Every finding on record at Bethesda Home of Aberdeen

Based on interview, record review, and policy review, the provider failed to ensure pressure injury prevention interventions were identified and implemented for one of one sampled resident (70) who developed a deep tissue injury (DTI) (a pressure ulcer/injury with purple or maroon discolored skin and underlying soft tissue damage, caused by intense, prolonged pressure) on her right heel. Findings include: 1. Observation and interview on 3/10/26 at 2:35 p.m. with resident 70 while she was in her room watching television, revealed that her bed was located next to the window. She had hard surface protective boots on both her lower legs and feet. There were Velcro straps that were wrapped around her lower legs, holding those boots in place. She stated that she had multiple sclerosis (a condition where the immune system attacks the nervous system, causing damage and scar tissue) and that she had a left heel pressure injury that developed before she was admitted to this facility from another long-term care facility. After she was admitted to this facility, she received a protective boot for her left foot and heel. Resident 70 stated she then developed a pressure injury to my right heel. She reported that 24/7 (twenty-four hours a day, seven days a week) continuous boot use on her left foot and the involuntary movement of her left leg while in bed caused friction between her right and left heels, which she believed contributed to the development of the pressure injury on her right heel. The resident stated that the left heel injury had healed. 2. Observation and interview on 3/12/26 at 1:31 p.m. with resident 70 revealed resident 70 was in her room, sitting in her wheelchair, sorting through clothes, with tennis shoes on both of her feet. Resident 70 stated that she had attended a wound care appointment earlier that day, and that the wound care staff informed her that her left heel was healed. Her right heel would only need iodine on the scab until it falls off, and no dressing was required for her right heel at this time. Resident 70 stated she was instructed to continue to wear both protective boots when in bed and occasionally during the day. Resident 70 stated that when she was in bed, she was able to adjust her upper body using the grab bar (bar attached to the bed) located on the left side of her bed and by holding onto the windowsill on the right side. She said that she could not independently reposition her lower body and that her legs occasionally had muscle spasms. She was able to feel the pressure injury on her right heel and stated that it hurt. 3. Review of resident 70's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her Brief Interview of Mental Status (BIMS) assessment score was a 15, which indicated her cognition was intact. Her diagnoses included: Multiple Sclerosis (MS), paraplegia (the loss of motor and sensory function in the lower body), muscle wasting and atrophy (wasting of muscle tissue, leading to reduced size, weakness, and limited mobility) of the right and left thighs and lower legs, and muscle weakness. Her 1/21/26, 2/4/26, and 2/11/26 Braden Scale (a tool used to assess the risk of developing pressure ulcers) assessment scores were all 19, which indicated she was not at risk for the development of a pressure injury. There were no further documented Braden Scale assessments after 2/11/26. Resident 70's Wound-Weekly Observation Tool assessments revealed that on 2/5/26, she had developed a facility acquired, Type [of wound]: pressure to her right heel. The assessment identified the Pressure Ulcer Stage as a suspected DTI (SDTI). The wound measurements were 22 millimeters (mm) by 32 mm, with no depth recorded. The peri-wound tissue (the skin surrounding a wound edge) was described as Pink, dry, intact. The treatment was Foam dressing weekly et [and] Multipodus boot [a specialized, rigid orthopedic device designed to prevent and correct pressure ulcers [injury] in bedridden or immobile patients]. On 2/9/26 the measurements of her SDTI were 20 mm x 30, with no depth recorded. The treatment was Foam dressing weekly et Multi-podus boots. Resident 70's 3/9/26 right heel SDTI measurements were 15 mm x 25 mm, with no depth recorded. The SDTI was described as Pink, dry, intact. Treatment was Foam dressing et Multi-podus boots to BLE [bilateral lower extremities]. The wound was described as Wound is [the] same in size as [the] previous week's measurement. Scab is starting to lift up around the edges. Will continue ordered tx [treatment] and to monitor. Resident 70's 1/19/26 Dietitian Nutritional Assessment, completed by Registered Dietitian Nutritionist (RDN) X, indicated she had a pressure injury to her left heel and resident reports her legs are 'too weak' to return [to her home]. Resident does have history of MS, and Resident does have [a] history of MS and endorses lower extremity weakness. Will communicate [the] addition of 1 oz [ounce] of Prosource daily to CDM [certified dietary manager]. Her 2/10/26 Dietitian Nutritional Assessment indicated writer [RDN] was also notified of SDTI to [the] right heel that was identified by resident [70's] nurse. 4. An interview on 3/12/26 at 1:45 p.m. with certified nursing assistant (CNA) K regarding resident 70's right heel SDTI injuries revealed that when she arrived at work in the morning, resident 70 typically had her protective boots on her feet. CNA K stated that she would then remove the boots and place shoes on resident 70 so the resident was able to use a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to go into the bathroom. Afterward, resident 70 was assisted into a wheelchair using the sit-to-stand lift, and the protective boots were then placed back on her feet. CNA K reported that resident 70 was able to use her call light. She stated that the staff repositioned residents and attempted to offload resident 70's heels; however, resident 70 would sometimes allow the staff to offload her heels, and at other times she refused. Resident 70's left leg would sometimes twitch when a staff member was applying her protective boots. 5. An interview on 3/12/26 at 2:00 p.m. with registered nurse (RN)/resident care coordinator (RCC) H regarding resident 70's heel pressure injuries revealed that resident 70 was admitted to the facility with a pressure injury to the left heel and was referred to wound care, who ordered a boot for the resident's left heel. Resident 70 wore a foam boot on the left heel until the Podus boot (an orthopedic device with a rigid outer frame and a soft, often removable, liner that keeps the ankle in a neutral position while elevating the heel to eliminate pressure) arrived. RN/RCC H was unable to recall when the Podus boot arrived. RN/RCC H reported that the pressure injury on resident 70's right heel was identified as a facility-acquired SDTI, which she attributed to the resident sitting in her wheelchair, wearing shoes, and having a diagnosis of MS. At that time, resident 70 was wearing a shoe on the right foot. RN/RCC H stated that a Podus boot for the right foot was subsequently ordered. Before that, interventions included the use of skin preparation and a foam dressing. RN/RCC H reported that resident 70 could reposition and move her legs while she was in her bed and that her legs were floated (the process of elevating the legs off the bed to remove contact, ensuring they do not bear weight) when she was in her bed to reduce pressure to her heels. 6. Review of the provider's revised 6/1/22 Pressure Injury Prevention and Management policy revealed Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on all residents upon admission/re-admission within 24 hrs [hours], weekly x [times] four weeks, after a change of condition, after any newly identified pressure injury, and quarterly. Review and revise Care Plan with needed interventions . Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Interventions will be documented in the care plan and communicated to all relevant staff. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify [the residents'] physician to obtain orders as needed. 7. Review of the provider's 2025 Pressure Injury Prevention Guidelines revealed Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Consider use of prophylactic dressings for prevention of sacral and heel pressure injuries. Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon [a tendon connecting calf muscles to the heel bone]. 8. Interview, record review, and policy review, on 3/12/26 at 2:09 p.m. with director of nursing (DON) B revealed resident 70 was admitted to the facility with a SDTI on her left heel. Resident 70 had developed a facility-acquired SDTI on her right heel shortly after she was admitted . She stated the Braden Scale assessments were completed when a resident was admitted to the facility and then weekly for the next three weeks, if they had a pressure injury or a significant change in condition, each quarter, when they returned from hospitalization, and when a resident developed a new pressure injury. After DON B reviewed the providers Pressure Injury Prevention and Management policy and the Pressure Injury Prevention Guidelines policy she stated she expected a resident's Braden Scale assessment to be completed with every new pressure injury, and weekly until the pressure injury was healed. After reviewing resident 70's 2/11/26 Braden Scale assessment, she agreed that question 1's answer to Ability to respond meaningfully to pressure-related discomfort was incorrect and should have been coded at least slightly limited impairment. She stated, Even her diagnoses would have indicated that. She indicated question 8 Friction & [and] . was coded incorrectly and should have been coded as Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. She stated that resident 70 was unable to move independently in bed, and in hindsight, maybe [we] should have ordered two [Podus boots] to begin with. She confirmed resident 70's left side Podus boot could have rubbed her right heel if resident 70's leg spasmed when she was in bed. After reviewing resident 70's care plan, DON B confirmed that resident 70's care plan should have included the necessary care she required, and her care plan had not included her not being able to reposition her legs, the use of Podus boots, or that her heels were floated. She stated that pressure injuries are typically included in the residents' care plans. She indicated RN/RCC H was responsible for updating resident 70's care plan, or that RN/RCC H should have asked MDS RN F for help in updating it. DON B stated, We should have been repositioning [resident 70], and we do have pressure-reducing mattresses, or pillows.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed food safety standards to:*Maintain a clean and sanitary food service environment in one of one main kitchen and one of one activity room kitchenette.*Store raw meat to prevent potential cross-contamination in one of one walk-in cooler.*Label and date bulk food ingredients in one of one activity room kitchenette according to the provider's policy.*Ensure one of one activity room dishwasher used for special events reached the temperature required for sanitizing residents' drinkware and dishes.*Ensure hand hygiene (washing hands or using hand sanitizer) was performed after direct contact with soiled surfaces and resident equipment by certified nurse aide (CNA) (M) before the CNA poured water into glasses for three of three sampled residents (1, 19, and 67) during one of two observed meal services. Findings include: 1. Observation on 3/10/26 at 8:35 a.m. in the dining room revealed the popcorn machine was sitting in the bar area. The machine had leftover popcorn kernels in the bottom of the basin and the kettle had a black burnt-on oily residue. Observation during the initial kitchen tour on 3/10/26 from 8:41 a.m. to 9:16 a.m. revealed there was limescale buildup in the dishwasher. There was a crusty white residue that had built up on the wash arms, inside the doors, and within the door seams of the dishwasher. The handwashing sink in the dishroom appeared stained and had food debris in the basin and in the drain. The walk-in freezer floor was made of stainless steel. Some areas of the floor had turned black with a buildup of an unknown residue. There was a collection of empty food packaging, food crumbs, and dirt on the floor. There was an opened bag of diced onions in the walk-in cooler that did not have an open date on it to indicate when the bag was opened. There was a metal rack of raw meat in the walk-in cooler. There were two 10-pound tubes of ground beef on the top shelf, four packages of beef stew meat on the middle shelf, and at least three cases of raw pork loin chops on the bottom shelf. There was a missing ventilation hood panel above the cooking equipment in the kitchen. There was a beverage station in the dining room. The coffee dispenser had limescale buildup on the spouts. The juice dispenser had an unidentified black substance buildup near the spouts, and the refrigeration vents had a buildup of dust. 2. Observation on 3/10/26 at 12:04 p.m. during lunch service in the main dining room revealed that certified nurse aide (CNA) M was assisting residents into the dining room for the noon meal. She assisted resident 1 to her table in the dining room by pushing her wheelchair. CNA M then knelt down on the dining room floor, unlocked resident 1's wheelchair foot pedals, moved them back, and adjusted resident 1's feet under the table. CNA M then stood and, without performing hand hygiene, picked up resident 1's water glass from the table and poured a glass of water for resident 1. CNA M then picked up resident 67's water glass from the same table and poured him a glass of water. She did not perform hand hygiene after pouring water and exited the dining room. At 12:15 p.m., CNA M returned to the main dining room, pushing resident 19's wheelchair. She assisted resident 19 to her table, touched her right foot pedal lock to adjust it, but resident 19 refused to have her foot pedals adjusted. Then, without performing hand hygiene, she picked up resident 19's water glass from the table and poured a glass of water for her. She did not perform hand hygiene after pouring the water and then exited the dining room. 3. Observation on 3/11/26 at 9:35 a.m. in the activity room kitchenette revealed the microwave had splatters of crusted food on the inside. There were two containers labeled Sugar and Flour in the cupboards. Neither container was labeled with the date it was filled. There was a spoon sitting within the sugar inside the sugar container. There was a standard household model dishwasher. It was an ASKO brand, and the model number was D5424. There were several different program options, including Daily wash, Heavy wash, Normal wash, Eco wash, Quick wash, and Rinse & [and] Hold. There were two additional options to choose from, including High temperature and Long dry. There were dishes inside the dishwasher, including coffee cups, a metal mixing bowl, a glass measuring cup, a crockpot ceramic bowl, a glass crockpot lid, and metal eating utensils like forks and spoons. 4. Interview on 3/12/26 at 8:32 a.m. with culinary associate V revealed that she had worked at the facility for about three months. At the end of each shift, they wiped down the outside of the beverage dispensers in the dining room, but she was never instructed to take the machines apart to clean the inside or the dispenser spouts. 5. Observation on 3/12/26 at 8:56 a.m. in the walk-in cooler revealed that the meat shelf had more meat on it than the observation on 3/11/26 during the initial kitchen tour. The top shelf had one 10-pound tube of raw ground beef. The tube of beef was sitting in a reddish puddle of liquid. Directly below that shelf, there was a container of raw turkey roast that was thawing in a pan. Directly below that shelf, there were two additional packages of raw turkey roast. Directly below that shelf, there were packages of raw beef stew meat. The sheet pan that the packages of raw beef stew meat were sitting on had a large puddle of red liquid. Directly below that shelf, there was a case of raw pork loin chops. 6. Interview on 3/12/26 at 8:57 a.m. with chef P revealed that raw poultry was supposed to be on the bottom shelf. Meats like fish were supposed to be at the top. He believed that raw ground meats, like the tube of ground beef in the cooler, could be stored above whole cuts of meat like the pork loin chops. He was not aware that whole cuts of meat were supposed to be stored above ground meats. When asked about cleaning tasks in the kitchen, chef P mentioned that each chef position was assigned cleaning duties daily. There was an additional cleaning checklist that any staff member could choose from to clean. He did not know how often the dishwasher was delimed. He confirmed that the freezer floor was usually swept, but he was not aware if there were any specific chemicals used to scrub or mop the freezer floor. When looking at the cleaning checklists, he confirmed that sweeping or cleaning the freezer was not included on the list. 7. Review of the above-described cleaning checklists revealed that there was one chef cleaning checklist, and one additional cleaning checklist that did not include the frequency expectations of the cleaning tasks. The March 2026 chef cleaning checklist included different tasks to complete Monday through Friday. The freezer, beverage dispensers, and dishwasher were not included on that list. The undated Cleaning Task checklist included various cleaning tasks in the kitchen and dining room. The handwashing sink in the dish room was marked as last cleaned on 12/24/25. The dishwasher was marked as last delimed on 1/5/26. The juice and coffee dispensers were marked as last cleaned on 1/6/26. There was a task item listed to Sweep/Mop walk in fridge but no tasks listed for cleaning the walk-in freezer. 8. Interview on 3/12/26 at 9:16 a.m. with culinary managers C and D revealed that staff should be sweeping the floors daily, and mopping the freezer floors monthly. They had a special chemical to mop the freezer floor. They expected the staff to delime the dishwasher every other week. Culinary manager D printed out a new dishwasher deliming schedule and posted it in the dish room for their main commercial dishwasher in the kitchen. Staff delimed the dishwasher the day before, and she commented that she did not know when the dishwasher was last delimed. They were not aware that the cleaning checklist indicated the main commercial dishwasher in the kitchen was last delimed in January 2026. Culinary manager C confirmed that raw poultry should be on the bottom shelf, then ground meats above that, then other meats like the beef stew meat above the ground meats, and fish at the top. Neither culinary manager C nor D were aware that the raw meat in the walk-in cooler was not stored that way. Culinary manager C said that the dishwasher in the activity room kitchenette was the responsibility of the activity department. They did not know if that style of dishwasher was capable of sanitizing dishes. 9. Interview on 3/12/26 at 10:25 a.m. with activities director I revealed that they used the household model dishwasher in the kitchenette to clean residents' coffee cups, happy-hour dishes like glasses, forks, and spoons, and other dishes used when baking treats for residents. The dishes cleaned in that dishwasher did not come into contact with TCS foods (time/temperature control for safety). She was not aware if that dishwasher was capable of sanitizing dishes or not. She used the generic brand of dish detergent pods and ran the dishwasher like normal. She did not know if the detergent pods contained chemicals for chemical sanitization. She said the popcorn machine was cleaned each time it was used. They usually just wipe it all out. The activities staff were responsible for monitoring and maintaining the food ingredients in the activity room kitchenette. She said that they did not usually store the scoop in the bulk ingredient containers. She was not aware that there was a spoon stored in the bulk sugar container. She was not aware of when those bulk ingredients were last filled, or when the containers were last cleaned. She indicated that activities staff and sometimes residents' family members would use the ingredients in the kitchenette to make treats for residents. 10. Review of the provider's dish detergent pods used for the activity room dishwasher revealed it did not contain any chemicals used for chemical sanitization of dishes. 11. Interview on 3/12/26 at 11:08 a.m. with culinary manager D revealed that a high-temperature commercial dishwasher needed to reach at least 180 degrees Fahrenheit to sanitize the dishes. She was not aware if the dishwasher in the activity room kitchenette had the capability to sanitize dishes. 12. Review of the owner's manual for the ASKO D5424ADA W/B/S dishwasher revealed that the maximum temperature reached during any of the wash and rinse cycles was 150 degrees Fahrenheit. When using the High temperature option, the maximum rinse temperature reached was 160 degrees Fahrenheit, but only for the Heavy wash cycle. The owner's manual did not include information on whether it had the capability to sanitize dishes. 13. Interview on 3/12/26 at 11:18 a.m. with administrator A revealed that the dishwasher in the activity room kitchenette did not reach 180 degrees according to the owner's manual. They did not have a way to monitor the maximum water temperature for that dishwasher. He confirmed items like resident coffee cups and happy hour dishes were cleaned in that dishwasher. The dishes cleaned in that dishwasher did not come into contact with TCS foods (time/temperature control for safety). There were no current respiratory or gastrointestinal infectious disease outbreaks in the facility. If the staff could not use that dishwasher for whatever reason, they had two backup dishwashers: one in the main kitchen, and one in the attached child daycare facility. 14. Interview on 3/12/26 at 4:15 p.m. with director of nursing (DON) B revealed that she expected the staff to perform hand hygiene before and after direct resident contact, after direct contact with resident equipment, and before assisting residents with a meal service. DON B acknowledged that hand hygiene should have been performed by CNA M before and after resident contact to help prevent the transmission of infection. 15. Review of the provider's revised 4/3/20 Hand Cleansing policy revealed that the staff should wash hands before and after resident contact. The policy described hand hygiene to be the primary means of preventing the transmission of infection. Staff should cleanse their hands before and after direct resident contact, before and after eating or handling food, before and after assisting a resident with meals, and after handling soiled equipment or utensils. 16. Review of the 2022 Food and Drug Administration (FDA) Food Code found at https://www.fda.gov/food/fda-food-code/food-code-2022 revealed that, Equipment food-contact surfaces and utensils shall be sanitized. Methods for sanitization include using hot water or chemicals. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under [Sections] 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 [degrees Celsius] [160 degrees Fahrenheit] as measured by an irreversible registering temperature indicator. Section 4-501.112 includes requirements for Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold [a central component or pipe fitting that consolidates, distributes, or controls the flow of fluids between multiple sources and destinations] must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 [degrees Celsius] (160 [degrees Fahrenheit]) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 [degrees Celsius] (194 [degrees Fahrenheit]) at the manifold, the water becomes volatile [unstable] and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 [degrees Celsius] (165 [degrees Fahrenheit]) for a stationary rack, single temperature machine, and 82 [degrees Celsius] (180 [degrees Fahrenheit]) for other machines are based on the sanitizing rinse contact time required to achieve the 71 [degrees Celsius] (160 [degrees Fahrenheit]) utensil surface temperature. 17. Review of the provider's 11/11/25 Cleaning Dishes in Dish Machine policy revealed that All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. 18. Review of the provider's 2021 Deliming Dish Machines policy revealed that the dishwasher was supposed to be delimed twice a month. 19. Review of the owner's manual for the main dishwasher in the kitchen revealed that the manufacturer recommended your dishwasher should be de-limed regularly; how often will depend on the mineral content of your water. The weekly maintenance checklist included clean accumulated lime deposits from the wash tank heating element. 20. Review of the provider's 2021 Cleaning Instructions: Coffee, Beverage, Juice, Frozen Yogurt, or Ice Cream Machines policy revealed the coffee machine was to be cleaned weekly by following the manufacturer's instructions, and the juice dispenser should be cleaned by disassembling the parts, running them through the dishwasher, and allowing them to air dry before reassembling. The outside of the machines should be cleaned with cool water and a cleaning solution. The policy indicated to follow the juice dispenser manufacturer's instructions. 21. Review of the provider's 2021 Food Storage policy revealed that food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The policy indicated that plastic containers with tight-fitting covers or sealable plastic bags must be used for storing.sugar.and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. In reference to storing meats, the policy included raw animal foods should be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. The policy did not indicate in what order the raw animal meats should be stored. 22. Review of the provider's 2021 Cleaning Instructions: Freezers policy revealed that freezers will be cleaned on a regular basis. Debris should be removed by sweeping. The floors were to be mopped using floor cleaner for below 0 [degrees Fahrenheit]. 23. Review of the provider's 6/1/24 Popcorn Machine Cleaning Policy revealed that the purpose of the policy was to ensure that all popcorn machines are cleaned regularly and properly to maintain food safety, equipment performance, and a sanitary environment for customers and staff. The policy indicated that the activities staff were responsible for cleaning and maintaining the popcorn machine. The policy indicated that the popcorn machine must be cleaned after each use by removing unpopped kernels and popcorn debris, wiping the interior surfaces and glass panels, cleaning the kettle exterior, emptying and cleaning the crumb tray, and wiping all interior and exterior surfaces. On a weekly basis, the staff were to perform a deep cleaning of the kettle and interior surfaces, and inspect for grease buildup and remove as needed. 24. Review of the provider's infection control program binder revealed no current resident cases of any respiratory or gastrointestinal infections or symptoms.

