.

Based on observations, resident and staff interviews, and review of the facility's policy titled, Physical Environment-Room Repairs, the facility failed to ensure that resident's rooms were clean and in good repair in two of five halls, in rooms (Rm) Rm 130, Rm 134, Rm 135, Rm 136, and Rm 143, and in the kitchen and laundry. Findings include: Review of the facility's policy titled Physical Environment-Room Repairs effective date 9/26/2023 stated under Policy: The center will ensure the residents have a safe, homelike, environment free from physical hazards. Under Procedure: 1. To ensure a safe, homelike environment. Findings from these rounds will be prioritized and the repairs made as indicated. 2. Apart from completing room rounds, a Maintenance Care App (application) for any repairs staff find need completed throughout the day. Any repairs requiring immediate attention are to be reported directly to the Maintenance Director or Administrator. 1. Observation on 4/14/2025 at 1:16 pm, on 4/15/2025 at 9:30 am and 3:05 pm, on 4/16/2025 at 12:16 pm, and on 4/17/2025 at 8:59 am inside resident Rm 136 revealed behind the head of bed B and to the side of bed B next to the window, the green painted wall was gouged or scrapped. Observation on 4/14/2025 at 1:25 pm, on 4/15/2025 at 3:10 pm, on 4/16/2025 at 8:10 am and 12:20 pm, and on 4/17/2025 at 9:06 am inside resident Rm 130 revealed broken sheetrock on the side and head of bed A. Observation on 4/14/2025 at 1:36 pm inside resident Rm 134 revealed a heavily coated dusty and broken air filter in the unit under the window. Observation on 4/15/2025 at 1:21 pm and 3:15 pm and on 4/16/2025 at 12:25 pm inside resident Rm 134 revealed the air filter had been cleaned but the filter was still broken and would not go all the way back down in the slot. R14 and her daughter who was visiting revealed the maintenance guy said that it needed repair. Observation on 4/17/2025 at 9:10 am inside resident Rm 134 revealed the broken air filter had been removed from the unit under the window. R14 was in bed B and her daughter was visiting and both stated the maintenance guy had removed the filter a few minutes ago to replace it. Observation on 4/14/2025 at 12:45 pm and on 4/17/2025 at 8:56 am inside resident Rm 135 revealed the top hinge to the bathroom door needed repair and the door leaned to one side causing it to rub and making it difficult to open and close the door. There was also broken sheetrock and broken tiles in the shower. Observation on 4/17/2025 at 1:25 pm inside Rm 143 revealed broken sheetrock at the side of bed A, bed height, and on the side of bed B above the baseboard under the window. Observation and interview on 4/17/2025 starting at 1:10 pm with the Administrator during walking rounds confirmed the following identified concerns needed cleaning, maintenance, or repair: Observation on 4/17/2025 at 1:24 pm inside Rm 143 of busted sheetrock at the side of bed A, bed height, and on the side of bed B above the baseboard under the window, confirmed by the Administrator who revealed it was from the bed being pushed against the wall and when they let the bed up and/or down it messed up the wall. He also confirmed the broken sheetrock by bed B below the window. Observation on 4/17/2025 at 1:26 pm in Rm 136 revealed a gouged wall at the head of bed B and to the side of the window. The Administrator confirmed it was scratched up and revealed it was the plastic (protective) wallboard and stated the white wallboard was showing/coming through the green paint from where it had been scratched/scuffed/gouged. Observation on 4/17/2025 at 1:28 pm in Rm 135 revealed the bathroom door top hinge needed repair, and broken tiles in the bathroom, confirmed by the Administrator. Observation on 4/17/2025 at 1:29 pm in Rm 134 revealed the broken air filter had been cleaned and removed by maintenance to replace it. Observation on 4/17/2025 at 1:30 pm in Rm 130 revealed broken sheetrock on two different walls, confirmed by the Administrator. 36377 2. Observation of the kitchen began on 4/14/2025 at 10:45 am and ended at 11:30 am. The following repairs needed were noted with the Dietary Manager (DM). Observation of walls on 4/14/2024 at 10:46 am of the dishwasher room revealed dirty floor tiles built up with dirt and grease, debris, and dirty walls, specially underneath the three-compartment sink and below the drying rack counter. Observation of the dishwasher door revealed a thick coating of rust. Observation of the chemical storage area on 4/14/2025 at 10:48 am revealed a dirty floor, large holes in the wall, and dark brown spots on the ceiling area. Observation of the kitchen exit door on 4/14/2025 at 10:50 am revealed the door failed to have a secure tight shut. Observation of the deep fryer on 4/14/2025 at 11:01 am revealed grease build up and a thick coating of rust on the side frame panel. Continued observation revealed a small hole which resulted in oil leaking from the fryer to the floor. Observation of the air conditioner unit duct on 4/14/2025 at 11:02 am revealed peeling aluminum. Observation of the door frame and wall corner edges on 4/14/2025 at 11:15 am revealed rugged edges and missing a wall seal and door frame seal. Interview on 4/16/2025 at 2:02 pm with the Maintenance Supervisor confirmed the holes in the walls in the chemical area. He reported that he had already started repairs in the kitchen. Interview on 4/17/2025 at 11:05 am with the Administrator, he described the missing tiles and dark greyish tile color in the kitchen dishwash area as actually a thin layer of the cement. The Administrator confirmed all needed repairs in the kitchen and reported that his maintenance staff had been very active in completing most of the repairs this week. 50941 3. Observation of the kitchen began on 4/14/2025 at 10:45 am and ended at 11:30 am. The following repairs needed were noted with the Dietary Manager (DM). Observation of walls on 4/14/2024 at 10:46 am of the dishwasher room revealed dirty floor tiles built up with dirt and grease, debris, and dirty walls, specially underneath the three-compartment sink and below the drying rack counter. Observation of the dishwasher door revealed a thick coating of rust. Observation of the chemical storage area on 4/14/2025 at 10:48 am revealed a dirty floor, large holes in the wall, and dark brown spots on the ceiling area. Observation of the kitchen exit door on 4/14/2025 at 10:50 am revealed the door failed to have a secure tight shut. Observation of the deep fryer on 4/14/2025 at 11:01 am revealed grease build up and a thick coating of rust on the side frame panel. Continued observation revealed a small hole which resulted in oil leaking from the fryer to the floor. Observation of the air conditioner unit duct on 4/14/2025 at 11:02 am revealed peeling aluminum. Observation of the door frame and wall corner edges on 4/14/2025 at 11:15 am revealed rugged edges and missing a wall seal and door frame seal. Interview on 4/16/2025 at 2:02 pm with the Maintenance Supervisor confirmed the holes in the walls in the chemical area. He reported that he had already started repairs in the kitchen. Interview on 4/17/2025 at 11:05 am with the Administrator, he described the missing tiles and dark greyish tile color in the kitchen dishwash area as actually a thin layer of the cement. The Administrator confirmed all needed repairs in the kitchen and reported that his maintenance staff had been very active in completing most of the repairs this week.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Resident Rights, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect for two of 48 sampled residents (R) (R50 and R40). Specifically, staff provided personal hygiene and bathing assistance to R50 without providing full visual privacy and failed to ensure proper placement of a dignity bag for R40's catheter bag. Findings include: Review of the facility policy titled Resident Rights dated 8/30/2017 stated under 5. Respect and dignity: The resident has a right to be treated with respect and dignity, including: . (8). Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 1. Review of R50's electronic medical record (EMR) revealed diagnoses of but not limited to chronic kidney disease, diabetes mellitus type 2, and absence of left leg. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Intensive Mental Status (BIMS) score of 15, indicates little to no cognitive impairment. During an observation on 4/14/2025 at 2:31 pm of R50, who resides in a two-bed room, Certified Nursing Assistant (CNA) GG was observed assisting R50 with a bed bath and personal hygiene care. R50 was observed naked sitting on the side of the bed. During the process CNA GG entered the room without completely pulling the privacy curtain and closing the window blinds to ensure R50, who was in Bed A, received privacy from anyone who entered the room and her roommate who resided in bed B. During an interview at the time of observation on 4/14/2025 at 2:31 pm, CNA GG verified failing to pull the privacy curtains to ensure privacy and close the window blinds. CNA GG reported not receiving training that privacy curtains should completely encircle the bed to provide full visual privacy. Interview on 4/14/2025 at 4:09 pm with Registered Nurse (RN) FF and R50, R50 verified that CNA GG failed to pull the privacy curtains or pull the window blinds while assisting her with her bath. R50 confirmed that she was completely naked. R50 reported that her preferences were to have full visual privacy without being exposed to anyone entering the room or visible to others who had open view from the parking lot (due to open window blinds). RN FF informed R50 and the Surveyor that privacy curtains and window blinds should have been pulled to ensure privacy during her bath. 2. Review of R40's EMR revealed diagnoses of but not limited to chronic kidney disease stage four (Stage 4). R40 had an order for a foley catheter dated 4/8/2025. Review of the quarterly MDS for R40 dated 12/27/2024 assessed a BIMS score of 10, which indicates moderate cognitive impairment. Observations on 4/14/2025 at 12:42 pm and 3:30 pm, 4/15/2025 at 10:01 am and 3:10 pm, and 4/16/2025 at 2:20 pm, revealed R40 lying in bed A (room door opened) with an attached catheter and drainage bag. Continued observation revealed the dignity bag was flipped to the opposite clear side and allowed open visual exposure to urine. During an interview on 4/16/2025 at 3:10 pm with RN FF, she verified that Certified Nursing Assistant (CNA) staff failed to reposition the dignity bag on the correct side facing the door to prevent the urine from being exposed to the doorway. She further stated that CNAs were trained on dignity. She could not pinpoint which CNA was working with on the dayshift. RN FF returned to the resident room and provided a different dignity bag that provided full coverage on each side. Interview with the Director of Nursing (DON) on 4/17/2025 at 3:55 pm, the DON reported that she just did an in-service and CNAs should be pulling privacy curtains during resident care services. She reported being unaware that this was happening. She further stated that her expectation was that any resident with a catheter should have a dignity bag.

Based on record review, staff interviews, and review of the facility policies titled, Bed Hold Policy and Facility Policy/Procedures, the facility failed to ensure a bed hold notice was provided at the time of transfer to a hospital for one of three residents (R) (R40) reviewed for hospitalization. Findings include: Review of the undated facility policy titled Bed Hold Policy stated under Medicaid Rights, Hospital Stays: The Medicaid program will provide payment to hold the Resident's bed for a period of seven days, while the Resident is in the hospital. Review of the undated facility policy titled Facility Policy/Procedure stated under Policy: It is the policy of [NAME] Nursing Center to hold a bed for a Medicaid resident admitted to the hospitals for seven days. A copy of this policy will be given to the resident and the representative before a resident is transferred for hospitalization, except in an emergency situation; then written notice will be given as soon as possible. Review of the electronic medical record (EMR) revealed that R40 was admitted with diagnoses of but not limited to chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) for R40 dated 12/27/2024 listed a Brief Interview for Mental Status (BIMS) score of 10, which indicates moderate cognitive impairment. Review of a Nurse's Note dated 1/6/2025 documented that R40 was sent to the emergency room (ER) and was admitted to an acute care hospital on 1/6/2025 and returned to the facility on 1/10/2025. Further record review revealed there was no evidence of documentation that the bed hold policy was provided to the resident/resident's representative for the resident's discharge to the hospital on 1/11/2025. Review of R40's Census Report and Nurse's Note dated 3/27/2025 documented that R40 was sent to the ER and was admitted to an acute care hospital on 3/27/2025 and returned to the facility on 4/1/2025. Further review revealed there was no evidence of documentation that the bed hold policy was provided to the resident/resident's representative for the resident's discharge to hospital on 3/27/2025. Record review of Census Report and Nurse's Note dated 4/4/2025 documented that R40 was sent to the ER and was admitted to an acute care hospital on 4/4/2025 and returned to the facility on 4/7/2025. Further record review revealed there was no evidence of documentation that the bed hold policy was provided to the resident/resident's representative for the resident's discharge to hospital on 4/7/2025. During an interview on 4/17/2025 at 11:47 am, the Director of Nursing (DON) reported that the resident's Responsible Party (RP) would receive a copy of the behold policy form if they were present in the facility; otherwise, a copy of the form was sent out with the resident. She reported that licensed nursing staff were responsible for sending out the copy of the bed hold policy forms. Residents bed hold policy forms were not kept on file. The DON confirmed the facility did not have a copy of R40's bed hold forms on file for each hospitalization. The DON confirmed that without this documentation, there was no written evidence that R40 received notifications of the seven-day bed hold. Interview on 4/17/2025 at 12:41 pm, the Clinical Coordinator/Licensed Practical Nurse (LPN) DD verified the facility did not have copies of R40 's bed hold forms to provide evidence that the bed hold policy notice was given at the time of R40's hospital transfers. She further stated that the Bed Hold Policy should be given to the resident by the nurse at the time of a resident hospital transfer. LPN DD reported that staff were not required to keep copies of any bed hold policy forms which were given to the resident.

Based on staff interviews, record review, and review of the facility policy titled, Care Plan, the facility failed to ensure care plan developement for one of 48 sampled residents (R) (R40) related to a foley catheter. The deficient practice had the potential for R40's needs and services to go unmet. Findings include: Review of the facility policy titled Care Plan with an effective date of 9/1/2022 stated under Policy: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed in Section H (Bowel and Bladder) an assessment for catheter usage and oxygen therapy. Review of R40's physician orders revealed an order for a foley catheter. Review of R40's care plan revealed no plan of care for a foley catheter. Interview with the MDS Coordinator and Director of Nursing (DON) on 04/17/2025 at 3:50 pm, the MDS Coordinator verified that a care plan for the foley catheter was not created. The MDS Coordinator reported that the care plan was created on day four of the survey (which was 4/17/2025). The MDS and DON reported that any nurse could have created a care plan. The DON reported creating a care plan was important because it guided the patient care of the residents. Review of R40's Physician Order dated 8/16/202 stated O2 (oxygen) at 2 lpm (liters per minute) via NC (nasal cannula) as needed (PRN) for SOB (shortness of breath), low oxygen saturation (sat). Interview on 4/17/2025 at 3:50 pm, the MDS Coordinator reported that her expectation was that staff follow the care plan for oxygen therapy.