Based on observation, interview, and record review, the provider failed to ensure the menu serving sizes and therapeutic diet menus were created and followed regarding:*One of one chef (P) failed to follow the menu serving sizes for each resident who was offered food at the facility for one of two observed meal services.*Nine of nine sampled residents (1, 7, 15, 17, 42, 48, 53, 75, and 90) who were prescribed a NAS (no added salt) diet, and eighteen of eighteen residents (9, 20, 21, 23, 27, 32, 33, 40, 41, 46, 50, 57, 63, 68, 71, 78, 79, and 87) who were prescribed a Heart healthy diet, and did not have their therapeutic diet created or followed. Findings include:1. Observation on 3/12/26 at 8:41 a.m. in the kitchen of chef P revealed he was serving breakfast from a steam table. He served ham and cheese egg scramble with a green-handled #12 scoop, and breakfast potatoes with a pair of tongs. There was a meal ticket printer that printed the residents' meal choices. Those meal tickets included the menu item, but not the serving sizes. 2. Review of the provider's menu and recipe binder at that time revealed that the serving size for the ham and cheese egg scramble was four ounces. The binder did not include a recipe or serving size for the breakfast potatoes. 3. Interview on 3/12/26 at 8:51 a.m. with chef P revealed that the facility did not have a chart noting scoop sizes. He said that they just have to know the amounts. He said he believed the green #12 scoop that he was using for the ham and cheese egg scramble was about four ounces. 4. Interview on 3/12/26 at 8:54 a.m. with culinary managers C and D revealed that they confirmed there was no conversion chart referencing scoop sizes. The green #12 scoop was three ounces, not four ounces. At that time, the survey team requested a copy of the menu with serving sizes for each meal during the survey week. Culinary manager D said they did not have menus with serving sizes listed because the serving size information was listed in each recipe within the menu and recipe binder. Record review and interview at that time with culinary managers C and D revealed that there were no recipes included in that binder for the breakfast potatoes, baked beans (on the menu for lunch on 3/12/26), and minestrone soup (on the menu for lunch on 3/12/26). Culinary managers C and D were not aware that those recipes were not included in the menu and recipe binder. Culinary manager D said the staff use iPads to order the residents' meals within a software program that, instead of listing serving sizes, tells the staff if the residents exceeded their allotted nutritional count for that meal. They confirmed that residents on therapeutic diets, such as a diabetic diet, heart healthy diet, or low sodium diet, all received the same menu as the regular diet. 5. Continued interview on 3/12/26 at 9:16 a.m. with culinary managers C and D revealed that it was standard for the staff to use the green scoop when serving the ham and cheese egg scramble. Culinary manager D confirmed the staff should have used a four-ounce scoop instead. They confirmed that using tongs to serve the breakfast potatoes was not the best choice as they could not verify the quantity served. 6. Review of the provider's menu for breakfast on 3/12/26 revealed the serving sizes were hand-written on the menu. The menu included four ounces of ham and cheese scramble, three ounces of breakfast potatoes, seven ounces of apple juice, one muffin, three-fourths cup of oatmeal, and seven ounces of milk. 7. Review of the provider's 11/11/25 dietitian-signed menu revealed that the following therapeutic diets were available: pureed, mechanically altered, gluten free, renal, and carbohydrate controlled. There was no menu for a heart healthy or no added sodium diets. 8. Review of the diet type report revealed that residents 1, 7, 15, 17, 42, 48, 53, 75, and 90 were prescribed a NAS (No Added Salt) diet, and residents 9, 20, 21, 23, 27, 32, 33, 40, 41, 46, 50, 57, 63, 68, 71, 78, 79, and 87 were prescribed a Heart healthy diet.

Based on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or resident's representative of the risk versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were given for two of two sampled residents (7 and 10). Findings include:1. Review of resident 2's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), unspecified psychosis not due to a substance or known physiological condition, unspecified hallucinations, delusional disorder (false beliefs and distorted views of reality), dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). She was unable to make decisions regarding her medical care, and her son was her power of attorney (POA, a designated person on a legal document to act on behalf of a resident). On 1/12/26, her mental health provider ordered aripiprazole 5 milligrams (mg) (an atypical antipsychotic medication that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) at bedtime for hallucinations (to see, hear, smell, taste, or touch something that is not there). The first dose was given on 1/12/26 at bedtime. There was no documentation that resident 2's POA was notified about the new medication, if risks versus benefits were discussed, or if consent was obtained regarding the use of that psychotropic medication. The aripiprazole was discontinued on 2/11/26 as her hallucinations and other mental health symptoms were continuing without improvement. 2. Review of resident 7's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. His 2/20/26 Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated his cognition was severely impaired. His diagnoses included anxiety disorder, symptoms and signs involving cognitive functions and awareness, delusional disorder, and dementia with behavioral disturbance. His 3/12/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area that read, The resident has potential to be verbally aggressive towards residents and staff r/t [related to] Poor impulse control, with an intervention that read, Keep family and physician updated. Another focus area read, The resident uses antipsychotic medications [a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions] r/t behavior management with an intervention that read, Discuss with MD [medical doctor], family re [regarding] ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness per policy. A 11/27/24 physician's order for mirtazapine (an antidepressant) 15 mg at bedtime for anxiety was received. There was no documentation that the resident's representative was notified of the new medication order, the indication for the medication, the risk versus benefits of that medication, or alternative treatments to that medication. On 1/8/25, the mirtazapine dose was ordered to be increased to 30 mg at bedtime. There was a progress note that stated the nurse had attempted to call the resident's representative but there was no answer. There was no further documentation that the nurse reattempted to call the resident's representative or that the resident's representative returned the call. A 2/5/25 physician's order for sertraline (an antidepressant) 25 mg every day for anxiety was received. A progress note indicated resident 7's representative was notified of the new medication but there was no documentation that the risk versus benefits or alternative treatments were addressed. On 3/7/25, there was a physician's order to reduce resident 7's mirtazapine to 15 mg for 28 days, then 7.5 mg for 28 days, then 3.75 mg for 14 days, and then to stop the medication due to ineffective behavioral results. Resident 7's representative was documented as having been notified of this change. On 3/17/25, there was a physician's order to increase resident 7's sertraline to 50 mg daily and started aripiprazole (Abilify, an antipsychotic medication) 5 mg at bedtime for mood and delusions. There was no documentation that the resident's representative was notified of the new medication order, the indication for the medication, the risk versus benefits of that medication, or alternative treatments to that medication. On 4/3/25, resident 7's mirtazapine was ordered to be continued at 15 mg every day at bedtime, the scheduled reduction of that medication was to be stopped, and his Abilify was increased to 10 mg at bedtime. There was no documentation that the resident's representative was notified of the changed medication orders, the indication for the changes, the risks versus benefits of those medications, or alternative treatments to those medications. On 4/16/25, resident 7's physician ordered to increase the Abilify to 15 mg at bedtime, decrease his mirtazapine to 7.5 mg for two weeks and then stop, and to increase his sertraline to 75 mg daily for two weeks, then increase it to 100 mg daily. Resident 7's representative was notified of the changed medication orders, but there was no documentation that resident 7's representative was informed of the indication for the changes, the risks versus benefits of those medications, or alternative treatments to those medications. On 6/24/25, resident 7's sertraline increased to 125 mg daily. Resident 7's representative was notified of the changed medication order, but there was no documentation that resident 7's representative was informed of the indication for the change, the risks versus benefits of the medication, or alternative treatments to the medications. On 7/17/25, resident 7's physician ordered lorazepam (an antianxiety medication) 0.5 mg every four hours as needed for anxiety and restlessness. There was no documentation that the resident's representative was notified of the new medication order, the indication for the medication, the risks versus benefits of that medication, or alternative treatments to that medication. On 12/2/25, resident 7's Abilify was decreased to 12.5 mg at bedtime. There was no documentation that resident 7's representative was informed of the changed medication order, the indication for the change, the risks versus benefits of the medication, or alternative treatments to the medications. On 3/5/26, resident 7's Abilify was decreased to 10 mg at bedtime. There was no documentation that resident 7's representative was informed of the changed medication order, the indication for the change, the risks versus benefits of the medication, or alternative treatments to the medications. 3. Interview on 3/11/26 at 4:36 p.m. with director of nursing (DON) B revealed that written informed consents were not obtained from a resident or resident representative before beginning a psychotropic medication. The residents' medications were reviewed with the resident or their representative upon admitting to the facility and the resident or resident's representative signed that medication list. Neither the medication list nor the residents' baseline care plan addressed the risks versus benefits of psychotropic medications. 4. Interview on 3/12/26 at 1:42 p.m. with licensed practical nurse (LPN) R revealed that when a resident had a new medication order or a change in the dose of a medication, the nurse was to call that resident's representative and notify them of the change. If the resident's representative could not be reached, that nurse would pass that on in her report to the next shift and place the order in a file folder labeled waiting for family. The next shift would then attempt to call the residents' representative to notify them of the medication order. When LPN R called to notify a resident's representative of a new medication, she reviewed the reason the medication was being ordered, the risks of the medication, and answered any questions the resident's representative had. Once the resident's representative was notified of the new medication or change in the dosage of the medication, the notification was to be documented in the resident's progress notes under the communication with family category. 5. Interview on 3/12/26 at 1:50 p.m. with Minimum Data Set (MDS) registered nurse (RN) E revealed that the nurses were to notify the resident's representative before a psychotropic medication was started. They did not have a consent form for psychotropic medications that contained the medications' risks versus benefits review with the resident's representative. She was not aware that the regulation required the risks versus benefits and alternative treatments to the medication was to be reviewed with the resident or the resident's representative before a psychotropic medication was started. She expected the staff to document in the resident's progress notes that they had notified the resident's representative when a new medication was started or if there was a change in that medication's dose. She explained that resident 7's representative was difficult to reach, and he did not call the provider back after he was called. She expected the staff to document any attempts made to contact a resident's representative in that resident's progress notes. 6. Interview on 3/12/26 at 1:57 p.m. with DON B revealed that a resident or the resident's representative was to be notified if there was a new medication ordered, a dose of a current medication was changed, or if a medication was discontinued and that notification was to be documented in a progress note in that resident's EMR. She expected the nurses to discuss the risk versus benefits as well as the reason the psychotropic medication was started, or why the dose of the medication was changed with the resident or the resident's representative. She stated they did not have a professional reference for the nurses to use when they reviewed the risks versus benefits of the psychotropic medications and alternative treatments. She mentioned that resident 7's family was difficult to reach at times, but she expected the nurses to document their attempts to reach resident 7's representative in a progress note. She was not aware that the regulation required the risks versus benefits and alternative treatments to be reviewed with the resident or the resident's representative before a psychotropic medication was started. 7. Further interview on 3/12/26 at 2:35 p.m. and 2:50 p.m. with DON B revealed that resident 2's POA was not too involved with her care. They left voicemails on his contact phone number because he rarely answered their calls. She confirmed that she could not find documentation showing that informed consent was obtained from resident 2's POA regarding the aripiprazole. There currently was no system in place to ensure staff were educating and obtaining informed consents from the residents and their representatives about changes in the residents' care. 8. Review of the provider's 10/5/22 Use of Psychotropic Medication policy revealed that the resident's attending physician was responsible for managing the resident's medications. The policy included that the residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.