Based on observations, record review, staff interview, and review of the facility's policy titled, Oxygen Administration, the facility failed to properly administer oxygen (O2) and properly maintain the oxygen concentrator for three of 14 residents (R) (R59, R53, and R40) currently using oxygen. The deficient practice had the potential of decreased blood oxygen levels, an increased risk of infection for the residents, and the danger of not knowing oxygen was in use. Findings include: A review of the facility's undated policy titled Oxygen Administration under Compliance Guidelines, number 5, Section a: Follow manufacturer recommendations for the frequency of cleaning equipment filters. The policy also states, 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 7. Cleaning and care of equipment shall be in accordance with the facility's Oxygen Safety Policy. The Oxygen Safety policy was requested, but the Director of Nursing (DON) stated that the facility had no such policy. 1. Review of the electronic medical record (EMR) revealed that R59 was admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), atrial fibrillation, and dependence on supplemental oxygen. Review of the Physician's Orders dated 10/4/2025 revealed and order for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) as well as an order to change the oxygen tubing and humidifier bottle every Wednesday on night shift. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed oxygen therapy. Review of the care plan, reviewed 1/28/2025, documented the problems/needs related to oxygen dependence included, risk for respiratory complications to include respiratory distress and infection. Interventions: Administer oxygen as needed per order; observe oxygen saturation and/or oxygen as ordered/indicated. Observation on 4/14/2025 at 1:11 pm of R59 revealed resident sitting up in bed with NC in their nose, O2 running at 2 LPM. The O2 tubing was noted to be crimped where the O2 tubing exited the humidification bottle, not allowing O2 to reach the resident. The filter was also noted to be caked with a thick layer of fluffy, white/gray substance resembling dust. The humidifier bottle was dated 4/9/25 [sic]. The resident denied shortness of breath (SOB). Observation on 4/14/2025 at 1:46 pm revealed the O2 tubing was still crimped. R59's nurse, Registered Nurse (RN) JJ was notified. RN JJ immediately checked and verified R59's tubing was crimped and she uncrimped it. Nurse JJ stated at that time that tubing should not be crimped. Observation on 4/15/2025 at 8:40 am, R59's O2 was checked. The tubing had been changed. R59's O2 was flowing freely, with no crimps noted in the tubing. The filter was still caked with a thick coating of fluffy, white/gray dusty substance. Observation on 4/17/2025 at 9:05 am, R59's O2 concentrator filter still noted to be dirty. Observation and interview on 4/17/2025 at 1:26 pm with the Administrator confirmed the dirty filter and he revealed that it should not be dirty and needed to be cleaned. The DON was also with the Administrator during the walking rounds and confirmed that the air filter to the O2 concentrator was dusty/dirty. The DON revealed that it was her expectation that the nurse on night shift (11:00 pm to 7:00 am) was to replace the O2 tubing and clean the air filter for the O2 concentrator weekly on Wednesday night. The facility had no smoking/no vaping signs outside of every resident room in the facility. There was no specific signage outside resident rooms indicating that O2 was in use. The Administrator stated, The no smoking or vaping signs should cover the Oxygen in Use sign rule. That was why we bought those stickers for every room. 50171 2. Review of R53's Face Sheet revealed diagnoses that included but not limited to urinary tract infection, site not specified, chronic obstructive pulmonary disease (COPD), unspecified. Review of R53's Quarterly MDS dated [DATE] revealed in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment; Section GG (Functional Status), resident requires minimal assistance with all Activities of Daily Living (ADL's); Section M (Skin), resident is at risk for pressure ulcers. Section O (Special Treatments, Procedures, Programs), resident receives Oxygen therapy. Review of R53's Physician's orders included but was not limited to NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (milliliter) (Insulin Aspart) Inject as per sliding scale: if 0 - 149 = 0 units, Insulin Degludec FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Degludec) Inject 15 unit subcutaneously at bedtime, Oxygen 2L (liters). Review of R53's care plans revealed a plan in place that have interventions that include administer medications as ordered, and administer oxygen as needed per order; observe oxygen saturations (sats) on room air and/or oxygen as ordered/indicated. An observation of R53 on 4/14/2025 at 1:45 pm revealed R53 lying in bed receiving O2 via NC, the oxygen was observed to be on 3.5 LPM. An observation of R53 on 4/14/2025 at 9:20 am revealed R53 was asleep in her bed receiving O2 via NC, the O2 was observed to be on 3.5 LPM. An observation of R53 on 4/16/2025 at 11:05 am revealed R53 was up in her wheelchair watching television. She was receiving O2 via NC, the O2 was observed to be set on 3.5 LPM. Interview on 4/16/2025 at 11:50 am with the DON confirmed that R53's O2 should be set on 2 LPM and any resident on O2 should have an order for O2 and the orders should indicate the flow. A physician was the only person that could say if the resident should be on O2 and what the flow should be set on. The DON revealed that she expected the nurse to check the resident's O2, make sure they were not in distress, and if they felt that the residents needed more O2, they should call the physician. The DON stated that she was not sure why it wasn't on two, because all of the residents O2 was checked at the beginning of each shift to make sure it was correct. 36377 3. Review of R40's EMR revealed diagnoses of but not limited to Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen. Review of the MDS assessment revealed a BIMS score, of 10 which indicates moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) resident was assessed for oxygen therapy usage. R40's care plan dated 7/23/2024 identified problem: My respiratory status is impaired due to Congestive Heart Failure, COPD, Obstructive Sleep Apnea; dependence on supplemental oxygen and listed an intervention to Administer oxygen as needed per order; observe oxygen saturations on room air and/or oxygen as ordered/indicated. Record review of R40's Physician Order and Medication Administration Record (MAR) dated April 2024 revealed an order dated 8/16/2023 that read O2 at 2lpm (liters per minute) via NC as needed for SOB, low oxygen saturation. Observation on 4/15/2025 at 2:00 pm to 3:37 pm. revealed R40 lying in bed receiving O2 by NC from her setting on 4 LPM. Signage posted on the doorway did not indicate O2 therapy was in use. During an observation at the time of an interview of R40 on 4/15/02025 at 3:37 pm, RN FF confirmed that R40's O2 setting was set on the wrong liter flow. She reported that R40 went out for a medical appointment and the O2 got set on the wrong liter flow. Signage posted on the doorway did not indicate O2 therapy was in use. Observation at the time of interview on 4/16/2025 at 1:20 pm of R40 with Licensed Practical Nurse (LPN) GG revealed resident lying in bed receiving O2 by O2 concentrator via NC on 3 LPM. LPN GG verified that R40 's O2 level was set on 3 LPM instead of 2 LPM. LPN GG adjusted the flow rate. Signage posted on the doorway did not indicate O2 therapy was in use. Interview on 4/17/2025 at 4:00 pm, The DON reported that her expectation was that nurses should have been making multiple rounds to monitor the resident 's O2 flow rate. She stated that prior to R40's fall, R40 had a history of adjusting her O2 flow rate. Since the fall, R40 was non-ambulatory and unable to get out of bed and adjust her O2 flow rate.

Based on observations, staff interviews, and review of the facility's' policies titled, Date Marking for Food Safety and Food Nutrition Sanitation and Food Products, the facility failed to ensure ice was covered and transported in a sanitary manner, food items were properly stored, labeled, and dated, and expired food items disposed of in a timely manner. In addition, the facility failed to follow the manufacture guidelines for proper sanitation procedures with the 3-compartment sink and dishwasher for sanitation of washing cookware and dishes. The dietary equipment was maintained under sanitized conditions free from rust and a pedal push garbage container was accessible to staff. The flooring and walls of the facility were free from dirt and debris. The deficient practice had the potential to affect 83 of 87 residents receiving an oral diet. Findings include: The facility policy titled Date Marking for Food Safety Effective (undated): Food and Nutrition Policy stated . The facility adheres to a date marking system to ensure the safety of ready -to -eat, time /temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The Food nutrition Manager or designee shall spot check refrigerators weekly for compliance, and document according. Corrective action shall be taken as needed. The facility policy titled, Food and Nutrition Sanitation and Cleaning Procedures dated [DATE]. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. The sanitation program will provide for inspections to be conducted of the food service areas. The kitchen tour began on [DATE] at 9:15AM and ended at 11:00AM. 1.Observation on [DATE] at 10:58 AM revealed Dietary Aide (DA) HH transporting ice from the ice machine to the kitchen. Continuous observation revealed ice (uncovered) contained in two large buckets. Interview at the time of observation DA HH reported that no one ever told her to cover the ice. She has been working for only three months. DA FF confirmed that this was deficient practice once the ice reached the kitchen. DA FF reported that she was in charge due to Dietary Manager absences. 2. Observation of dietary staff operating the dish washer revealed an empty container of sanitizer chemical attached to the unit. DA GG was interviewed, and she reported being unaware of the empty container. She had run 3 crates filled with plates, lids, and cups. DA FF replaced the container with a full container and asked DA GG to rewash the dishes. 3. During an observation of the 3 -Compartment sink, DA II was observed washing stacks of pots and pans with little to no liquid coming out. Continuous observation revealed the container labeled as Sanitizer Quart chemical tattled J.512 Sanitizer with a thin coating of chemical in the container. DA II She reported not being aware that the container had only a thin layer of substance. She confirmed not checking the containers. She emptied the sink before a testing of ppm could be completed to determine the measures. DA FF replaced the chemical with a full chemical and stated that it should have been replaced with a full Sanitizer container. 4.The push petal trashcan positioned next to the wash sink (only sink in the kitchen) had two large containers of chemical containers sitting on the lid. This prevented the lid from opening and staff were observed using a large alternate trash can without a pedal forcing them to lift the lid with their hands. 5.The sink hand knob fixtures were covered with dark sticky brown substances. The walls above the sink are covered with peeling paint. 6. 3-Compartment sink legs were covered with thick layers of dark brown substances. There were waiter pans above the sink resting on racks covered with thick dark brown substances mixed with dirt and debris. Holes observed in the wall. On the floor was a dirty oven mitten, and built-up substances of dirt, grime, and debris. Above the 3-compartment sink was peeling paint, and the walls covered stained with dark brown substances. DA FF confirmed that the dark brown substances were rust. 7.A dirty cloth resting on the rack by the sink. Next to the dirty cloth on the rack was waiter pans and bowls -rack. A closer observation of the rack revealed thick dark brown substances coating the rack. A sign above the sink stated Sanitizer Test Station. DA FF confirmed that the dark brown substances were rust. 8. Observation of the walk-in-cooler revealed uncooked beef in a plastic bag filled with blood and surrounded by watery blood in a thin cookie sheet waiter pan lying on a 4-tier floor stand rolling rack cart. The beef was on the top and other items were placed below. DA FF reported that beef should have been discarded this weekend by Sunday dietary staff. The beef was not labeled. Directly below were other non-meat items on the 2nd and 3rd shelf and on the bottom shelf (4th shelf) was uncooked raw pork chops (in pan covered with foil paper dated [DATE] to [DATE]). She stated that the pork chops were going to be cooked today. She confirmed a problem with the running pan of blood from the beef having the potential to affect the other items below. 9. Continuous observation of the walk-in-cooler revealed four heads of lettuce lying on top of a box uncovered and a box containing lettuce not completely sealed exposing the lettuce. There were plastic containers containing expired food all dated [DATE] with discard date listed [DATE] (lettuce, onions, bell pepper. At the time of observation, DA FF reported that all the food items should have been discarded. 10. Observation of three large bins (flour, thickening, and meal) revealed lids not completely covered lid and allowing large gaps of exposure. Continuous observation of the thickening revealed a plastic cup resting in the meal. 11. Observation of the plate and lid warmer revealed rust inside the container. DA FF confirmed that the brown dark brown reddish substances were rust. Interview with Administrator on [DATE] at 11:39 AM, the surveyor shared the photos of the kitchen concerns. Admin revealed that his expectations are that kitchen meets dietary sanitation standard and all dietary staff follow the dietary safety. He further reported that dietary staff are responsible for reporting rust. He described the kitchen equipment as being fairly new. The rust may be a result of dietary staff using cleaning products that causes rust. He confirmed that the substances were rust build up. He said the dish washer is a low-temp- high temp machine. He reported that if the chemicals was not attached per his Register Dietician, that the machine would automatically change over to high temp and dishes should be sanitized. The Administrator asked the surveyor to speak with the RD. He said the plan is to do training /in-services and that there will be some changes in the future with the staff. He stated that the problems in the kitchen were uncalled for. Interview and an observation of the dishwasher on [DATE] at 12:20 PM with the RD revealed that the dishwasher did not automatically switch over to high-temp. The RD attempted several times. He stated that the dishwasher is a CMA Model EST -44 High Temperature- Low Temperature Conveyor Dish machine and able to switch. When operating as low temp the temp is 120F and requires the attachment of sanitizer without the sanitizer connected, the machine supposed to switch over to high temp. RD attempted to see if the machine would switch (and the wait time and tries lasted for 40 minutes) and the machine would not reach the 150-rinse temp. DA GG was on site and reported to RD and surveyor that she has never ran the dishwasher as a high temp dishwasher. She was not familiar with the process.