Based on observation, interview, record review, and the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review revealed the provider failed to ensure staff electronically submitted Minimum Data Set Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments to the Center for Medicare and Medicaid Services (CMS) within the required 14 day time frame from the residents' discharge for three of three sampled discharged residents (33, 43, and 92).Findings include: 1. Review of resident 33's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. He was discharged to the hospital on [DATE]. His 11/4/25 discharge tracking MDS assessment was not transmitted to CMS. 2. Review of resident 43's EMR revealed she was admitted to the facility on [DATE]. She was discharged on 11/25/25 to her daughters' home. Resident 43's 11/25/25 discharge tracking MDS assessment was not transmitted to CMS.3. Review of resident 92's EMR revealed she was admitted to the facility on [DATE]. She passed away on 12/5/26 while at the hospital. Resident 92's 12/5/25 discharge tracking MDS assessment was not transmitted to CMS.4. An interview and record review on 3/11/26 at 2:52 p.m., with Minimum Data Set (MDS) registered nurse (RN) F, regarding the tracking and transmission of discharge MDS assessments revealed she was responsible for ensuring the MDS assessments were transmitted to CMS within the required time frames. She reported she used the RAI Manual Version 1.20.1 October 2025 for reference, and acknowledged she was aware of the required MDS transmission timelines, including completion of a resident's discharge MDS within fourteen days of the date of discharge and transmission to CMS within fourteen days of the MDS completion date.After reviewing the discharge MDS assessments for residents 33, 43, and 92, she confirmed that those discharge tracking MDS assessments were not transmitted to CMS. She reported she was using an electronic MDS system along with a paper cheat sheet tracking form to monitor MDS transmissions. Resident 43's 1/4/26 discharge was not added to her paper tracking form.Upon further review of the discharge MDS assessments, MDS RN F identified that resident 33's discharge MDS assessment was not completed and therefore not transmitted to CMS. She acknowledged the assessment should have been completed within seven days of resident 33's discharge from the facility.Additionally, MDS RN F reported that Resident 92 had passed away at the hospital; however, the discharge MDS assessment incorrectly indicated the resident had passed away in the facility.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 revealed Assessment Transmission . Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records).

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (2) with dementia and episodes of hallucinations, behaviors, and agitation, had person-centered interventions included in the resident's plan of care for the staff to implement to assist the resident during those episodes to meet her dementia care needs. Findings include:1. Observation and interview on 3/11/26 at 9:44 a.m. in the Morning Dove Lounge revealed that resident 2 was sitting in a recliner. She had her left leg pulled up towards her torso, and she appeared to be trying to adjust her gripper sock or the cuff of her pants. Her walker was in front of her. She was not wearing shoes. When asked how she was doing that day, she mumbled about there being a bum on or near her left foot. She was not easily understood. She put her left foot back down on the floor, reached forward, and continued to point and readjust her pant leg while talking about the bum. 2. Interview on 3/12/26 at 12:29 p.m. with certified nurse aide (CNA) K revealed that resident 2 often wandered throughout the facility without shoes on. They helped resident 2 put gripper socks on in the mornings in case the resident decided to take her shoes off. She confirmed that resident 2 often experienced hallucinations about a lost dog or children. They would not try to bring her out of the hallucinations, instead they would validate her experience by acknowledging the dog or children that were not actually there. This helped the resident remain calm instead of worrying about the lost dog or children. 3. Review of resident 2's electronic medical record (EMR) revealed that her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), unspecified psychosis not due to a substance or known physiological condition, unspecified hallucinations, delusional disorder (false beliefs and distorted views of reality), dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Her care plan included a Background focus area that was last updated on 10/3/24 that read, [Resident 2] has been living at [a local assisted living center] since 11/10/23. In recent weeks became very paranoid / untrusting / seeing / talking to someone not there. The associated care plan goals, last revised on 9/5/25, included, Will adjust to LTC [long term care] stay and relying on others for cares as needed through next review. Will show interest in planning / organizing her daily routine through [next] review. Enjoy time with family as they visit through next review. The associated care plan interventions, all initiated on 7/18/24 and not revised since, included, Give cues, reminders, supervision and hands on direction. Keep lines of communication open with Resident / Family / Staff. Provide opportunity to plan / organize her day of offering activities which will provide opportunity to enhance her optimum level of functioning / well being in LTC. Her care plan did not include any focus areas, goals, or interventions related to her usual hallucinations or the staff's approaches to address her hallucinations. There were several progress notes that documented her hallucinations, including a 2/26/26 behavior note that read, Resident actively hallucinating this shift. Seeing children and becoming agitated when staff doesn't acknowledge them. Loudly saying, 'open your eyes boys and girls, your parents are here.'. Her 2/23/26 quarterly Minimum Data Set (MDS) assessment included that she experienced hallucinations and delusions. Her Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated that she had severe cognitive impairment. Her 6/16/25 annual MDS assessment Care Area Assessment worksheet included that she had Long-standing mental health problem associated with the behavioral disturbances, such as schizophrenia, bipolar disorder, depression, anxiety disorder, post-traumatic stress disorder, Delusions, and Hallucinations. The care plan considerations associated with those conditions read, Delusions and hallucinations have been observed. [Diagnoses] of anxiety and depression and on [medications] for [the] same. Does follow with [local psychiatric provider.] 4. Interview on 3/12/26 at 3:11 p.m. with social services director W revealed that she and the other social worker were responsible for the behavior portion of a resident's care plan. However, they reviewed and revised each resident's care plan as an interdisciplinary team. If a resident had hallucinations, she said, We might put a history of hallucinations. She confirmed that resident 2's care plan did not include interventions for the staff to consider when the resident was experiencing her hallucinations. Resident 2's care plan did include, however, that she had a history of paranoia and seeing things that are not there. She expected staff to utilize the resident's care plan, the electronic medical record, and for other experienced staff to know how to take care of each resident. 5. Review of the provider's 4/2019 Comprehensive Care Plans policy revealed that the policy statement read, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy included utilizing the comprehensive MDS assessment and all triggered Care Area Assessments when developing the comprehensive care plan. One of the topics described to be included in each comprehensive care plan included, The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, record review, interview, and policy review, the provider failed to ensure the staff followed nursing professional standards related to following physician orders regarding blood glucose monitoring and physician notification for one of one sampled resident (3) who had low blood sugar levels, and oxygen saturation (percentage of oxygen in the blood) monitoring for one of one sampled resident (32) with physician's orders to keep her oxygen saturation levels above 90 percent. Findings include: 1. Interview on 3/10/26 at 3:00 p.m. with resident 3 revealed he received insulin. He had a history of low blood sugar levels in the mornings. He mentioned that he did not feel any different when his blood sugar level was low. The staff usually gave him a glass of juice if his blood sugar was low. Sometimes, his blood sugar level got as low as 50 to 57 (milligrams per deciliter, mg/dL) in the mornings. 2. Review of resident 3's electronic medical record (EMR) revealed he had a diagnosis of Type 2 Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar) with diabetic chronic kidney disease. He had a current 3/2/26 physician's order for Accuchecks [a brand of blood glucose monitoring systems] BID [twice per day] [notify] Dr. [doctor] if BS [blood sugars] [are] less than 70, or greater than 400 two times a day. His previous order for blood sugar level checks read, Accuchecks BID Dr. if BS less than 70, or greater than 400 every morning and at bedtime. That order was active from 9/2/25 through 3/2/26. On 2/8/26 his blood sugar was 55 mg/dL, on 2/7/26 his blood sugar was 59 mg/dL, and on 10/16/25 his blood sugar was 65 mg/dL. There was no documentation that his physician was notified of those low blood sugar levels. 3. Interview on 3/12/26 at 4:08 p.m. with LPN T revealed that if a resident's blood sugar fell below or above specified parameters, the resident's physician was to be notified. 4. Interview and record review on 3/12/26 at 4:10 p.m. with staff education director/infection preventionist U revealed that she confirmed there were no physician notifications for the above-listed dates. She said that she talked to the nurse that was on shift those days, and that nurse informed her that resident 3 also experienced low blood sugars on 2/2/26, 2/3/26, and 2/4/26. She notified the physician of those low blood sugars, and the physician did not change any interventions. The nurse told staff education director/infection preventionist U that she did not notify resident 3's physician on 2/7/26 and 2/8/26 because she did not think he would change any of the resident's interventions or provide further direction to address resident 3's low blood sugar levels. 5. Interview on 3/12/26 at 4:11 p.m. with DON B revealed that she expected the staff to notify the residents' physician each time the blood sugars were out of the specified ranges according to the physician's orders. 6. Review of the provider's 7/28/23 Glucometer Standards (Assure Pro) policy revealed that critical high and low tests of residents will be managed according to their physician's orders. The instructions read, Check each resident's [parameter] and report per physician's order. 7. Review of the provider's 5/24/23 Physician Notification Policy revealed that it is the policy of this facility to timely notify the physician.of changes in resident condition. The policy defined promptly as results shall be relayed with little or no delay to the ordering physician. The policy explanation included, The facility must promptly notify the attending physician. of changes in resident condition that falls outside the 'normal' range for that specific resident, in accordance with facility policies and procedures. Delayed notification may contribute to delays in changing the course of treatment or care plan. 8. Observation on 3/11/26 at 9:03 a.m. in resident 32's room revealed that there was an oxygen concentrator machine (a device that filters room air into purified oxygen) at the foot of her bed. The machine was turned on, but no one was in the room using it. 9. Review of resident 32's EMR revealed that she had a 6/3/25 physician's order for O2 [oxygen] at 2L [liters] via nasal cannula [flexible tubing with prongs that delivers oxygen through the nose] to keep sats [saturation; percentage of oxygen in the blood] above 90% [percent] every morning and at bedtime related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA [low oxygen levels in the body]. Resident 32's medication administration record, treatment administration record and record of vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) documentation indicated that her blood oxygen saturation was last documented as measured on 3/1/26. From 1/1/26 to 3/11/26, her blood oxygen saturation levels were documented as measured a total of six times. Her care plan included a 4/29/25 intervention that read, OXYGEN SETTINGS: O2 via nasal [cannula] @ [at] 2L at night and when sleeping. 10. Interview on 3/11/26 at 3:39 p.m. with registered nurse (RN) Q revealed that a resident's blood oxygen saturation was to be monitored more frequently if the oxygen flow rate was adjusted. If the resident asked for oxygen, she expected the resident's blood oxygen saturation level to be measured before administering oxygen and rechecked an hour later. 11. Interview on 3/11/26 at 3:42 p.m. with LPN S revealed that resident 32 usually received oxygen with the use of the oxygen concentrator at night. 12. Interview on 3/11/26 at 3:51 p.m. with RN Q revealed that she reviewed resident 32's EMR and confirmed that the resident's oxygen order in the EMR system did not include blood oxygen saturation checks. 13. Interview on 3/11/26 at 4:01 p.m. with DON B revealed that she expected the staff to monitor and measure a resident's blood oxygen saturation levels according to the physician's orders. She expected the staff to measure resident 32's levels before she went to bed each night. She confirmed staff was not doing that. 14. Review of the provider's 12/10/24 Oxygen Administration policy revealed that the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.

Based on observation, interview, record review, and policy review, the provider failed to ensure safe food was at safe temperatures prior to serving residents food by one chef (H) during an observed breakfast meal service. Findings include: 1. Observation and interview on 11/19/24 at 7:45 a.m. with chef M, chef H, and culinary services manager (CSM) D revealed: *Chef M was at the steam table serving breakfast to residents and stated chef H would have done the food temperatures this morning. *Chef H was by the ovens and the food prep area, and stated she forgot to take the food temperatures that morning. -The food temperature logs indicated food temperatures had not been documented that morning and chef H stated she would sometimes take the food temperatures but not log them and sometimes she would just forget to take the food temperatures. -She stated she should check the temperatures of the food coming out of oven and at the steam table. *CSM D told chef H to temp the next batch of food and log those temperatures. Chef H completed that task. 2. Record review and interview on 11/19/24 at 8:00 a.m. regarding food temperatures and documentation with CSM E revealed: *She stated she did not know the food temperatures (temps) had not been done that morning and that temps were not being documented on the logs. -She agreed the temperature logs indicated food temps had not been done as they should have been. -She stated she would check the logs periodically and had not been monitoring them for a while because the temps were being done, and said I see now they aren't logging them again. *When asked how she would know food temperatures were at the appropriate temperature to safely serve food to residents without temping food before serving it to the residents, she stated, I don't. *Food temperature logs were reviewed with CSM E and indicated multiple dates for breakfast, lunch, and supper did not have food temperatures documented. -There was no log sheet started for that week which indicated it should have been started on Sunday 11/17/24. -She expected that food would have been temped three times per day at each meal and documented on the logs. -She stated, We will have to start monitoring the logs again. *She stated she wasn't sure what the policy said and would have to look that up. 3. Observation on 11/19/24 at 11:11 a.m. revealed food temperatures were done for the lunch meal with no concerns and now placing temp log on wall beside steam table with logs from lunch and supper noted on the log. 4. Interview on 11/19/21 at 11:15 a.m. with chef G revealed, Food temps should have been checked with each meal and logged. 5. Interview on 11/20/24 at 9:56 a.m. with chef M revealed he would have temped and logged two meals, twice for each meal, once for food removed from oven then again for food in the steam table during his shift. 6. Interview on 11/20/24 at 12:10 p.m. with administrator A revealed he was not aware that food temperatures were not taken or logged at meal times and expected that the residents' food would be temped with each meal. We have come a long way in kitchen and dining, but temps should have been done. 7. Record review of food temperature logs from 10/19/24 to 11/19/24 revealed the residents' food for thirty 38 of 67 meals had not been temped or logged for breakfast, lunch, and supper. 8. Record review of the Provider's 2021 policy and procedure for food temperatures revealed, the temperatures of all food items will be taken and properly recorded prior to service of each meal.