47948 Based on observations, resident and staff interviews, and review of the facility's policies titled, Oxygen Administration, Medication Administration, Medication Administration: Oral and Nasal Inhalations, Hand Hygiene, COVID-19 Prevention, Response and Reporting, and Water Management Policy the facility failed to ensure infection control measures were followed during the administration of nasal and oral inhalation medications for one of 29 residents (R) (R40), and hand hygiene was performed during medication administration for one of five residents (R40). The facility also failed to decrease the chance of COVID-19 spread by allowing two residents (R68 and R70) to cohort in the same rooms as positive tested COVID-19 residents (R64 and R65). The facility failed to develop and implement water management policy and procedures for testing, to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system. Further, the facility failed to post signage at the entrance of the facility to notify/warn visitors that COVID positive residents were in the facility. These deficits had the potential to affect 87 residents who resided in the facility. Findings include: A review of the Facility policy titled Medication Administration: Oral and Nasal Inhalations last reviewed 10/17/2023 revealed 10.) Clean inhaler as directed in package, thoroughly and frequently. Facility policy titled Oxygen Administration revised 1/8/2024 revealed Keep delivery devices covered in plastic bag when not in use. Facility policy titled Medication Administration revised/reviewed 5/30/2023 revealed Policy Explanation and Compliance Guidelines: 14.) Administer medication as ordered in accordance with manufacturer specifications. 15.) Observe resident consumption of medication. 16.) wash hands using facility protocol and product. Review of facility policy titled, Hand Hygiene last reviewed/revised 6/14/2023 revealed Either soap and water or Alcohol Based Hand Rub is required before applying and after removing personal protective equipment (PPE), including gloves. And After handling items potentially contaminated with blood, body fluids, secretions or excretions. Review of facility policy COVID-19 Prevention, Response and Reporting dated revised/reviewed on 5/10/2023 revealed 15.) Resident placement considerations: a.) Residents with suspected or confirmed SARS-Co V-2 infection should be placed in a single-person room with the door kept closed, if safe to do so, and a dedicated bathroom if possible. i.) If cohorting, only residents with the same respiratory pathogen should be housed in the same room, MDRO colonization status and/or presence of other communicable diseases should also be taken into consideration during the cohorting process. ii.) If limited single-rooms are available, or if numerous residents are simultaneously identified to have known SARS-Co V-2 exposures or symptoms concerning COVID-19, residents should remain in their current location. Facility documentation titled January 2024 Empty Rooms Five Minute Flush Water Run revealed that on 1/19/2024, there were five empty rooms available in the facility, rooms 145, 146, 153, 156 and 158, and on 1/26/2024 there were five empty rooms available in the facility, rooms 160, 108, 116, 145 and 146. 1.) An observation on 1/31/2024 at 8:55 am. revealed Licensed Practical Nurse (LPN) CC coached and supervised R40 to administer her own ordered Brezrti Aerosphere 2 puffs via inhaler and Flonase 2 puffs nasally to both nares per residents request. LPN CC brought the nasal medication and inhaler out of R40's room after use and placed them directly on top of the medication administration cart without placing them on a barrier or cleaning the appliances. LPN CC then proceeded to place them in their respective boxes and placed them back in the medication cart. An interview on 1/31/2024 at 8:57 am with LPN CC revealed that she wasn't aware that inhalers and nasal medications needed to be cleaned after using on a resident before placing them back into the medication cart. Review of the Breztri Aerosphere medication insert revealed the mouthpiece should be cleaned on a weekly basis with running warm water for a total of 60 seconds. The actuator then is to be air dried before placing the canister back into the actuator. Review of the Flonase Nasal spray information retrieved on 2/1/2024 from https://www.flonase.com/products/flonase-allergy-relief/how-to-use/#:~:text=Adults%20should%20take%20two%20sprays,consult%20your%20doctor%20or%20pharmacist revealed instructions for cleaning after use included to wipe the nozzle clean with a tissue and replace the green cap. An interview on 1/31/2024 at 9:06 am with LPN BB revealed that after she uses an inhaler, she wipes the inhaler off with a tissue before placing it back on the medication cart. An interview on 2/1/2024 at 10:58 am with the Director of Nursing (DON) revealed it is her expectation that when residents receive inhaler or nasal medications, the device is cleaned prior to placing them back into the medication cart. She stated that she wasn't sure what the policy stated, but she usually cleaned the inhaler administration device and nasal probe for nasal medications before placing them back into the medication cart. She revealed that if resident desires administer inhaler, nasal or eye medications themselves while the nurse is present, she didn't consider that self-administration of medications since the nurse controls the medication and ensures they are administered correctly. 2.) Record review revealed R74 had a BIMS score of 12, suggesting moderate cognitive impairment, and had a diagnosis of cerebral palsy and chronic obstructive pulmonary disease (COPD). An observation on 1/30/24 at 9:42 am. revealed the continuous positive airway pressure (CPAP) mask for R74 was observed lying on her bedside dresser and not stored in a plastic bag. An interview with R74 revealed that she is supposed to wear her CPAP at night. An observation on 1/31/2024 at 9:35 am. revealed R74 revealed lying in bed with eyes closed and oxygen via nasal canula in place. CPAP mask was noted lying on the bedside table without a protective covering. An observation and confirmation on 1/31/2024 at 12:25 pm with LPN AA revealed R74's CPAP mask was not stored in a plastic bag but should have been placed in one when the CPAP wasn't in use. Review of medical records revealed R22 had a BIMS score of 11, suggesting moderate cognitive impairment, and a diagnosis of COPD and non-Alzheimer's dementia. AN observation on 1/30/24 at 9:36 am. revealed R22's nasal canula oxygen not in use, hanging over the oxygen concentrator and not covered. There was no label on the tubing as when changed and no date on the humidifier bottle. Record review revealed tubing and humidification bottle changed every Saturday in January 2024. An observation on 1/31/2024 at 9:33 am. of R22's oxygen, nasal canula, revealed the oxygen not currently in use with tubing lying over the oxygen concentrator without a protective covering. An observation and confirmation on 1/31/2024 at 12:25pm with LPN AA revealed R74's nasal canula was not in use and not being stored in a plastic bag but lying over the oxygen concentrator. 3.) An observation on 1/31/2024 at 8:55 am. revealed LPN CC handed R40 her inhaler and nasal spray, coached and supervised the resident to administer the medications per the residents' request. After the nasal spray and inhaler medication administration was completed, LPN CC was observed removing her gloves in the resident's room and brought the nasal medication and inhaler out of R40's room after use and placed them directly on top of the medication administration cart without placing them on a barrier or cleaning the appliances. LPN CC did not sanitize her hands after removing gloves in R40's room and proceeded to use the computer keyboard to document the medication administered. LPN CC then placed the inhaler and nasal spray in their respective boxes and placed them back in the medication cart without sanitizing the appliances, her hands, top of the medication cart top after the contaminated nasal and inhalation medication had been placed directly on it or the computer keyboard. An interview on 2/1/2024 at 10:58 am. with the Director of Nursing revealed that all staff were to sanitize their hands before and after removing gloves and before touching anything else. 4.) Review of medical records and facility documents revealed R64, who had a BIMS score 5 which suggests severe cognitive impairment, had obtained a positive COVID-19 test on 1/23/2024. R64 is and has been the roommate of R70 since before 1/23/2024 has a BIMS score of 13 suggesting he is cognitively intact and was found to have a negative COVID-19 test on 1/23/2024 and 1/29/2024. An observation on 1/30/2024 at 11:14 am. revealed R70 self-propelled his wheelchair in the hallway without a face mask conversating with staff and other residents. An observation on 1/30/2024 at 1:30 pm. revealed signage was present for the appropriate personal protection equipment (PPE) required to be donned prior to entering the resident room in which R64 and R70 resided along with COVID-19 precautions on the outside of the resident's room door. A cart with PPE readily available for use was observed outside of the resident's room. An observation on 1/31/2024 at 12:15 pm. revealed R70 being pushed by staff in his wheelchair back to his room. An interview with R70 revealed he had been at a doctor's appointment and was just returning to the facility. R70 was noted to not have a face mask in place or any other PPE. Review of R70's medical record revealed he was ordered Amoxicillin Capsule 500 mg, give one capsule by mouth three times a day for dysuria for seven days, with the first dose given on 1/26/2024. 