Based on observation, interview, record review, and policy review, the provider failed to develop in collaboration with hospice a comprehensive care plan for one of one resident (288) who received oxygen and hospice services. Findings include: 1. Observation and interview on 11/19/24 at 9:42 a.m. with resident 288 in her room revealed: *She was short of breath, spoke softly, and was wearing oxygen nasal cannula tubing (tubing with nasal prongs) on her face. *There was an oxygen concentrator (a device that delivers concentrated oxygen) with a humidifier attached to it. The oxygen flow rate was set at 5 Liters (L) per minute. *A portable oxygen tank was on the back of her wheelchair. 2. Review of resident 288's electronic medical record (EMR) revealed: *Resident 288 had been admitted on [DATE] from home with continued hospice services. *Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea. *There was a physician's order dated 11/7/24 for O2 [oxygen] [with a flow rate of] 1 5L/N/C [liters via nasal cannula] every morning and at bedtime for comfort. 3. Interview on 11/21/24 at 8:40 a.m. with certified nursing assistant I revealed: *She confirmed that resident 288 was receiving hospice services. -She knew how to care for residents receiving hospice services because the nurse reviewed that information with her before each shift. *Her worksheet and the care plan in the provider's EMR also provided information about how much assistance a resident needed for transfers and personal care. *Hospice provided a bath to residents once a week. *She was unable to locate a hospice care plan for resident 288. 4. Review of resident 288's current care plan revealed: *Focus area: SOB [short of breath] with resting, exertion and laying flat [Resident 288] was admitted on hospice from home. -Intervention: O2 [oxygen] continuously. *Focus area: Resident and family have opted for hospice benefits and comfort care only. -Intervention/Task: Keep family and hospice involved in care planning and decision making as well as updated on any changes in conditions or orders. *The care plan did not include: -The type of oxygen delivery systems used by the resident included continuous oxygen via nasal cannula from an oxygen concentrator with a humidifier, nebulizer treatments, and a portable oxygen concentrator. -The frequency of cleaning and that equipment and changing the oxygen tubing and humidifier. -That resident 288 required assistance administering her nebulizer treatments. -Equipment settings for the prescribed flow rate. -Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. -Monitoring for complications associated with the use of oxygen. -Goals integrated from an updated hospice plan of care when the resident moved from her private residence to the facility. -The services and equipment that hospice was providing to the resident. 5. Review of the hospice binder at the north nurse's station regarding resident 288 revealed: *It contained information about which nurse was assigned to resident 288 and instructions for when and how facility staff were to contact hospice. *The hospice plan of care was not located in that binder. *There was no documentation of the resident's oxygen needs or interventions in that binder. 6. Review of resident 288's paper Hospice Plan of Care provided upon request revealed: *It had not been uploaded into resident 288's electronic medical record. *Location Type: Private Residence. *Service Location Home. *Start of care date 09/22/2024. -Resident 288 was admitted to the facility on [DATE]. *Oxygen; 1 ea [each] as directed; Instructions Use 2L/min [liters per minute] via nasal canula [cannula]. *Oxygen; inhalation; gas; 1-5L as needed; Purpose: SOB. *Goal #10: Patient/Caregiver will demonstrate progressive independence in the management of oxygen therapy as evidenced by appropriate adherence to ordered therapy and demonstration of appropriate safety measures by time of discharge. 7. Interview on 11/21/24 at 8:45 a.m. with director of nursing (DON) B revealed: *The services hospice provided to the residents varied from resident to resident based on their hospice diagnosis. -This information would have been found on the resident's care plan. *Minimum Data Set (MDS)/registered nurse (RN) K and infection control RN J were responsible for updating resident facility developed care plans but any nurse can. -The care plan should have been updated when there is any change in the care that a resident received. *Hospice had a separate care plan that was part of the resident's overall care plan. -The hospice care plan was to be uploaded in their EMR system point click care (PCC) when it was completed. -She expected that the hospice care plan would have reflected the care resident 288 was receiving in the facility. -Resident 288's hospice care plan should have been updated when she moved from her private home to the facility. *She confirmed that resident 288's care plan should have included: -Her oxygen needs which included: -The need for assistance completing her nebulizer and the use of the humidifier. --Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to. -The amount of oxygen she received and the equipment she used. --Hospice provided resident 288 with an oxygen concentrator and she had her own portable oxygen tank. --Hospice provided the oxygen humidifier and nasal cannula tubing for the concentrator and for the portable, however, it was the responsibility of the facility nursing staff to change that oxygen tubing and humidifier. -The frequency of cleaning of the oxygen equipment and changing the oxygen tubing -Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to. Review of the provider's 5/30/23 Oxygen Administration policy revealed: *The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: -The type of oxygen delivery system. -When to administer, such as continuous or intermittent and/or when to discontinue. -Equipment setting for the prescribed flow rate. -Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. -Monitoring for complications associated with the use of oxygen. 8. Review of the provider's April 2019 Comprehensive Care Plan policy revealed: *It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. *The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment.

Based on observation, interview, record review, and policy review the provider failed to maintain the cleanliness of the oxygen concentrator, tubing, and humidifier and to administer the nebulizer treatment appropriately after determining the resident could not self-administer that treatment for one of one observed sampled resident (288) who received oxygen. Findings include: 1. Observation on 11/19/24 between 8:25 am and 9:02 a.m. with resident 288 in her room revealed: *At 8:25 a.m. registered nurse (RN) F started her nebulizer (neb) machine for the administration of her neb medication treatment and then left the room. -Resident 288 asked the surveyor to return when she completed that nebulizer treatment. *At 8:40 a.m. the nebulizer treatment was running and resident 288 was wearing a neb mask. *At 8:55 a.m. the nebulizer was still running and resident 288 was holding the mask in her hand. *At 9:02 a.m. RN F walked by resident 288's room and into room [ROOM NUMBER]. Resident 288's nebulizer was still running at that time, and her neb mask was on the floor. Observation and interview on 11/19/24 at 9:42 a.m. with resident 288 in her room revealed: *Her breakfast tray was on the table. The individual containers were wrapped in plastic wrap and the fruit cup was unopened. She stated she could not open the fruit cup. I'll just leave it. *She ate in her room by choice. *She was short of breath, spoke softly, and wore oxygen via a nasal cannula. *The oxygen concentrator was stored in the bathroom. -The oxygen concentrator was covered in white dust, and the filter on the back contained visible lint and debris. -The oxygen flow meter was set at five liters. -The oxygen tubing and the humidifier were not labeled or dated. -An oxygen humidifier container with a green top was attached between the concentrator and the tubing. -The humidifier container was dry and contained an unidentified white flaky substance at the bottom. *There was a portable oxygen tank on the back of her wheelchair. -The nasal cannula connected to the portable oxygen was not labeled or dated. 2. Observation and interview with RN F in resident 288's room on 11/19/24 between 9:47 a.m. and 9:56 a.m. revealed: *The concentrator was stored in the bathroom because of the noise it produced and to provide more space in the room. *She stated the oxygen tubing and humidifiers were changed once a week on Wednesday as ordered on the treatment administration record (TAR). *When asked what was in the humidifier, she tapped the humidifier, and stated, A smidge of water. *When asked to confirm that there was no water in the humidifier, she stated there was dry water in the bottom of the container, and stated It's dirty, and that she would go get some sterile water. *She stated that there should have been a sticker on the oxygen tube with the date it had been changed, but it must have fallen off. *At 9:56 a.m. RN F returned to resident 288's room with an oxygen humidifier with a black top that contained water, a nasal cannula, and green oxygen tubing. -She replaced the existing humidifier and tubing and dated it on a piece of tape. *She did not change the oxygen tube on the portable oxygen unit which hung on the back of the wheelchair. *There was no visible jug of distilled water in resident 288's room or bathroom. 3. Interview on 11/19/24 at 10:15 a.m. RN F regarding resident 288's oxygen humidifier revealed: *When asked what had been in the humidifier which she had removed from resident 288's room she stated, Dry water that has been dry for a day. *When asked where the oxygen humidifier brought to resident 288's room had been filled she took the surveyor to the unit kitchenette. *When asked again where the water had come from, she stated The water jug was actually kept in the medication room. *When asked to see the jug, she stated it had been empty and thrown away and the trash had already been taken out. *The water jugs to fill the oxygen humidifiers came from the main kitchen. -She stated there were no more jugs of water on the unit and she would have to get more from the kitchen. *RN F stated she needed to pass medications and ended the interview. 4. Interview on 11/19/24 at 10:21 a.m. with RN C regarding oxygen equipment revealed: *Oxygen humidifiers were to be filled with distilled water. *She showed the surveyor a one-gallon jug stored in the unit's utility room. *Each resident with an oxygen humidifier was expected to have a jug of distilled water in their room. -That jug would be dated on the day it was opened. *Open bottles of distilled water were not stored in the medication room or the kitchenette. *She had not seen resident 288's humidifier and was unaware of where RN F would have filled her humidifier. *Hospice provided resident 288's concentrator, humidifier, and oxygen tubing. *The facility provided the distilled water, and the facility nurse changed the tubing every week on Wednesday, but not the humidifier. -She expected the nurse would have checked the humidifier and refilled it with distilled water as needed. 5. Interview on 11/19/24 at 10:29 a.m. with RN L in resident 288's room revealed: *Hospice had provided resident 288 with the oxygen concentrator. *RN L confirmed that there was no jug of distilled water in resident 288's room. -She stated the distilled water would have been provided by the facility. *At 10:32 a.m. RN F entered the room, placed an unopened jug of distilled water, dated 11/19/24, on resident 288's bedside table, and then left the room. 6. Observation on 11/20/24 at 9:55 a.m. in resident 288's room revealed the nasal cannula attached to the portable oxygen on her wheelchair was resting on the floor. 7. Interview on 11/21/24 at 8:45 a.m. with director of nursing (DON) B revealed: *Hospice provided resident 288 with an oxygen concentrator and she had her own portable oxygen tank. *Hospice provided the oxygen humidifier and nasal cannula tubing for the concentrator and for the portable, however, it was the responsibility of the facility staff to change that oxygen tubing and humidifier. *There was an order in the resident's treatment administration record (TAR) to change oxygen tubing once a week on Wednesdays. -She expected that oxygen tubing would have been marked with the date they were changed on a small piece of tape. *She expected the oxygen humidifier to have been filled by the nurse with distilled water provided by the facility whenever it was low and needed more water. -Distilled water was kept in a one-gallon jug, with the date it was opened, in each resident's room who required it. *She expected the nurse to clean the oxygen concentrator filter weekly when the tubing and humidifier were changed. -The concentrator was to have been cleaned monthly. *Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to. -She expected that the nurse would have stayed with resident 288 while she completed her nebulizer treatment. 8. Interview on 11/21/24 at 9:35 am with infection control RN J revealed: *There were hooks for oxygen tubing to hang on in each resident's room. -She expected oxygen tubing, when not being used, to have been hung on those hooks. *Oxygen humidifiers were filled with distilled water as needed. -Each resident who required humidified oxygen would have had a dated one-gallon jug kept in their room. 9. Review of resident 288's electronic medical record (EMR) revealed: *Resident 288 had been admitted on [DATE] from home with continued hospice services. *Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea. *Her Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact. *An 11/7/24 physician's order for O2 [oxygen] 1-5L/N/C [liters via nasal cannula] every morning and at bedtime for comfort. *An 11/7/24 physician's order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG [milligram]/3ML [milliliters]. 1 vial inhale orally four times a day. *An 11/7/24 physician's order for Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083%. 1 vial inhale orally via nebulizer every 4 hours as needed for SOB [shortness of breath]. *Her Medication Self-Administration Safety Screen completed on 11/13/24 revealed: -Medications being considered for resident self-administration included: --Albuterol 0.083% q4hour [every four hours]. --Ipratropium-Albuterol Inhalation .05-2.5mg/3ml. -The resident can correctly administer inhalant medications according to proper procedure, was marked Unable. -It is reported that this resident is not capable of taking her neb [nebulizer] treatments unsupervised as before, weakness. Resident reports she falls asleep when she takes it and cant [can't] hold it. will switch to a mask. -IDTC [interdisciplinary team] feels resident is safe to administer listed medications? was marked No. *A physician's order to Clean O2 concentrator with Clorox wipes, clean filters, change tubing. Every day shift every Wed [Wednesday] Clean O2 concentrator with Clorox wipes, clean filters with water and air dry, put new tubing on machine and date with tape. If they have a tank put new tubing on [the] tank. -This was marked as completed on 11/13/24. Review of the provider's 5/30/23 Oxygen Administration policy revealed: *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. *Cleaning of concentrators and filters will be completed weekly. *Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. *Change humidifier bottle weakly Use only distilled water for humidification. *Cleaning and care of equipment shall be in accordance with facility policies for such equipment. *Staff shall monitor for complications associated with the use of oxygen intake precautions to prevent them Respiratory infections related to contaminated humidification systems.

Based on record review, interview, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure an integrated plan of care had been developed and made accessible between the provider's nursing staff and hospice agency for one of one sampled resident (288) who received hospice services. Findings include: 1. Review of resident 288's facility care plan revealed: *She had been admitted on [DATE]. *Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea. *[Resident 288] was admitted on hospice from home. *A focus area: Resident and family have opted for hospice benefits and comfort care only. *A goal: Will receive additional support from hospice. Have comfort and dignity maintained on [a] daily basis. *Interventions/Tasks: -Keep family and hospice involved in care planning and decision making as well as updated on any changes in conditions or orders. -Keep hospice staff involved with changes and notify them in [the] event of death. -Maintain [an] open line of communication and involvement with hospice staff. -Offer emotional/spiritual support to [the] resident and family. Review of resident 288's paper Hospice Plan of Care provided upon request revealed: *It had not been uploaded into resident 288's electronic medical record. *Location Type: Private Residence. *Service Location: Home. *Principal Program: Home Hospice. *Start of care date 09/22/2024. -Resident 288 was admitted to the facility on [DATE]. Review of the hospice binder at the north nurse's station regarding resident 288 revealed: *It contained information about which nurse was assigned to resident 288 and instructions for when and how facility staff were to contact hospice. *The hospice plan of care was not located in that binder. *There was no documentation of the resident's oxygen needs or interventions in that binder. 2. Interview on 11/21/24 at 8:40 a.m. with certified nursing assistant I revealed: *She confirmed that resident 288 was receiving hospice services. -She knew how to care for residents receiving hospice services because the nurse reviewed that information with her before each shift. *Her worksheet and the care plan in point click care also provided information about how much assistance a resident needed for transfers and personal care. *Hospice provided a bath to residents once a week. *She was unable to locate a hospice care plan for resident 288. Interview on 11/21/24 at 8:45 a.m. with director of nursing (DON) B revealed: *The services hospice provided to the residents varied from resident to resident based on their hospice diagnosis. -This information would have been found on the resident's care plan. *Minimum Data Set (MDS)/registered nurse (RN) K and infection control RN J were responsible for updating resident facility developed care plans but any nurse can. -The care plan should have been updated when there is any change in the care that a resident received. *Hospice had a separate care plan that was part of the resident's overall care plan. -The hospice care plan was to be uploaded in their EMR system point click care (PCC) when it was completed. -She expected that the hospice care plan would have reflected the care resident 288 was receiving in the facility. -Resident 288's hospice care plan should have been updated when she moved from her private home to the facility. *She confirmed that resident 288's care plan should have included: -Her oxygen needs which included: -The need for assistance completing her nebulizer and the use of the humidifier. --Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to. -The amount of oxygen she received and the equipment she used. --Hospice provided resident 288 with an oxygen concentrator and she had her own portable oxygen tank. --Hospice provided the oxygen humidifier and nasal cannula tubing for the concentrator and for the portable, however, it was the responsibility of the facility nursing staff to change that oxygen tubing and humidifier. -The frequency of cleaning of the oxygen equipment and changing the oxygen tubing -Resident 288 had been able to self-administer her nebulizer treatments when she came into the facility, but it had been determined that she was no longer able to. 3. Review of the provider's 1/17/19 Hospice and Nursing Facility Services Agreement revealed: *Facility's representative will perform the following duties: (a) Collaborate with Hospice staff and coordinate Facility staff's participation in the care planning process . *Joint Responsibilities/Mutual and Hospice Promises. Development and Implementation of Plan of Care Hospice and Facility shall jointly develop and agree upon the Patient's plan of care Hospice and Facility each shall maintain a copy of each Patient's plan of care in the respective clinical records maintained by each Party. *Hospice Plan of Care. All services provided to Hospice Patients under the Agreement must be in accordance with the plan of care. -The plan of care shall identify the care and services needed and specifically identify whether Hospice or Facility is responsible for performing the respective functions that have been agreed upon and included in the plan of care. -The plan of care shall reflect the participation of Hospice, Facility and the Hospice Patient and such Patient's family, to the extent possible including a description of the Hospice Services, Inpatient Services and Room and Board Services furnished by Facility.

Based on observation, interview, record review, and policy review the provider failed to ensure: *One of seven refrigerators was set at an appropriate temperature for safe food storage. *Two of seven refrigerators were monitored for safe temperature control. 1. Observations on 7/24/23 at 3:27 p.m. in the kitchen revealed: *The south refrigerator had four glass doors. *The gasket around the bottom right door was torn in several places. *The thermometer on the front of the refrigerator read 51 degrees. *The thermometer on the inside of the refrigerator read 58 degrees. *Refrigerator temperatures should be maintained between 35 and 41 degrees. *The refrigerator contained the following: -Fifty-nine bowls of cherry crisp dessert. -thirty-three bowls of lettuce salad. -thirty-six cups of French salad dressing. -Six ham salad sandwiches. -Two cakes labeled Hawaiian. Interview on 7/24/23 at 3:29 p.m. with culinary dining assistant I about the above observations revealed: *The south refrigerator was mainly used for salads, desserts and sandwiches for the residents. *He thought the refrigerator should have been at 40 degrees or below. *The kitchen staff recorded the refrigerator temperatures daily. Observations on 7/24/23 between 4:31 p.m. and 5:39 p.m. in the kitchen revealed: *The south refrigerator had temperature ranges from 49 to 51 degree readings from the thermometer on the front of the refrigerator. *The thermometer on the inside of the refrigerator had readings between 52 to 54 degrees. *Kitchen staff had taken the 33 bowls of lettuce salad and served them to the residents for supper. Observation and interview on 7/25/23 at 7:54 a.m. with culinary manager G revealed: *The south refrigerator had a temperature of 47 degrees on the thermometer on the outside of the refrigerator. * The thermometer on the inside of the refrigerator had a reading of 43 degrees. *She had issues with that refrigerator in the past and had a repair man work on it. *She would have staff empty the refrigerator and discard the remaining contents as it was not holding a temperature of 41 degrees or below. *She needed to call the repair man and have him look at it. Review of the provider's Freezer and Refrigerator Temperature Sample Form for July revealed: *All refrigerators and freezers were to have both internal and external temperatures checked and recorded at least twice a day. *The south refrigerator was missing documentation for the mornings of July 9, 10, 13, 14, 15, 16, 18, 19, 21, 22, 23, and 24. *The south refrigerator was missing documentation for the afternoons of July 2, 3, 6, 7, 11, 13, 15, 16, and 21. Interview on 7/26/23 at 9:02 a.m. with culinary manager F revealed: *The refrigerator was not holding proper temperature. *The repair man would have to come back and work on it again. *She knew the refrigerator temperatures were to have been recorded twice a day. *It was her expectation that staff would monitor the refrigerator temperatures according to the provider's policy. 2. Observation and record review on 7/25/23 at 8:25 a.m. in the activity room revealed: *The activity refrigerator contained an egg carton flat with five eggs with no expiration date. *An egg carton with six eggs. *The expiration date on that egg carton was 12/12/22. *The refrigerator monthly temperature log had only been completed on April 12, 2023 and May 3, 2023. *There was no documentation for the months of June or July 2023. Interview on7/26/23 at 1:40 p.m. with activities director E regarding the activity refrigerator revealed she:*Had gotten the eggs from the main kitchen, but was unsure when she had gotten them. *Had known that the food items needed to have an expiration date on them. *Refilled the small egg carton from the main kitchen as it was easy to store in the refrigerator. *Agreed the documentation for monitoring refrigerator temperatures in the activity room was missing. Review of the provider's 2021 Food Storage policy from [NAME] & Associates, Inc. manual revealed: 13. Refrigerated food storage: a. All refrigerator units should be kept clean and in good working condition at all times. b. TCS foods must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated food to assure temperatures are maintained at or below 41 degrees F. Temperatures for refrigerators should be between 35 to 39 F. Thermometers should be checked at least two times each day. (See Sample Freezer and Refrigerator Temperature Forms on the following pages.) Check for proper functioning of the unit at the same time. c. Every refrigerator must be equipped with an internal thermometer .

Based on observation, interview, and policy review, the provider failed to ensure appropriate use of personal protective equipment (PPE) and appropriate hand hygiene had been followed for two of two observed meal services by nine of nine observed staff (cook E, culinary assistant (CA) F, dietary manager (DM) D, cook R, dietary aide (DA) S, certified nurse assistant (CNA) Q, DA V, CNA T, and DA U). Findings include: 1. Observation on 5/10/22 from 11:40 a.m. through 12:20 p.m. of staff assisting in the resident dining area during the noon meal service revealed: *No hand sanitizer had been observed in the main dining area. *A sink to wash hands had been available for staff to use in the beverage serving area. -Staff were not observed to have used it. *Cook E had on gloves and was observed to have repeatedly touched: -Her surgical mask. -Her glasses. -Her face. -The serving tongs. -The dinner plates. -Food on the plates she had dished out. *She had not changed gloves, washed her hands, or performed hand hygiene after she had touched the above listed items. *While she dished the food, she repeatedly picked up liver with a spatula, touched the liver with her gloved hand, and placed it onto the plates to be served. *With those same gloved hands she touched and arranged food on the plates without using utensils. *She touched the top surface of the clean plates with gloved hands. *DM D: -Had not performed hand hygiene after she delivered meal trays to residents. -Placed her hand over the top of uncovered beverage glasses and dessert saucers. -Pulled her surgical mask up and down without completing hand hygiene. -Had worn her surgical mask below her nose. *Cook R: -Placed drinks on meal trays, touched his surgical mask and had not performed hand hygiene. -Wore his mask below his nose. *DA S: -Had worn her surgical mask below her nose. -Delivered meal trays and had not performed hand hygiene between trays. 2. Observation on 5/10/22 from 11:40 a.m. through 12:20 p.m. of the noon meal service revealed: *DA U wore her surgical mask below her chin and mouth. -She had been taking food orders at the residents dining tables using an iPad. -She had touched her mask, the iPad, residents, and had not performed hand hygiene. 3. Observation on 5/10/22 during the noon meal service of CNA Q revealed: *At 12:17 p.m. she had put on a pair of gloves and handled a dinner roll. -She pulled the dinner roll apart and had spread butter on both sides. *At 12:18 p.m. she had taken off her gloves. -She had not performed hand hygiene. -She had assisted another resident with his pureed meal. 4. Observation on 5/10/22 from 5:05 p.m. through 5:31 p.m. of the evening meal service revealed: *CNA T wore his surgical mask under his nose. -He pulled his mask up and down and had not performed hand hygiene. *DA V wore his surgical mask below his nose and mouth. -He pulled his mask up and down and had not performed hand hygiene. -He placed his hand over the top of uncovered beverage glasses and dessert saucers he delivered to residents. 5. Observation on 5/10/22 at 5:09 p.m. of CA F during the evening meal service revealed she: *Had been wearing gloves. *With those gloved hands opened the door that led into the dining area. *Walked into the dining area. *Returned to the kitchen, opened the door and began plating the food. *Held a clean dinner plate to her chest, placed it back on the counter and then served food on it. *Touched her surgical mask and continued to plate food. *Had not been observed performing hand hygiene or washing her hands. Observation on 5/10/22 at the evening meal service of CA F revealed: *At 5:10 p.m. she had on gloves and with those gloved hands repeatedly touched: -Clean dinner plates. -Serving utensils to dish food on the plate. -Dietary slips of paper labeled Cook Printer. *At 5:19 p.m. she used the same gloved hands to reach in a covered container to handle unwrapped saltine crackers and placed them on a plate beside a bowl of soup. -She then set the plate on the serving bar over the steamtable. -She continued the evening meal service with the same gloved hands. 6. Interview on 5/11/22 at 3:02 p.m. with DMs C and D regarding the above observations of cook E and CA F revealed: *They had noticed staff touched their surgical masks. *If staff touched their surgical mask, they should have performed hand hygiene or washed their hands. *Cook E had not been known to wear gloves while serving food. *Food should never be touched without a serving utensil or tong. *They would expect their staff to follow appropriate infection control procedures with gloves, hand washing, and when wearing PPE. *They had not had time to complete dietary training due to the COVID-19 pandemic. Interview on 5/12/22 at 10:30 a.m. with cook E revealed: *She was ServSafe certified which was current through 6/16/26. *The surveyors had made her feel nervous while she worked. *She was aware she had touched her face, mask, and glasses. *She had not changed her gloves or washed her hands but should have. *Since they had started a new meal service process it had been hard to keep up with the food orders from the residents. *She was concentrating on getting the food out as quickly as possible. *The facility had not done dietary training recently. *She could not remember the last time dietary training had taken place. Interview on 5/12/22 at 1:38 p.m. with cook R revealed: *He had worked at the nursing home for five years. *He had completed ServSafe certification and it had been good through 4/28/23. *He agreed he had moved his surgical mask up and down on his face and had not performed hand hygiene. *Infection control would have been a concern when hand hygiene had not been completed. *They used to have hand sanitizer on all of the dining room table during the COVID-19 outbreak. *When the dining room opened back up, the hand sanitizer had not been put back on the tables. *Dietary training had not taken place for the past two years. Interview on 5/12/22 at 1:53 p.m. with DM D regarding the above observations of CA F revealed she: *Was concerned as there was a problem with this process. *Asked They were wearing gloves? *Had expected them not to be wearing gloves during meal service. *Excepted them to wear gloves only when handling ready to eat foods. Interview on 5/12/22 at 2:06 p.m. with DA S revealed she: *Had worked at the nursing home for three years. *Agreed that she had touched her surgical mask and had not performed hand hygiene. *Knew that a surgical mask should have been worn over the top of the nose. *Knew that hand hygiene was to be performed between delivered trays to the residents. *Could not remember when she had received dietary training last. Interview on 5/12/22 at 5:16 p.m. with director of nursing (DON) B and administrator A revealed: *They would expect staff to follow appropriate infection control practices. *Surgical masks should have been worn to cover the nose and mouth. *Hand hygiene should have been performed between tasks. *If the surgical mask had been touched, hand hygiene should have been completed. 7. Review of the provider's undated Food Safety and Sanitation policy revealed: * .D. All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in any unsanitary way such as smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes, touching face, hair, other people, etc. Review of the provider's undated Employee Sanitary Practices policy revealed: *2. Wash hands before handling food. *4. Use utensils to handle food. *Note: Follow all federal , state and local requirements. Review of the provider's undated Surgical Mask Policy revealed: *Surgical masks will be utilized to protect the residents, staff, and visitors from illness. *4. Keep hands away from face.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (56 and 75) identified at risk for developing skin integrity injuries and who did acquire skin injuries received timely assessments provided by professional licensed staff. Findings include: 1. Observation and interview on 05/10/22 at 11:33 a.m. with resident 56 and her son revealed she: *Had a facility acquired pressure ulcer to the left heel for some time. *Had been going to the wound care specialist and it was starting to heal. *Wore pressure reduction booties to both feet. -Did not like to wear them and tried to get them off. -Was stubborn about leaving them on. -They placed them on her overnight. *Had a pressure reduction cushion in her wheelchair and a pressure reduction mattress on her bed. Review of resident 56's medical record on 5/11/22 revealed: *She was admitted on [DATE] and readmitted on [DATE] following a hospitalization . *diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *The Braden scales for predicting pressure sore risk completed on 8/5/21, 8/10/21, 9/2/21, and 10/8/21 had shown she was at risk to high risk for skin breakdown. *A computer generated comprehensive care plan had risk for pressure injury listed with hand written pressure reduction interventions on it and it was kept in a binder at the nurses station. *A 8/5/21 skin/wound note had been completed at readmission from the hospital and was documented as follows: -Hospital admission skin assessment: Checked resident's skin and no concerns noted at this time. Has a bruise on her right arm due to IV at hospital. No sores or [CONDITION(S)] to be reported. *A 10/8/21 wound weekly observation tool documented she had a facility acquired left heel pressure ulcer staged as a suspected deep tissue injury. *There was no documentation of a head-to-toe licensed nurse assessment between the 8/5/21 skin/wound note and the 10/8/21 wound/weekly observation tool. Observation and interview on 5/12/22 at 9:10 a.m. of licensed practical nurse (LPN) O completing wound care for resident 56 revealed: *The left heel wound was clean, pink with 100% granulation of the wound bed. *The left heel wound was cleansed with normal saline. *A Dakins wet to dry dressing was applied at the left heel then covered with gauze and taped in place. *Dressings were completed daily. *The wound weekly observation tool documentation was completed weekly by a licensed nurse. *She was followed by the wound clinic. *She confirmed certified nurse assistants inspect her skin during bathing weekly and reported any concerns to nursing. *She confirmed a licensed nurse completed a head to toe skin assessment twice monthly on the days she was scheduled on the nurse skin assessment calendar. 2. Observation and interview on 05/10/22 at 10:50 a.m. with resident 75 revealed: *He was sitting in a wheelchair and had pressure reduction boots on both feet. *There was a pressure reduction cushion on his wheelchair seat and a pressure reduction mattress on his bed. *There was a tube of barrier cream on his bedside table. *He had diabetes, was on a diabetic diet, and received insulin injections. *There was a bottle of diet pop, two bottles of regular pop, a bag of M&M's candy, and a bag of sugar free candy on his bedside table. *There was a new pressure ulcer on his right foot. Review of resident 75's medical record on 5/11/22 revealed: *He was admitted on [DATE]. *diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] awareness, cognitive communication deficit. *The Braden scales for predicting pressure sore risk completed on 1/10/22, 1/17/22, 1/24/22, 1/31/22, 2/7/22, and 4/8/22 shown he was at risk, moderate risk, and high risk for skin breakdown. *Nutritional screenings dated 1/12/22, 1/17/22, 2/23/22, and 4/8/22 documented he was at risk for skin breakdown. *A computer generated comprehensive care plan had risk for pressure injury listed with hand written pressure reduction interventions on it and it was kept in a binder at the nurses station. *A 4/8/22 skin/wound note was documented as follows: -Head to toe assessment completed. No open areas or new injury noted. Resident receives lotion to feet at HS [at bedtime] and [MEDICATION(S)] cream to buttocks routinely. Has a specialty panacea mattress. Is extensive 1-2 person assist. Has a foam cushion in WC [wheelchair]. He does have impaired vision from [CONDITION(S)]. Is diabetic (watch feet closely). Reposition of resident requested frequently. *A 5/8/22 skin/wound note was documented as follows: -large blister found on the inner right heel during HS cares. Blister is intact. Boots placed on resident's feet and lower legs once he was settled into bed. *There was no documentation of a head-to-toe licensed nurse assessment between the 4/8/22 skin/wound note and the 5/8/22 skin/wound note. *A 5/9/22 wound weekly observation tool documented he had a facility acquired right inner heel stage II pressure ulcer. *A 5/12/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 5/11/22 at 4:05 p.m. of LPN O completing wound care for resident 75 revealed: *He was sitting in his wheelchair. *A large blister was present to his inner right heel. *She applied [MEDICATION(S)] to the wound and left it open to air. -She reported his right foot was to have the pressure reduction boot only when he was laying in bed. *A pressure reduction boot was located on his left foot. 3. Observation and interview on 5/11/22 at 10:35 a.m. of whirlpool room and whirlpool cleaning with certified nursing assistant (CNA) P revealed: *CNA's inspect the resident's skin during bathing. *CNA's report resident's skin concerns to the nurse. *Documentation was completed on a bath/skin/nail care log form. *At the end of the day CNA's used the log form to document in the residents' electronic medical record (EMR). *Bath/skin/nail care log forms were routed to the charge nurse at the end of the day. *She received education for skin care, skin inspection, what to report to the nurse at new hire orientation, CNA training, and annual training. 4. Interview on 5/11/22 at 4:15 p.m. with resident care coordinator J regarding the facilities skin assessment process revealed: *CNA's/bath aides inspect skin during bathing and report any concerns to the nurse. *Braden scale assessments were completed on residents at admission, quarterly, and as needed with patient changes. *Residents with a high risk for pressure injury were placed on a calendar and received a nurse skin assessment once monthly. *Residents with a high risk for pressure injury that had a wound were placed on a calendar and received a nurse skin assessment twice monthly. *Nurse skin assessments were documented in the resident EMR under a skin/wound progress note. *Residents with wounds had a wound weekly observation tool documented in their EMR. Interview on 5/12/22 at 3:53 p.m. with director of nursing (DON) B regarding the facility skin assessment process revealed: *Resident care coordinator nurse J was in charge of wound care. *Residents were assessed for skin risk at admission, quarterly, and as needed with changes in condition utilizing the Braden scale and other assessments such as the nutrition screening. *Residents who were identified as high risk for skin breakdown were placed on a nurse skin assessment calendar monthly. *CNA's are trained and completed skin inspection of residents at weekly bath. They document skin inspections on a log, in the chart, and communicate any skin concerns to nursing. *Residents who have been identified with skin concerns that have developed are placed on the calendar for a nurse skin assessment twice monthly. *She confirmed nurses do not complete weekly skin assessments for all residents identified as at risk for developing skin breakdown. *Nurses complete wound assessments weekly for resident with wounds. *Nurses and CNA's received skin and wound care training at new hire orientation and had annual skills station training that included skin and wound care. *She agreed it was not in the CNA's scope of practice to complete skin assessments. 5. Review of the providers Resident Care Coordinator Job Description revealed: *JOB SUMMARY: -The primary purpose of the Resident Care Coordinator position is to coordinate and supervise all resident care staff and the care provided on the unit according to established policies, procedures, and standards. The Resident Care Coordinator position is to ensure a full continuum of resident centered care is provided and to develop and achieve optimal outcomes for each resident. *DUTIES AND RESPONSIBILITIES: -Identifies and documents alterations in resident health status based on ongoing assessment. -Is clinically astute to physiological changes impacting the resident condition and in acting on observations regarding resident conditions. Review of the providers Pressure Injury Prevention and Management policy revised 1/8/19 revealed: *Policy: -The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. *Policy Explanation and Compliance Guidelines: -2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. -3. Assessment of Pressure Injury Risk --e. Nursing assistants will inspect skin daily and during baths weekly and will report any concerns to the resident's nurse immediately after the task and will chart in the resident's electronic record and bath log. --f. Training in the completion of the pressure injury risk assessment, full body skin assessment, and pressure injury assessment will be provided as needed. -4. Interventions for Prevention and to Promote Healing --b. Evidence based interventions for prevention will be implemented for all residents who are at risk or who have a pressure injury present.