5) observations and record review of R68, a resident who was cohort with a Covid -19 positive resident in a semi-private room revealed Resident 's roommate had tested positive on 1/23/2024. Observation on 1/30/2024 at 10:22 AM revealed R68 ambulating in hallway using his walker with no mask. Observation on 1/30/2024 at 12:00 PM revealed R68 (sitting at a table by himself) eating lunch in dining room with a total of 15 residents. The resident was observed leaving the dining room without a mask. Observation on 1/31/2024 at 12:00 PM R68 in dining room eating lunch and leaving dining room with no mask. Observation on 1/31/2024 at 3:30 PM in room with door closed with his roommate (a Covid -19 positive resident). Resident and his roommate did not have on a mask. Observation on 2/1/2024 at 10:00 AM in room, door closed with his roommate (a Covid-19 positive resident). Resident and his roommate did not have on a mask. Observation on 2/1/2024 at 12:50 PM R68 ambulating on hallway with his walker. Resident did not have a mask on. Record review of R68 record revealed the following diagnoses but not limited to psychotic disorder with delusions due to known physiological condition, chronic obstructive pulmonary disease, unspecified paroxysmal, atrial fibrillation, unspecified systolic (congestive) heart failure, and primary hypertension. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed Brief Interview Mental Status Score as a 14 that indicates cognitive intact. Record review of R68 's immunization record revealed that resident has a history of refusal of completion Covid -19 vaccinations. He was known only to receive Covid 19 dosage 1 and refusal for SAR-COV-E (Covid -119) Dose 2. He refused Covid -19 Moderna Bivalent Booster. He has received influenza (10/11/2023) and Pneumovax Dose 1(3/11/2020). Record review of R68's vitals revealed the resident 's vitals within the normal limits. Record review revealed that R68 was care planned for restrictions to ensure his safety and safety of others. The care plan stated the identified problem as Should COVID-19 restrictions be put in place; I will have the potential for alteration in my mood state and psychosocial well-being secondary to the changes and restrictions on visitation imposed by the CDC guidelines because of the COVID-19 virus and risk of exposure. I am concerned that I will not be able to see and interact with persons who are important to me. The following interventions/approaches listed were to Avoid group situations such as communal dining and group activities. Encourage and support the resident via in-room activities that are important and vital to the resident. Include activities aided by technology as possible. During an interview on 1/31/2024 at 10:30 AM, R68 reported not wanting to move and not wanting to wear a mask. He further stated that he loves his room. He confirmed that the facility staff approached him about moving. Interview on 1/31/2024 at 11:20 AM, the Infection Control (IPC) revealed that R68 did not want to move. She confirmed speaking with the resident and family. She reported that this was not documented in the system that the resident refused to move. She reported that however, she will go back and put the late documentation in the electronic record. She further stated that R68 's brother is his Power of Attorney (POA). The brother is very involved in the resident care. Resident is being monitored for signs and symptoms. The resident has not shown any signs of Covid 19. Resident is very resistant and refused to stay in room. 6.) Review of the policy titled, Water Management Policy, dated 1/26/2022 Revealed under Policy: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens could grow and spread in the facility's water systems. During an interview on 1/31/2024 at 8:45 am with the Infection Preventionist (IP), she indicated the water was tested by the city annually and confirmed the testing result records that had been provided. Review of the testing records revealed they were for the period January 1 to December 31, 2022, was negative for findings, and no issues were reported. She further stated that she was not aware of the facility conducting testing of the water, but the Administrator would know about water testing. During an interview on 1/31/2024 at 4:40 pm with the Nursing Home Administrator (NHA), he revealed their water came from the city, they rely on testing by the city water department official, and the Annual Drinking Water Quality Report, because that is their water source. He revealed the water supply going into the building was checked by the city official, and his understanding was that the city testing was sufficient. He confirmed the city water department official had not educated the Maintenance Supervisor on water management testing of the water system because the current Maintenance Director was the third one that they had in the past six months. He tried to contact the city water department official by phone for further guidance but could not reach him. He stated he would continue to try to reach him and have an update in the morning. During a follow-up interview on 2/1/2024 at 3:24 pm with the NHA, he confirmed the water supply going into the building was checked by the city official, but no water inside the facility was tested . Interview further revealed his understanding was that testing the water source was sufficient, and did not realize it was not, or that the facility should be performing water testing in house. The Centers for Disease Control and Prevention website titled Legionella indicated, Legionella bacteria are typically found naturally in [NAME] environments but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. (ASHRAE Standard 188: Legionellosis: Risk Management for Building Water Systems January 2018. ASHRAE: Atlanta 7.) Observation on 1/30/2024 at 8:32 am, observation at 1/31/2024 at 8:30 am, and on 2/1/2024 at 8:30 upon entry, to the facility's main entrance was noted to not have signage informing visitors of COVID-19 presence in the facility. Observation inside the lobby revealed masks and hand sanitizer were available, but again there was no signage posted in the lobby. Upon further entry through the double door into the hallway, posted on the door was a sign that informed staff of a return to N-95 mask usage, bi-weekly testing, and advised visitors with symptoms or sickness not to enter, but did not specify that residents inside had COVID. There was no signage posted, no sign-in and no screening in place for visitors. Observation on 2/1/2024 at 9:00 am, a visitor entered the facility. The receptionist at the front desk engaged the visitor, providing important information about the presence of COVID-19 within the building, advised the visitor to wear a mask, but there was no signage posted, and no sign-in or screening for COVID. An interview on 2/01/24 at 11:14 am with the Infection Preventionist (IP) revealed that signs directed at staff were also visible to visitors, and it was a deliberate choice not to post signs at the front entrance because they felt it fostered fear and/or discouraged visits, reflecting a sensitivity to past restrictions during the COVID-19 pandemic that they felt mentally and emotionally harmed the residents.

Based on observations, staff interviews, and review of the facility policy titled, Disposal of Garbage and Refuse the facility failed to ensure that the dumpster area was maintained in sanitary conditions as it relates to dumpster lids being secured/tightly fitted at all times. The deficient practice had the potential to promote the harboring of pest, insects, and other organisms. Findings include: Review of facility policy titled: Disposal of Garbage and Refuse effective date 12/21/2018 revealed The facility shall properly dispose of kitchen garbage and refuse. (7). Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpster shall be kept covered when not being loaded. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. (10). Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. An observation (that also included an interview) on 1/30/2024 at 9:31AM of the facility dumpster with Dietary Aide (DA) FF revealed two dumpsters positioned side by side. The first dumpster was opened and filled with trash (piled to the top) and not secured with the dumpster lid. The second dumpster was closed. Continued observation of the second dumpster revealed dumpster lid badly damaged (dents/bent) on both sides causing the lid to lift up leaving a large gap. The condition of the damage lid and facility staff not ensuring dumpster lids closure allowed garbage exposure to water, animals, and pest. DA FF confirmed the condition of the dumpsters. She reported that lid should be closed and confirmed kitchen staff are trained to ensure dumpster lids are closed. She stated that the second dumpster damaged lids have been that way for a while and She could not say exactly for how long. A observation (that also included an interview) on 1/31/2024 at 10:04 AM of the facility dumpsters with DA GG revealed continuous problems with the facility dumpsters. Dumpster one trash was emptied however, the dumpster lid remained open. An anonymous staff was observed putting trash in dumpster one and walking away without ensuring the lid was closed. DA GG confirmed that staff forgot to close the dumpster lid. Dumpster two lid remained in the same condition damaged on both sides and not tightly fitting. Interview on 2/1/2024 at 11:36 AM, the Housekeeping Supervisor (HKS) reviewed photos of the dumpsters with the surveyor. HKS Supervisor confirmed the deficient practice. He reported that his housekeeping staff have received education and training on keeping the dumpster lid closed at all times. The housekeeping and the dietary staff are responsible for ensuring the dumpster area is clean and lids closed. Staff are responsible for reporting any issues with the dumpster to him. Interview on 2/1/2024 at 11:39 AM, the Administrator reviewed photos of the dumpsters with the surveyor. The Administrator confirmed the deficient practice. The Administrator reported that his expectations are the dumpster lids should be closed at all times. He said the plan is to do training /in-services and that there will be some changes in the future with his staff (regarding the dumpster).