Based on observation, interview, policy and procedure review, and manufacturer's review, the provider failed to maintain proper infection control practices for: *Proper cleaning procedure of the whirlpool tub A in one of three whirlpool tub rooms. *Proper storage of cleaning tools in three of three whirlpool tub rooms A, E, and G. *Proper cleaning of two of two randomly observed resident's bathrooms. Findings include: 1. Observation and interview on 9/24/19 from 9:20 a.m. to 9:34 a.m. of cleaning and sanitizing tub room A's whirlpool tub with certified nursing assistant (CNA) A revealed she: *Usually completed between eleven and thirteen baths each shift she worked. *Used a Magic eraser to scrub down the inside of the tub rather than a scrub brush that was available. -She stated she had been trained to do it that way. *Had used the brush only when scrubbing down the tub chair and when rewetting the surface of the tub during the ten minutes while the chemicals sanitized the tub. *Had failed to use the air blower function of the tub to blow out any remaining water from the jets after rinsing out the inside of the tub after it had been sanitized. *Stated the tub was ready for the next resident's bath. *Soiled, used Magic erasers were discovered in a storage cabinet and had been placed inside a container along with a resident's hygiene and care supplies. Interview on 9/25/19 at 4:18 p.m. with the infection control nurse regarding cleaning of the whirlpool tubs revealed she: *Had been unaware that CNA A used Magic erasers to scrub the inside of the tub. *Would not want the used Magic erasers to be stored along with resident activity of daily living (ADL) supplies. *Would expect the bath aides to follow their policy and procedure for proper whirlpool tub cleaning and to use the scrub brush provided. Observation on 9/26/19 from 9:35 a.m. to 10:37 a.m. revealed soiled, used Magic erasers stored in tub rooms A, E, and G had dirty, used Magic erasers stored along with residents' ADL supplies. Review of the manufacturer's instructions for use of the Magic erasers revealed they were a single use item. Review of the provider's revised 6/18/15 Whirlpool Cleaning procedure revealed: Finish rinsing the interior surfaces of the tub with the shower sprayer. Start the air blower by pushing the Aqua-Aire button. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. Stop the Aqua-Aire blower by again pushing the Aqua-Aire button. Interview on 9/26/19 at 8:27 a.m. with the director of nursing (DON) regarding whirlpool tub cleaning revealed she: *Had been unaware the bath aides were using Magic erasers for the tub cleaning. *Stated the Magic erasers would be a single-use item if they had been used for cleaning. *Would not want the dirty Magic erasers to be stored in the with residents' ADL supplies. *Would expect the bath aides to follow their policy and procedure for cleaning the whirlpool tubs. Interview on 9/26/19 at 10:47 a.m. with CNA [NAME] regarding the procedure for cleaning the whirlpool tubs revealed the CNAs that were the bath aides had used Magic erasers on tubs. It was their practice to reuse them. 2. Observation on 9/24/19 at 3:22 p.m. of housekeeper B and observation on 9/25/19 at 10:14 a.m. of housekeeper D cleaning two random residents' bathrooms revealed: *They had both used a spray bottle with disinfectant to spray the sink in the bathrooms. *The back of the sinks each had an empty denture cup with the lid opened located beside the faucets along with other personal ADL grooming supplies including toothbrushes, toothpaste tube, and emesis basin. *They had not removed those items prior to spraying the sink which could cause the spray particles to fall onto the items. *Housekeeper D had not allowed ten minutes for sanitizing prior to wiping down the sink with a clean cloth. Further interview on 9/25/19 at 4:18 p.m. with the infection control nurse regarding the housekeeper cleaning of the residents' bathrooms revealed: *She had been in charge of housekeeping and also provided training on infection control to all staff. *Training had been provided to all staff for infection control on a yearly basis and was also reinforced in monthly staff meetings. *Personal items should have been moved out of the way before spraying disinfectant on the sink area. *She would expect the housekeeping staff to follow their policy and procedure for cleaning the residents' bathrooms. Further interview on 9/26/19 at 8:27 a.m. with the DON regarding resident room cleaning by housekeeping staff revealed: *Her expectation would be the housekeeping staff would follow their policy and procedure for cleaning the residents' rooms, so they did not have issues with infections being spread to other residents. *The housekeepers should have been moving residents' personal items out of the way before spraying disinfectant on the sink area. Review of the manufacturer's instructions for use of the disinfectant revealed the chemical was to remain on the surface area for ten minutes in order for it to be properly sanitized. Review of the provider's (MONTH) 2013 policy and procedure for Cleaning Bathrooms revealed: *Spray bathroom cleaner in sink and on faucet. Spread and wipe around sink and faucet with clean, dry rag. Wipe countertop, picking up and moving personal items on counter as you go along. Using dry rag, wipe inside of sinks and faucets. Chrome faucets should have a polished look. Be sure to put personal items back in their original spots.

Based on observation, interview, record review, and policy review, the provider failed to follow physician's orders for one of one sampled resident (31) who had a chronic recurring facility acquired pressure ulcer. Findings include: 1. Review of resident 31's medical record revealed: *An admitted [DATE]. *[DIAGNOSES REDACTED]. Review of a 11/1/18 physician's order for resident 31 revealed: *Patient (resident) to ambulate 4 x (times) per day. *Four times a day for pressure ulcer lower back. *Ensure pt (patient) ambulates 4 times per day. Observation and interview on 9/23/19 from 4:37 p.m. through 5:02 p.m. with resident 31 revealed: *At 4:37 p.m.: -He was in a wheelchair (w/c) in his bathroom attempting to pull his pants up. -He moved himself from the bathroom to the living area. -He stated he had sores on his bottom for over a year: --It would heal. --It would reopen. --It was currently opened. -His physician told him he needed to get out of his w/c and walk if he wanted the sores to heal. -One of the staff had told him he needed to have a staff person assist him to use the walker. -He felt there were not enough staff to help him walk when he used the walker. *At 5:02 p.m.: -An unidentified staff person came into his room and offered to take him to the dining area. -He was not asked if he wanted to walk to the dining area. -She pushed him in his w/c to that area. Observations on 9/24/19 at the following times of resident 31 revealed: *At 7:45 a.m.: -He was in the dining area in his w/c. -The walker was not present at the table. *At 11:55 a.m.: -He was being pushed by a staff member in his w/c to the dining area. -The walker was not present. *At 4:45 p.m.: -He was being pushed by a staff member in his w/c to the dining area. -The walker was not present. Observations on 9/25/19 at the following times of resident 31 revealed: *At 11:58 a.m.: -He was being pushed by a staff member into the dining area in his w/c. -The walker was not present. *At 5:40 p.m.: -He was in the dining area in his w/c. -The walker was not present at the table. Observation on 9/26/19 at 11:42 a.m. of resident 31 revealed a staff member was pushing him in his w/c to the dining area. The walker was not present. Interview on 9/25/18 at 2:16 p.m. with registered nurse (RN) H regarding resident 31 revealed: *She did not attend specialized training for pressure ulcers. *Recently three other staff members had been sent to the training. *RN H did all the resident measurements and documentation on pressure injuries and venous injuries. *His pressure ulcer would heal up and close, but then reopen and drain. *There was another staff member who assisted with wound care that had attended the above specialized training for pressure ulcers. Interview by telephone on 9/26/19 at 10:20 a.m. with licensed practical nurse (LPN) F, physician G's nurse regarding resident 31, revealed: *Physician G was not in the office at that time. *She was familiar with him and the physician's plan of care for him. *The physician had diagnosed the wound as: Chronic/recurrent/sacral/lower/midback/wound/ulcer. *He was seen in (MONTH) 2019 in their clinic for the wound. *He did not see the wound care team at (hospital name), because they were told the facility had their own wound nurse. *The physician had written the order for him to walk to dining, because he had reported he was not getting walked by the staff. *The physician and she had come to an interdisciplinary team meeting and discussed the staff needed to offer to walk him, because he might not want to bother them. Continued interview on 9/26/19 at 11:01 a.m. with resident 31 revealed: *He believed they did not have enough staff to walk him. *If he asked a staff member to walk him to meals then they would. -He did not like to ask the staff members, because he knew they were very busy. *He had not walked today to breakfast, because they had used the w/c to take him to get a bath. -After his bath they used the w/c to take him to the dining room. *He used to walk a lot before he was admitted . -It was getting harder to walk, because he had not been walking as much. *He felt his health was declining, because he could not walk without staff assistance. Interview on 9/26/19 at 11:21 a.m. with the director of nursing regarding resident 31 revealed: *He received restorative therapy one time a day for five days a week. *His pressure ulcer would heal and close, and then reopen and drain. *The certified nursing assistants (CNA) should have offered to walk him to all meals. -This was in addition to restorative therapy. *He often refused for various reasons when the CNAs asked him. *She had seen him walking but was not sure how often. -It was probably at lunch time, because that was when she was in the building. *The wound nurse had not had any certification or training specifically on wound treatment. *They would use (hospital names) wound clinic for residents if the physician had made a referral. Review of the (MONTH) 2019 treatment administration record for resident 31 revealed on: *9/23/19: he had refused to walk to the dining area for his 5:00 p.m. meal. *9/26/19: Documentation revealed he had walked to breakfast and lunch. Review of resident 31's 7/31/19 quarterly Minimum Data Set (MDS) assessment revealed: *He: -Required one person with limited assistance to walk. -Was not steady when standing, walking, or turning around. *In the seven days during the assessment period he had not refused any care. *The Brief Interview for Mental Status assessment score was fifteen indicating there was no cognitive impairment. Review of resident 31's weekly wound observation tool from (MONTH) 2019 through (MONTH) 26, 2019 revealed: *The pressure ulcer on his lower back was coded as facility acquired. *On 5/21/19: he occasionally refused to walk to dine because he does not want to wait for assistance. *There was no further documentation for refusal to walk-to dine. *He was on a turning and repositioning routine. *The pressure ulcer had not healed. Review of the provider's 8/24/17 Pressure Injury Prevention and Management policy revealed: *When they received physician's orders the facility would follow them specifically. *The wound nurse would notify the physician if the pressure ulcer was not healing and would get recommendations and new orders.

Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation had been completed and documented for one of one sampled resident (2) who had a fall with injury during a transfer by one of one nursing assistant (NA) (A). Findings include: 1. Review of resident 2's medical record revealed: *A 7/17/17 admitted . *[DIAGNOSES REDACTED]. *A 7/17/17 and on 10/19/17 Morse Falls Scale score of sixty, indicating high risk for falls. *A 7/21/17 admission and 10/10/17 quarterly Minimum Data Set (MDS) assessment reflected: -His Brief Interview for Mental Status (BIMS) score was three on 7/21/17 and six on 10/10/17; indicating he had cognitive impairment. -He required extensive asstance of two staff for transfer, bed mobility, and toilet use. -His balance was not stable during transitions and walking. -He used a walker or wheelchair for mobility. *A 7/26/17 Care Area Assessment reflected he had sustained a fall in 2014 that had resulted in a [MEDICAL CONDITION] that impaired his ability to complete activities of daily living (ADLs) and communicate. *His 7/26/17 care plan had a focus area for ADL self-care performance deficit. -The identified intervention reflected requires ext (extensive) assistance by two staff to move between surfaces. Review of the 10/20/17 nurse progress notes revealed: *Aid comes to nurse stating the resident was on the floor. *Aid assisted resident to floor with gait belt during transfer to bed. *CNA (certified nursing assistant) present for transfer from wheelchair to bed using FWW (front wheeled walker). *Noted large skin abrasion to right side of back with bruising noted to same area. *There was only one nursing assistant present during the transfer. Review of the 10/20/17 physician's fax revealed: *The resident had a fall with an injury. *A skin abrasion and bruising had been noted to his right back area. Review of the 10/20/17 Witness Fall incident report revealed: *Aid assisted resident to floor with gait belt during transfer to bed.*CNA present for transfer from wheelchair to bed using FWW. *No injuries noted post incident. *Predisposing situation factors: -During transfer. -Using wheeled walker. *Other info: left blank. *Notes dated 10/23/17: -IDCP (interdisciplinary care plan) team, floor nurses, and therapy reviewed recent occurrence and plan of care. -A staff member was assisting resident into bed at the time of the occurrence. -Nursing staff report resident has increased weakness at night. -He is legally blind and has impaired cognition. -He continues to work with his RT (restorative program). -No indications of abuse or neglect noted. *There was no further documentation regarding education provided to NA A regarding following the care plan for resident 2 during a transfer. Interview on 12/6/17 at 10:30 a.m. with the MDS nurse and registered nurse (RN) B regarding resident 2's above fall revealed: *They had a daily stand-up with the floor nurses, physical therapy or occupational therapy, printed off the fall reports, and discussed fall interventions. *Both confirmed NA A:-Had transferred the resident alone. -Had not followed the care plan during the transfer of him. *The CNAs had a sheet printed off in a yellow book at the nurses desk that indicated how the resident was to have been transferred. *The information had stated to use extensive assistance of two for transferring him. *There was no documentation of the abrasion or bruising to his right back. *There was no documentation of using two staff during a transfer. *They had not completed a thorough investigation. Interview on 12/6/17 at 11:25 a.m. with the director of nursing (DON) and the MDS nurse regarding resident 2 revealed: *The care plan that NA A had used on 10/20/17 indicated to use two staff to assist him during transfers. *NA A had told the DON she had transferred the resident by herself. *NA A had not followed the care plan during the transfer of the resident. *The DON felt the fall investigation piece had been complete, but the documentation piece was missing. *The investigation piece should have been clearer. *NA A should have followed the care plan. *There was no documentation regarding a follow-up with NA A regarding not following the care plan during the transfer of the resident. Review of the provider's 3/28/17 Comprehensive Care Plan policy revealed the facility would develop and implement a comprehensive care plan for each resident that included measurable objectives. Review of the provider's 4/10/17 Fall/Accident Prevention and Management policy revealed The facility provides an environment that is free from accidental hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable incidents.

Based on observation, interview, record review, policy review, and procedure review, the provider failed to prevent pressure ulcers from forming while in the facility for four of four sampled residents with pressure ulcers (1, 2, 11, and 15). Findings include: 1. Observation and interview on 6/7/17 at 9:15 a.m. of resident 1's pressure ulcer wound care by registered nurse (RN) B revealed: *His left heel had an area with a dark red scabbed center with a lighter colored area with raised edges surrounding the scabbed area. *RN B had found the pressure ulcer on 3/23/17. *She knew of no brace or anything on the left leg or foot that would have caused the blister. Review of resident 1's medical record revealed: *He had been admitted on [DATE] following a left [MEDICAL CONDITION] on 2/27/17. *His [DIAGNOSES REDACTED].>-Dementia with behavioral disturbances. -Anxiety disorder. -Gastric reflux. -Muscle weakness. -[MEDICAL CONDITION]. Review of then skin assessments using the Braden scale revealed: *On 3/2/17 he was at moderate risk for pressure ulcer development. *On 3/14/17 he was at risk for pressure ulcer development. *On 4/23/17 and 5/7/17 he was at moderate risk for pressure ulcer development. *On 5/26/17 he continued at risk for pressure ulcer development. Review of skin condition documented in the nutritional screens revealed: *On 3/8/17 he had no pressure ulcers. *On 5/10/17 he had a stage 2 pressure ulcer on left heel. *On 5/29/17 he had a pressure ulcer on the left heel. Review of the skin portion of the Minimum Data Set (MDS) assessment revealed: *On 3/8/17 he was identified at risk for skin breakdown but had none. *On 3/15/17 he continued at risk for skin breakdown but had none. *On 3/30/17 the skin portion had not been filled in. *On 4/19/17 he was identified at risk for skin breakdown and had one stage 2 pressure ulcer that was first noted on 3/23/17. *On 4/26/17 he continued at risk for skin breakdown and had one stage 2 pressure ulcer. *On 5/26/17 he continued to have one stage 2 pressure ulcer. *On 5/30/17 he continued at risk for skin breakdown and had one stage 2 pressure ulcer. Review of the skin observation documentation during bath days revealed: *In March 2017 seven bath skin observations documented showed no opened areas. *In April 2017 four bath skin observations documented showed no opened areas. *In May 2017 seven bath skin observations documented showed no opened areas *In June 2017 two bath skin observations documented showed no opened areas Review of the nursing documentation regarding the skin condition for resident 1 revealed: *On 3/14/17 RN B's nursing screening/assessment identified no pressure ulcers. *On 3/21/17 RN L documented there were no skin changes, incisions had not required a dressing change. *On 3/23/17 RN B documented a stage 2, flat blister type area on the left heel, 4 centimeters (cm) by 4 cm. She: -Added floating heels to interventions. -Notified director of nursing and resident care coordinator. -Notified the wound nurse who completed a wound assessment. 2. Observation on 6/7/17 at 1:50 p.m. of resident 2's pressure ulcer wound care by licensed practical nurse (LPN) A revealed: *Three opened areas on the left buttock and one on the right buttock. -The two smaller ones on the left were both scabbed over, less than a cm in width, above and closer to the gluteal crease. -The third larger area was in the mid lower area of the left buttocks, had the top layer of skin missing, and was approximately 3cm by 5 cm. -The one larger area on the right buttock had the top layer of skin missing and was approximately 3 cm by 6 cm. *The resident stated the two larger pressure ulcer areas were the most painful for him. *[MEDICATION NAME] cream was applied to all of the above pressure areas. Observation, interview, and care plan review, on 6/7/17 at 2:00 p.m. with resident 2 regarding his pressure ulcers revealed: *He used a wheelchair with a gel cushion in the seat. *He had gotten his electric scooter on 3/9/17. -He used a commercially made wooden chair cushion that he brought from home in the scooter seat. -The cushion had a terrycloth cover with one-half inch light foam inside it. *The gel cushion in his wheelchair had been discontinued on 3/10/17. *He stated his buttocks areas started hurting about a week after he had started using the electric scooter. *There was a two inch coccyx cushion in the scooter at the time of the observation and interview. *The terrycloth covered cushion described above was in his wheelchair. *He was observed using only his scooter during the survey. - He verified he almost always used his scooter since he had gotten it. Review of resident 2's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-History of polio with right side deficit. -Lumbar 2 and 3 compression fractures. -Peripheral [MEDICAL CONDITION]. -Hypertension. -Gastric reflux. -[MEDICAL CONDITION]. *Nursing found no concerns with the condition of his skin on admission. Review of skin assessments using the Braden scale revealed: *On 12/28/16 he was at risk for pressure ulcer development. *On 3/24/17 he continued to be at risk for pressure ulcer development. Review of the skin condition documented in nutritional screens revealed: *On 1/2/17 he was at risk for pressure ulcers but had no skin concerns. *On 3/27/17 he was at continued risk for pressure ulcer but had note at the present time. Review of skin portion of the MDS assessments revealed: *On 1/3/17 he was identified as at risk for skin breakdown but had none. *On 3/27/17 it listed he was at continued risk for pressure ulcers, but he had none at the present time. Review of skin observation documentation during bath days revealed: *On 1/20/17 it was the only bath day skin observation had been documented. -No concerns were noted. *No other documentation or observations were noted on bath days by bath aides. Review of nursing and physician documentation regarding the skin condition for resident 2 revealed: *On 3/24/17 the nursing screening listed his skin as warm, dry, and pink, with no breakdown. *On 5/11/17 an unidentified certified nursing assistant (CNA) called licensed practical nurse (LPN) D into the resident's room to see pressure ulcers. -There were three on the inner left buttock and two on the inner right buttock. -The ulcers were bleeding at that time. -The resident had stated It's very sore. -No notation was made regarding further notification regarding the pressure ulcers. *On 5/12/17 registered nurse (RN) E identified three small sores on insides of buttocks. -There was no drainage. -The resident had stated it hurt if he sat too long. -No notation was made regarding further notification regarding the pressure ulcers. *On 5/19/17 LPN D wrote a small sore noted to inner buttocks. - No notation was made regarding further notification regarding the pressure ulcers. *On 5/20/17 RN E wrote small sore on right buttock. -Resident stated it hurt a little at times, and he tried to shift around to remove the pressure. -No notation was made regarding further notification regarding the pressure ulcers. *On 5/25/17 his physician wrote to have the wound nurse assess the open area to the right buttock. *On 5/26/17 LPN A identified a small open area on left inner coccyx. *On 5/26/17 the wound nurse completed an observation tool identifying and documenting pressure ulcers. -The pressure ulcer on the coccyx was added to the undated care plan -The coccyx pressure reducing cushion was added to the motorized scooter on the undated care plan. *On 6/3/17 RN F noted skin irritations due to tape used in the pressure ulcer dressing. *On 6/6/17 the wound nurse noted a small sore to the left inner buttock and a small patch of excoriated skin to the right buttock. -There was no notation regarding the excoriated area or the second scabbed over area on the left buttock seen the next day by surveyor. 3. Observation on 6/7/17 at 2:33 p.m. of resident 11's pressure ulcer wound care by LPN A revealed: *One opened area on the coccyx with a scabbed area approximately 3 cm in width with a scab at the center and reddened opened area surrounding the scabbed area. *A second scabbed area under 0.5 cm in width just below and to the left of the coccyx on the left buttock. Review of resident 11's medical record revealed: *She had been admitted on [DATE]. *She had a [DIAGNOSES REDACTED]. *She was incontinent of urine and bowels. *She was unable to move without assistance. *She was to be repositioned every two hours. Review of skin assessments using the Braden scale revealed: *On 12/19/16 her Braden score showed she was at a high risk for the development of pressure ulcers. *On 3/13/17 her Braden score showed she was at risk for development of pressure ulcers. *On 4/28/17 her Braden score showed she was at a high risk for the development of pressure ulcers. *On 5/14/17 her Braden score showed she continued at a high risk for the development of pressure ulcers. Review of the skin condition documented in nutritional screens revealed on 12/20/16 the nutritional screen stated she was at high risk for pressure ulcer development. Review of the skin portion of the MDS assessments revealed: *On 12/20/16 she was identified at risk of developing pressure ulcers, but having none at the time of assessment. *On 3/15/17 she was identified as having one stage 2 pressure ulcer. *On 4/22/17 she was listed as not having any pressure ulcers. *On 5/15/17 she was identified as having one stage 2 pressure ulcer. Review of skin observation documentation during bath days revealed: *In January, 2017, the bath aides documented opened area on 1/6/17 and 1/7/17. -No opened area was documented on the eight other bath days. *In February, 2017, one bath day skin observation was entered on 2/3/17 and it showed no opened areas. *On 3/6/17 the bath day skin observation documented no opened areas. *On 3/29/17 the bath day skin observation documented no opened area. *In April, 2017, no bath day skin observations were documented. *On 5/8/17 the bath day skin observations documented no opened areas. *5/10/17 the bath day skin observations documented no opened areas. *On 6/5/17 the bath day skin observations documented no opened areas. Review of nursing documentation regarding the skin condition and pain for resident 11 revealed: *On 12/19/16 the nursing screening/assessment identified the skin was warm, dry, and pink, with no open areas. *On 12/20/16 during pain interview the resident identified pain at a level ten of ten (worst) at her bottom and lower back/hip area. *On 1/4/17 the wound nurse identified a stage 2 pressure ulcer on her right coccyx that was 12 millimeters (mm), by 12 mm, by 1 mm in depth. *On 2/6/17 the wound nurse identified a second stage 2 pressure ulcer on her sacrum that was 2 mm, by 2 mm, by 2 mm in depth. *On 2/14/17 changes in treatment included: -A low air loss mattress was placed on her bed. -The cushion in the wheelchair was changed from a gel cushion to a Roho cushion. -The physician was asked for an order to try [MEDICATION NAME] wound paste. *On 2/21/17 the pressure ulcer on the right coccyx was healed. *On 3/7/17 the wound nurse listed only the sacral wound. *On 3/13/17 the nursing screening/assessment tool completed by RN G listed the sacral pressure ulcer as healed. *On 3/15/17 her pain interview identified continued pain rated as 9 out of 10 at her lower back and bottom. *On 3/20/17 the wound nurse identified the sacral wound as present and unchanged. *On 3/28/17 the wound nurse identified the sacral wound as healed. *On 5/2/17 her pain interview identified her pain as ten of ten (worst) in the area of her lower back and bottom. *On 5/9/17 she had been admitted to hospice care. *On 5/11/17 the wound nurse documented a new pressure ulcer at sacrum which was 21 mm long, 13 mm wide and 1 mm deep. *On 5/14/17 LPN A documented a pressure ulcer in the coccyx area, not sacral area. * The weekly wound observations for 5/22/17, 5/30/17, and 6/6/17 documented a worsening sacral pressure ulcer. 4. Review of resident 15's medical record regarding pressure ulcers revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Hypertensive [MEDICAL CONDITION]. -Chronic [MEDICAL CONDITIONS]. -[MEDICAL CONDITION]. -Type 2 diabetes mellitus. -Abnormal coagulation. -Pain. -[MEDICAL CONDITION]. -Depression. *She had been admitted to hospice on 9/20/16. Review of the skin assessments using the Braden scale revealed: *On 9/22/16 she was at risk for the development of pressure ulcers. *On 12/19/16 she continued at risk for the development of pressure ulcers. *On 3/17/17 she continued at risk for the development of pressure ulcers. Review of the skin condition documented in nutritional screens revealed on 12/21/16 she was at moderate risk for pressure ulcer, but had no skin concerns. Review of the skin portion of the MDS assessments revealed: *On 9/23/16 she was listed at being at risk for development of pressure ulcers, but had none at the present time. *On 12/21/16 she continued at risk for development of pressure ulcers, but had none at the present time. *On 3/20/17 she was identified as having two stage 2 pressure ulcers. -The oldest had first been noted on 3/15/17. Review of skin observation documentation during bath days revealed: *In January 2017 five bath skin observations identified no opened areas. -On 1/24/17 a scratched area was documented; the location was not identified. *In February 2017 six bath skin observations identified no opened areas. *In March 2017 five bath skin observations identified no opened areas. *In April 2017 there had been no bath skin observations documented. Review of the nursing documentation regarding the skin condition for resident 15 revealed: *On 1/25/17 a hospice nurse identified an excoriated, reddened area to both buttocks. Calazyme cream was applied. *On 2/1/17 a hospice nurse identified a stage 2 pressure ulcer on her left buttock that was 2 mm in width. -Had a pressure relieving pad in chair and in her wheelchair, and low air loss mattress on bed.*On 2/3/17 was the following: -The wound nurse documented a stage 2 pressure ulcer on the left buttock. -RN H updated her physician regarding the opened area and requested [MEDICATION NAME] dressing. *On 2/10/17 RN I identified two red skin tears on left buttock. *On 2/13/17 the wound nurse identified one wound on the left buttock. *On 2/28/17 the wound nurse identified the left buttock wound had healed. *On 3/4/17 RN J documented continued abrasion on left buttock; wound dressing was applied. *On 3/6/17 RN I documented red abrasion on left buttock. *On 3/8/17 hospice nurse documented red and purple abrasion to upper left buttock area. *On 3/15/17 hospice nurse documented: -A new unstageable pressure ulcer on right lateral heel 0.7 cm in length and 1 cm in width. -A stage 1 pressure ulcer on left bunion, and on top of both feet. -Continued pressure ulcer on left buttock. *On 3/16/17 RN H faxed physician to have wound nurse see regarding pressure ulcers. *On 3/16/17 the wound nurse documented: -Re-opening of the left buttock pressure ulcer. -A second stage 2 pressure ulcer on the right lateral heel, an unopened blister 0.7 cm by 1 cm. -Stated other areas not reddened at time of assessment. -Added floating heels and no shoes to interventions. -Changed gel cushion in recliner to pressure relieving coccyx cushion. 5. Interview on 6/7/17 at 3:15 p.m. with the wound nurse revealed: *She was not notified of any stage 1 pressure ulcers. When she was notified wounds were usually at a stage 2. *Residents were to get two baths a week and CNAs were to do skin observations on bath days and document it. *She was not involved in teaching new CNAs. *A new wound would not be assessed over a weekend; it would be assessed on Monday after the weekend. Interview on 6/8/17 at 9:00 a.m. with the primary instructor for CNAs regarding skin observation revealed: *She instructed the CNA students and newly hired CNAs on skin observation and what pressure ulcers looked like. *She had not instructed them on what or how to chart observations. *She was unable to pull up the document they would chart on. *She stated she thought there had been a turning schedule document, but she was not sure. Interview on 6/8/17 at 9:15 a.m. with the director of nursing revealed: *She agreed prevention of pressure ulcers was their goal. *She agreed the above four residents had their pressure ulcers found at stage 2. *She agreed there should have been documentation of skin conditions at the time of bathing to identify possible problem areas. *She agreed there was possibly a system problem in prevention and identification of stage 1 pressure ulcers, and notification of new pressure ulcers. Interview on 6/8/17 at 9:30 a.m. with RN C regarding documentation revealed: *Bath aides were to document skin observations with each bath. *She had not found a turning schedule document to chart on in their documentation system. Review of the 2/26/16 Skin Assessment policy revealed: *There was to be a full body skin assessment by a licensed or registered nurse on admission, readmission, quarterly, and when there was a significant change in condition. *There was no plan identified informing staff of what to do with information once a pressure ulcer was found. Review of the 2/26/16 Pressure Ulcer Prevention procedure revealed: *Observation, assessment, and basic preventative measure must be ongoing to prevent the onset of impaired skin integrity. *Observe skin with particular attention to bony prominences daily during routine skin cares. *Residents who are independent with ADL's will have skin observed weekly during their bath. *Residents who are in bed, who are not independent with repositioning side to side, will be assisted by staff every 2 hours and as needed. *An individualized repositioning schedule may be necessary for residents at increased risk or with existing pressure ulcers. *Use supplemental devices as warranted to relieve pressure. *Residents in a chair who are not independent with repositioning should be assisted every one hour with repositioning.