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to provide oxygen therapy as ordered for one of 27 Residents (R) (R17) that were receiving oxygen therapy. The deficient practice had the potential to increase the probability of R17 to have respiratory difficulties. Findings include: A review of the policy titled, Oxygen Administration, effective date 1/8/2024, under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. During a review of the Electronic Medical Record (EMR), it was revealed in the Minimum Data Set (MDS) section C (Cognitive Pattern) C0500 a Brief Interview for Mental Status (BIMS) of 99 which indicates the individual gave a nonsensical or impractical response. Section J (Health Conditions) R17 has shortness of breath (SOB) or trouble breathing with exertion, shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Review of the Physician's orders for R17 revealed resident was currently receiving Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT 1 puff inhale orally one time a day related to Chronic Obstructive Pulmonary Disease (COPD), Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 6 hours for wheezing monitor breath sounds before and after treatment, Bilevel Positive Airway Pressure (BIPAP) at bedtime and as needed, Oxygen 2 liters per minute via nasal cannula while in bed and as needed, change oxygen tubing and humidifier bottle weekly and BIPAP tubing weekly. Pertinent diagnoses include COPD, Obstructive Sleep Apnea, Dependence on Supplemental Oxygen, Generalized Edema, and Shortness of breath. Review of residents plan of care revealed under focus: My respiratory status has the potential to become impaired due to COPD, dependence on supplemental oxygen; obstructive sleep apnea; SOB at times, Goal: I will remain free of exacerbation of COPD through next review. Interventions: Administer oxygen as needed per order; observe oxygen saturations on room air and/or oxygen as ordered/indicated, Observe for SOB upon exertion, while sitting at rest, and when lying flat. During observation on 1/30/2024 at 10:00 am the Resident was lying in bed with no distress noted; oxygen infusing at 3 1/2 liters nasal cannula. During observation on 1/31/2024 at 2:45 pm the Resident was lying in bed with oxygen on at 3 1/2 liters nasal cannula, no respiratory distress noted. During observation on 2/1/2024 at 9:24 am the Resident was sleeping in bed with no respiratory distress noted; oxygen infusing at 3 1/2 liters nasal cannula. During an interview on 2/1/2024 at 9:30 am with CNA II it was revealed this CNA stated the Resident requires total care; the CNA will put the oxygen nasal cannula on the Resident, but she does not adjust the liters. During an interview on 2/1/2024 at 9:45 am with LPN JJ, she reviewed the oxygen orders on the Medication Administration Record (MAR) and the order section for 2 liters nasal cannula. LPN JJ accompanied surveyor to Resident room. The nurse verified the oxygen setting was at 3 1/2 liters. She adjusted the machine to 2 liters. The Resident was sitting up in the chair, no distress noted. During an interview on 2/1/2024 at 10:15 am with the Nurse Laison, she reviewed the orders; this Resident has an order for oxygen at 2 liters nasal cannula. During an interview on 2/1/2024 at 10:55 am with the DON she expects the nurses to check the machine's functionality and to make sure the Resident is wearing the nasal cannula. The nurse needs to check the oxygen level. The CNA gets the saturation levels. The nurse who took the orders from the physician should make sure it is on the order form.

Based on record review, staff interviews, and review of facility policies Weight Monitoring Program, the facility failed to develop a comprehensive person-centered care plan for one resident (R #8) related to significant weight loss of 17 sampled residents. Findings include: Review of facility policy Weight Monitoring Program last revised 4/13/18, revealed 'Care Plans: Significant weight losses/gains will be addressed on the resident's care plan. The care plan will be updated upon identification of the SWC (significant weight change) during weight meetings. The WPC (weight program coordinator) will make available a copy of the weekly weight list to staff. Record review revealed R#8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for section K-Swallowing/Nutrition status indicated R#8 had a weight loss of 5% or more in the last month or a loss of 10% or more in six months and was not on a Physician prescribed weight loss program. Review of R#8's care plan did not address this weight loss. During interview on 4/7/22 at 2:17 p.m. with the MDS/Care Plan Coordinator confirmed R# 8 does not have a care plan to address his weight loss. Stated R#8 is talked about weekly in PAR (Performance Accountability Review) meeting. It was revealed care plans are updated at that time, but she is not sure why resident does not have a care plan addressing weight loss. During interview on 4/7/22 at 2:20 p.m. the Registered Nurse Resident Care Liaison revealed weight loss should be captured on the care plan.

Based on observations, staff interviews, review of facility records, and facility policy titled safe water temperatures,' it was determined the facility failed to ensure safe hot water temperatures, in seven resident rooms (room [ROOM NUMBER], 112, 113, 124, 127, 133, 150) and two common shower rooms, were maintained at less than 110 degrees Fahrenheit, to prevent the potential [MEDICAL CONDITION] the facility failed to conduct a root cause analysis to determine the cause of falls or evaluate the effectiveness of care planned interventions to evaluate if they were effective for one resident (R#82). The sample size was 45 residents. Findings include: Review of the facility policy Safe Water Temperatures, with an original date of 11/28/17, revealed The facility would maintain appropriate water temperatures in resident care areas. Policy explanation and compliance guidelines: 1. Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms [MEDICAL CONDITION] will respond appropriately. 2. Staff will be educated on safe water temperatures upon employment and on a regular basis. 3. Thermometers will be available as needed for use by all staff. 4. Staff will report abnormal findings, such as complaints of water too cold or hot,[MEDICAL CONDITION] redness, or any problems with water temperatures to the supervisor and/or maintenance staff. 5. Water temperature will be set to a temperature of no more than 110 degrees Fahrenheit, or the state's allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be kept in the maintenance office. 1. Observations on 11/26/18 between 11:00 a.m. and 12:17 p.m., during the initial screening of residents, revealed water from the sink in resident rooms felt very hot to the touch, this surveyor could not hold her hand under the running water for more than a few seconds. The temperature(s) (temp) of the water was checked with the surveyor's thermometer in the following rooms, and obtained the following temps: room [ROOM NUMBER]- 114 degrees Fahrenheit (F) room [ROOM NUMBER]- 118 degrees F room [ROOM NUMBER]- 122 degrees F room [ROOM NUMBER]- 118 degrees F room [ROOM NUMBER]- 123 degrees F room [ROOM NUMBER]- 116 degrees F room [ROOM NUMBER]- 116 degrees F On 11/26/17 at 12:20 p.m. the Maintenance Supervisor (MS) HH was asked to check the water, to verify temps and interview at that time revealed he was not aware of any unsafe hot water temps. Interview with HH revealed maintenance staff did ten random water checks every week, four from each wing, and both shower rooms, and they were scheduled to be done that day. HH further revealed the facility had three (3) hot water heaters, one controlled East wing, one controlled West wing and one controlled the kitchen and laundry. East wing consisted of rooms 101 to 126, West wing consisted of rooms 127 to 160. MS HH confirmed the following unsafe water temps, using the facility's digital thermometer, assisted by maintenance staff (II): room [ROOM NUMBER]- 121.0 degrees F at 12:30 p.m. room [ROOM NUMBER]- 122.0 degrees F at 12:34 p.m. room [ROOM NUMBER]- 112.0 degrees F at 12:38 p.m. East wing whirlpool shower- 138.0 degrees F at 12:42 p.m. room [ROOM NUMBER]- 123.4 degrees F at 12:45 p.m. West Wing Shower- 113.3 degrees F at 12:50 p.m. after running the water for 60 seconds. room [ROOM NUMBER]- 112.0 degrees F at 12:52 p.m. after running the water for one minute. room [ROOM NUMBER]- 113.0 degrees F at 12:55 p.m. after running the water for one minute. room [ROOM NUMBER]- 126.5 degrees F at 1:00 p.m. after running the water for one minute. At 1:05 p.m. MS HH confirmed the temps were too hot and revealed the hot water heater had a thermostat that needed to be adjusted, and immediately told (II) to go turn it down now. Maintenance worker (II) left to go adjust the thermostat on the hot water heater. MS HH revealed they check water temps weekly and they normally range between 110 to 115 degrees and if they found water above range, they adjusted the thermostat. The surveyor requested a copy of their weekly temp checks, and documentation to verify what they did if they found unsafe water temps. Interview on 11/26/18 from 1:25-1:45 p.m. with the Administrator revealed he was not aware of any unsafe water temps prior to today and further revealed they utilize an app called Gen-Core (GN-X care/maintenance care software) that integrates with the Point Click Care (PCC) to report, check and document issues, and receive alerts. All staff had access, could report issues from the kiosk and it went directly to maintenance staff, no complaints of hot water temps had been reported. they had stopped bathes in the shower and were checking the water temps every two hours. Interview on 11/26/18 at 4:41 p.m. with the Administrator confirmed they continued to have two elevated temps. room [ROOM NUMBER] tested between 111 to 113 degrees F and room [ROOM NUMBER] tested 114.5 degrees F. The Administrator, DON, and maintenance supervisor assured the survey team that they had put a plan of action in place, monitoring of temps were ongoing, they would provide documentation, and baths in the shower rooms had been stopped. A copy of the hot water temp policy was provided. Observation on 11/27/18 at 8:15 a.m. revealed the water in the East wing whirlpool shower was still very hot to the touch. MS HH was asked to check the water and interview at that time revealed they had some unsafe hot water temps overnight. Using the facility thermometer, MS HH confirmed water from the sink in the East wing whirlpool shower tested between 117 and 120 degrees F. MS HH provided the following temperature checks from overnight, using the facility thermometer: (MONTH) 26, starting at 1:00 p.m., thru (MONTH) 27 at 7:00 a.m., water temps ranged from 101.5 to 131. He confirmed they still had hot water issues. Interview on 11/27/18 at 9:45 a.m. with the Administrator revealed Central Plumbing out of Tifton had come and checked the hot water heaters and the mixer valve was bad. The parts needed for repair were in another state but had been ordered. Interview on 11/28/18 at 8:15 a.m. with HH revealed water temperature checks for (MONTH) 27 at 7:00 a.m. thru (MONTH) 28 at 5:00 a.m., using the facility thermometer, ranged from 67 degrees to 113.6 degrees F. Interview on 11/29/18 at 9:15 a.m. with HH revealed Central Plumbing was in the building for repairs to the hot water heater on East and West wing. At that time he provided documentation of temp checks from (MONTH) 28 at 7:00 a.m. thru (MONTH) 29 at 7:00 a.m., the temp range was from 60 degrees F to 115 degrees F 2. Review of the facility Falls Management policy date revised 3-12-15, revealed that the intent of the facility is to provide an environment which remains as free of incident hazard a is possible .the facility utilizes previous evaluation and current data to assist staff in identification of resident's specific risks and causes in an effort to identify appropriate intervention to reduce the likelihood of the resident falling and to try to minimize complications from falling .implement action plan based on root cause analysis set a re-evaluation timeline to determine how the plan is working .if falling recurs despite initial interventions, stall will implement additional or different interventions, or indicate why the current approach remains relevant. Review of the resident's Admission Record revealed that she had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 11, indicating that she was cognitively intact; required limited assistance from one staff person for transfer; used a wheelchair for mobility; required extensive assistance from two staff members for toilet use; was frequently incontinent of bladder and bowel, was on a toileting program; and had two or more falls since the last assessment (Quarterly MDS dated [DATE]). Review of the Quarterly MDS dated [DATE] revealed that the resident had a BIMS of 9, indicating that she had some confusion; required limited assistance from one staff member for transfers; required extensive assistance from one staff member for toilet use; was frequently incontinent of bladder and bowel; and was on a toileting program. Review of the resident's care plan initiated 6-7-18 revealed that the resident had falls on 8-29, 8-31, 9-3, 9-11, 9-12, 9-13, 9-16, 9-20, 9-23 ,9-24, 9-27, 9-28, 9-29, 10-6, 10-7, 10-12, 10-13, 10-18, 10-24,10-29, 11-2, 11-3,11-9, 11-11, 11-15, and 11-19 without injuries. Continued review revealed interventions for staff to assess the resident's wheelchair for appropriate size and assess the need for footrests, keep the bed in low position, keep call light in reach, observe gait; assist with equipment as needed, orientation to new room and roommate, remind to use call light for needed assistance, scheduled toileting program, and for therapy to evaluate and treat as indicated. Review of the resident's records revealed that a root cause analysis for the falls had not been completed. During an interview on 11/28/18 at 11:00 a.m. with RN Resident Care Liaison (RCL) revealed that falls are discussed during the morning clinical meeting the day after the fall. The fall is then discussed weekly in an interdisciplinary team (IDT) meeting for the four weeks after the fall. During an interview on 11/28/18 at 1:00 p.m. with the Director of Nursing (DON) revealed that when a resident has a fall, the fall is discussed in the morning meeting the next day after the fall. Continued interview revealed that the facility was unable to provide documentation that a root cause analysis had been completed for any of the falls. Further interview revealed that the DON stated that the resident has the right to fall.

Based on observation, interview and review of policy titled Cleaning Procedures the facility failed to ensure that the floor in the dry goods area of the kitchen was kept clean, failed to ensure that sanitary sink drains were used and failed to ensure that a fan and a kitchen shelf were kept clean and sanitary. The facility census was 91 residents. Findings include: Review of the policy titled Cleaning Procedures and dated 7/2/17 revealed that floors were to be wet mopped daily with detergent/sanitizer and water and then rinsed. Review of the cleaning schedule revealed that walls and fans were to be cleaned by everyone on Wednesday. Observation and interview on 11/28/18 at 8:26 a.m. with the Dietary Manager (DM) revealed that the floor in the dry good area was very sticky. The DM stated that she kept a cleaning schedule posted and that the dry good area was to be mopped routinely on Monday and Thursday when supplies were delivered and as needed. The DM confirmed that the floor was very sticky in the dry goods area. Observation on 11/28/18 at 8:59 a.m. of the three-compartment sink with the DM revealed that paper towels were being used in place of the sink drain [MEDICATION NAME]. The DM confirmed that paper towels were being used in place of the sink drain [MEDICATION NAME] and stated that the drain [MEDICATION NAME] break easily. She stated that she needed to order new drain [MEDICATION NAME]. Observation on 11/28/18 at 9:04 a.m. of two fans in the kitchen revealed a build-up of dust on one fan that was located over the covered chest that contained the plate warmers and facing the steam table. There was a heavy build-up of dust on the shelf below the second fan that was at the entrance from the dining room into the kitchen. The shelf held the pitchers used to serve beverages. Interview with the Dietary Manager confirmed that there was a build-up of dust on the one fan and on the shelf below the other fan. Interview on 11/29/18 at 12:36 p.m. with the Regulatory Compliance Nurse revealed that the expectation was that there would be no accumulation of dust on fans or shelves that house dishes or food items.