A. Based on observation, interview, record review, and policy review, the provider failed to provide a secure environment to prevent one of one sampled residents (8) who was at risk for elopement from leaving the facility unnoticed. Findings include: 1. Observation on 4/12/16 at 12:15 p.m. of resident 8 revealed he was able to ambulate independently with the assistance of a walker. 2. Review of resident 8's complete medical record revealed he had a [DIAGNOSES REDACTED]. *Review of 8/3/15 fax showed the provider requested the removal of the Wanderguard alarm bracelet from resident 8 because the resident had not attempted an elopement. The physician approved the request on 8/4/15. *Review of the 2/21/16 Elopement Notice found he was last seen at 2:35 p.m. in chapel/coffee social which is held near the front door. *Review of the 2/21/16 Report of Resident Occurrence revealed: -The event occurred on a Sunday afternoon. -He had wandered out of the building at approximately 3:05 p.m. -An employee on her way home from work noticed a man she thought was a resident walking with his walker outside across the street. -The employee returned to the facility and alerted the nursing staff. -A search of the building was completed and resident 8 was not found. -The police were called and facility staff went out to search for the missing resident. -He was found by the staff at 3:42 p.m. on the 1600 block of 12th avenue SE. -He was dressed in a long sleeve shirt, pants, shoes, and socks, but had no coat on. -The temperature outside was 28 degrees Fahrenheit (F) with no wind. -His body temperature upon his return to the facility was 92.7 degrees F. -He had walked out the front door. That door was attended during the day hours Monday through Friday. The door was only alarmed and locked at night. -After the elopement the provider's plan was to alarm the door if they were unable to have the door watched. Review of Elopement Notices revealed: *Resident 8 had attempted elopement on 3/23/16 going out the G wing door at 2:15 a.m. *Resident 8 had attempted elopement on 4/1/16 going out the Adult Day Center door at 8:15 p.m. *He had been brought back into the facility each time when the door alarm sounded. Interview on 4/13/16 at 3:15 p.m. with the director of nursing revealed she agreed the front door was not consistently attended during the day hours. Review of the provider's undated Elopement policy revealed: *Definition of elopement was when a resident left the facility building undetected without supervision of staff or a responsible party. *Policy: To allow a maximum amount of physical movement for all residents while minimizing the risk of resident elopement. B. Based on observation, interview, and policy review, the provider failed to answer call lights in a timely manner for three of three random residents (6, 19, and 20). Findings include: 1. Observation on 4/12/16 from 7:55 a.m. through 8:18 a.m. of resident 19's room revealed the call light had been going off during that whole time. It had been turned off at 8:18 a.m. The call light was activated at the onset of the observation. 2. Observation and interview on 4/13/16 at 8:05 a.m. with housekeeper R outside resident 20's room revealed: *The resident was yelling out for help, and his door was closed. *His call light had not been turned on. *Housekeeper R went into the room. -There were no staff in the room, he asked the resident what he needed. -He then informed the resident he would put his call light on and left the room. *Care staff had not returned to the resident's room until 8:32 a.m. *Licensed practical nurse K had been at the nurses station during the above mentioned time frame but had not gone to answer the call light. Interview on 4/13/16 at 8:40 a.m. with certified nursing assistant S revealed resident 20 wanted to get up. She stated usually he did not get up until 9:00 a.m. They assisted other residents to get up prior to helping him. She had seen the call light on but was assisting another resident. She then went down the other hall to help another staff member. Surveyor: 3. Observation on 4/12/16 from 3:49 p.m. to 4:11 p.m. in the hallway outside of resident 6's room revealed: *His bathroom call light was already on at 3:49 p.m. *That call light remained on until 4:11 p.m. when it was answered by the infection control nurse. Interview on 4/12/16 at 4:12 p.m. with resident 6 revealed: *It was not uncommon for him to wait thirty minutes for a call light to be answered. *He waited longer during the day than during the night. *He believed it was because he was at the end of a hall. Surveyor: 4. Interview on 4/13/16 at 9:30 a.m. with the director of nursing (DON) revealed the expectation was call lights would be answered within ten minutes. All staff could stop in to see what the resident needed including housekeeping staff and charge nurses. Interview on 4/13/16 at 2:10 p.m. with the DON and the education staff person revealed they had a committee for evaluating times of call lights. But had stopped it about one month ago. The educator and the DON were the ones responsible for conducting audits while the committee was meeting. They had not been doing audits in the past month. Review of the provider's 12/15/14 Use of Call Light policy revealed staff were to respond promptly to residents' call for assistance. All personnel should have been aware of call lights at all times. Staff should answer call lights promptly even if they were not assigned to that resident.

Based on record review, interview, and policy review, the provider failed to ensure professional standards were followed regarding bowel management protocols for two of five sampled residents (1 and 14). Findings include: 1. Interview on 4/11/16 at 4:15 p.m. with resident 1 revealed he was doing good except he had bowel issues the night before. Review of resident 1's medical record revealed he had: *No bowel movements on 2/29/16, 3/1/16, or 3/2/16. -Been given a suppository on 3/3/16 at 5:25 a.m. for constipation and had a large bowel movement. -Not been given milk of magnesia prior to the suppository. *No bowel movements on 3/4/16, 3/5/16, 3/6/16, or 3/7/16. -Been given a suppository on 3/8/16 at 5:37 a.m. for constipation. -Been given milk of magnesia on 3/8/16 at 3:44 p.m. to promote a bowel movement. *No bowel movements on 3/12/16, 3/13/16, 3/14/16, or 3/15/16. -Been given a suppository on 3/16/16 at 5:07 a.m. for constipation. -Not been given milk of magnesia prior to the suppository. *No bowel movements on 3/17/16, 3/18/16, 3/19/16, 3/20/16, or 3/21/16. -Been given milk of magnesia on 3/18/16 at 3:24 p.m. and on 3/22/16 at 12:38 a.m. to promote a bowel movement. -Been given a suppository on 3/22/16 at 5:23 a.m. for constipation and had a large bowel movement. *No bowel movements on 3/23/16, 3/24/16, and 3/25/16. -Been given milk of magnesia on 3/24/16 at 3:48 p.m. and on 3/25/16 at 4:00 p.m. to promote a bowel movement. -Been given a suppository on 3/26/16 at 5:21 a.m. for constipation and had an extra large bowel movement. *No bowel movements on 3/28/16, 3/29/16, and 3/30/16. -Been given milk of magnesia on 3/30/16 at 4:12 p.m. to promote a bowel movement. -Been given a suppository on 3/31/16 at 5:14 a.m. for constipation. *No bowel movements on 4/1/16, 4/2/16, 4/3/16, and 4/4/16. -Been given milk of magnesia on 4/2/16 at 4:03 p.m. and on 4/3/16 at 3:57 p.m. to promote a bowel movement. -Been given a suppository on 4/5/16 at 5:13 a.m. for constipation and had an extra large bowel movement. 2. Review of resident 14's medical record revealed he had: *No bowel movements on 3/5/16, 3/6/16, or 3/7/16. -Been given milk of magnesia on 3/8/16 at 3:41 p.m. to promote a bowel movement. *No bowel movements on 3/23/16, 3/24/16, 3/25/16 or 3/26/16. -Been given milk of magnesia on 3/27/16 at 2:43 p.m. to promote a bowel movement. 3. Interview on 4/13/16 at 2:00 p.m. with the director of nursing regarding residents 1 and 14 revealed the process used for bowel management included giving the resident prune juice if they had not had a bowel movement for one day. The prune juice was provided by the dietary department. If a resident had not had a bowel movement in two days they were to have been given a laxative. If a resident had not had a bowel movement for three days then a suppository would be given. They had not followed that protocol with resident 1 regarding the above situations. Interview on 4/13/16 at 4:00 p.m. with licensed practical nurse K revealed if a resident had not had a bowel movement in twenty-four hours they would be put on the prune juice list for the dietary department. If they had not had a bowel movement in forty-eight hours then they would be given a laxative. If they had not had a bowel movement in seventy-two hours then they would be given a suppository. Review of the provider's undated Bowel Elimination: Bowel Control Program policy revealed: *Certified nursing assistants were to document on the bowel movement log. *The medication nurse was responsible for checking the daily BM log. *If a resident has not had a BM (bowel movement) for one day, give prune juice. *If a resident has not had a BM for two days a laxative should be given. *If a resident has not had a BM for 3 days, a suppository or enema is given.

Preceptor: Based on observation, record review, interview, and job description, the provider failed to ensure medically related social services were planned and implemented for one of one sampled resident (3) with a significant decline in eating, walking, and communication. Findings include: 1. Observation on 3/5/13 at 12:30 p.m. of resident 3 in the assisted dining room revealed: *She was sitting in a wheelchair. *She had been served pureed food. *Staff were feeding her. *Her arms were stiff against her chest. *When staff spoke to her she did not respond back. Observation on 3/6/13 at 3:55 p.m. of resident 3 revealed a relative was in her room speaking to her, but she did not respond back. She had been laying in bed and her arms were stiff against her chest. She had tears in her eyes. Interview on 3/6/13 at 9:25 a.m. with registered nurse C regarding resident 3 revealed: *She had fell shortly after being admitted into the facility. *She had "behaviors" when she had first came into the facility. *She had not been able to bear weight since she had fell and now used a wheelchair all the time. Review of resident 3's 3/21/12 through 3/1/13 interdisciplinary notes revealed she: *Had been admitted on [DATE]. *Had been pleasant, spoke to staff, and could move legs and arms upon admission. *Had been able to voice her concerns to staff upon admission but had a significant decline in that area. *Had a fall with major injury the first week in the facility. *Had a daughter who visited often, and who was very upset about the fall. *Had obtained a pressure sore while at the facility. *Had become anxious regarding going to the bathroom, and when staff used the lift to transfer her. *Had a significant weight loss. *Had been started on a pureed diet on 7/18/12. *Had several medication changes. *Had been more alert after discontinuing risperidone (medication used to treat psychosis and other mental or emotional conditions). *Had a decline in her ability to communicate. *Had been crying and weepy several times. *Had not received any interventions by the social services department during the period from 3/21/12 to 3/1/13 to help in the areas of decline noted above. Interview on 3/6/13 at 1:15 p.m. with resident care coordinator E regarding resident 3 revealed the social services department had not attempted any interventions with her except for completing the quarterly assessments. The interventions provided by nursing, dietary and activities were reactive instead of proactive. Interview on 3/6/13 at 2:30 p.m. with the licensed social worker regarding resident 3 revealed: *She had completed the quarterly assessments on 9/13/12 and 12/7/12. *On 9/13/12 the resident was not able to be interviewed. *On 12/7/12 the resident was able to be interviewed. *She was told by the activities staff if a resident was interviewable or not interviewable. *Staff believed the difference had been due to discontinuing the risperidone on 9/7/12. *She had not been aware the resident had been started on risperidone again on 1/17/13. *She had not been aware the resident was on a pureed diet, and staff were now feeding her. *She had not provided any interventions to the resident regarding the areas of decline. Review of the provider's undated social services job description revealed staff were to provide services to residents and their families regarding the social and emotional aspects of illness, disability and aging in a long term care facility. They were to work with emotional problems including assisting residents and families with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care.

Preceptor: Based on observation, interview, record review, and policy review, the provider failed to: *Notify the physician related to a resident's change in condition and elevated blood sugars for one of one sampled resident (2). *Follow and clarify physician's orders for one of one sampled resident (2). *Ensure there had been complete and accurate documentation for one of one sampled resident (2) regarding high blood sugar levels. *Involve the physician with the holding of multiple doses of insulin for one of one sampled resident (2). Findings include: 1. Review of resident 2's complete medical record revealed: *She had been admitted on [DATE] with a re-admission date of [DATE]. *She had [DIAGNOSES REDACTED]. *She had been recently hospitalized due to unresponsiveness and [MEDICAL CONDITION] (a severe blood infection). *Her blood sugar levels had been hard to maintain at a normal range (70-130). *On 2/26/13 she had been diagnosed with [REDACTED]. The last dose of the [MEDICATION NAME] had been give to her on 3/2/13. Review of her blood sugar flow sheet dated 3/5/13 and 3/6/13 revealed the following blood sugar levels: *On 3/5/13: -At 7:00 a.m. 229, 11:00 a.m. high, 1600 (4:00 p.m.), 2000 (8:00 p.m.) high. -She had been given the appropriate dose of [MEDICATION NAME]by injection as directed by the physician's orders. *On 3/6/13: -At 5:15 a.m. her blood sugar had been 324 with no insulin given as that had been an as needed reading (PRN). -At 7:00 a.m. 273 with the appropriate dose of [MEDICATION NAME]had been given as directed by the physician's orders. Review of resident 2's interdisciplinary progress notes (IDPN) dated 3/5/13 at 10:43 a.m. and 9:48 p.m. revealed: *No documentation by the nursing staff had been found to support the physician had been notified on 3/5/13 or 3/6/13 of her "high" blood sugar readings. *No documentation between the hours of 10:43 a.m. and 9:48 p.m. had been found regarding the 11:00 a.m. and 4:00 p.m. high blood sugar level readings. Interview on 3/6/13 at 4:20 p.m. with registered nurse (RN) A revealed: *According to their blood glucose monitor manufacturer a "high" reading would have indicated a blood sugar level of greater then six hundred. *The physician would have not have been notified of the "high" blood sugar readings. *The physician had provided the nursing staff with orders to only notify him when her blood sugars had been less then fifty. *Resident 2 was an unstable diabetic and her blood sugar levels fluctuated greatly from high to low. Because of that the physician had not wanted to be notified of any high blood sugar readings. *She had been aware resident 2 had recently finished an antibiotic for a UTI. *They did not re-check urine after the residents had finished their antibiotics unless they would have been symptomatic. She did not feel resident 2 was symptomatic, as she had been voiding without any difficulties. Random observations from 3/5/13 through 3/6/13 of resident 2 revealed: *She had appeared to have been sleeping during two meals. *She had made no attempt to eat or drink on her own and had to be fed by the staff with increased encouragement. *She had remained sleeping during ADL and a dressing change to her buttocks on 3/5/13 at 11:00 a.m. *She had not been easily aroused when the staff or this surveyor had made attempts to awaken her. Interview with a family member on 3/6/13 at 7:45 a.m. revealed: *Resident 2 had a history of [REDACTED]. *They had not been aware the nursing staff were notifying the physician only when her blood sugar levels were less than fifty. *They were under the impression the physician would have been notified if her blood sugar levels had reached over five hundred. *When she had a blood sugar level greater than five hundred with two consecutive readings she would have had an infection. 2. Review of resident 2's physician's orders dated 9/13/12, 11/7/12, and 2/15/13 revealed: *On 9/13/12 the order had read to notify the physician when her blood sugar levels were less than fifty and above four hundred. That order had been signed and dated by the physician on 1/18/13. *On 11/7/12 the order had read to notify the physician if blood sugar levels had been less than fifty. The physician had not signed or dated that order. *On 2/15/13 the re-admit order had read to notify the physician when her blood sugar levels were less than seventy and greater than four hundred. The physician had electronically signed and dated that order. No documentation had been found in the resident 2's complete medical record to support the nursing staff had attempted to clarify the above physician's orders. 3. Review of resident 2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *Several dates and various times had been initialed and circled by the nursing staff in the routine insulin areas. *The dates and times of day had varied from 7:00 a.m. to 8:30 p.m. *At times the staff would have provided an explanation as to why those dates and times of day had their initials circled. The insulin dosage that was to have been given at those various dates and times had been held. *The explanations by the nursing staff had indicated the various insulin doses had been held due to either a lower blood sugar level, she had not eaten her meal, or she had not eaten enough of her meal. *No physician's order had been found to indicate the nursing staff should have held her insulin at any given time without physician notification first. Interview with the director of nurses (DON) on 3/6/13 at 3:50 p.m. on all of the above revealed: *She confirmed that this had not been an acceptable scope of practice by the nursing staff. *She agreed the physician should have been notified on all of the above situations. Review of the provider's undated documentation and general charting rules policy revealed: *No guidelines had been found in that policy for the nursing staff to follow on appropriate and accurate charting rules. Review of the provider's undated physician orders and clarification policy revealed no guidelines for the nursing staff to follow for clarifying, holding, and timeliness of the physician's orders to be signed had been found. Review of the provider's 2/28/12 medication administration documentation policy revealed no policy had been found to support the holding of insulin without prior notification and orders from the physician. Refer to F157 and F281.

A. Based on record review, interview, and policy review, the provider failed to ensure professional standards were followed by two of two nurses (S and T) regarding physician's orders for one of two hospice residents (20). Findings include: 1. Interview with the director of nursing on 5/3/11 at 10:00 a.m. and at 11:45 a.m. revealed: *Physician's orders had not been followed for the [MEDICATION NAME] and [MEDICATION NAME] for resident 20. *There had been a medication error with the [MEDICATION NAME] and [MEDICATION NAME] for resident 20. (Refer to F333, finding 1.) *The provider did not have a specific policy for following physician's orders. She confirmed there was a nursing standard which indicated nurses were to have followed physician's orders. *The labels on the two different [MEDICATION NAME] containers should have been reviewed more closely even though the different concentrations made it more confusing to the nurses. (Refer to F333, finding 1.) Review of the undated medication-administration of oral medication from a bottle policy revealed: *"Check the medication to be given on the medication record sheet." *"Read the label on the medication bottle." *"Compare the label on the bottle with the medication sheet." *"Dispense the medication from the bottle." *"Read the label on the bottle when putting it away." *"Administer the medication." Review of the undated general medication guidelines policy revealed: *"When there is any question as to the accuracy of a calculated dose, the amount of drug to be used, the solution to be used or the accuracy of the order, check with the physician." *"The nurse is responsible for all medications given." Review of the undated licensed practical nurse (LPN) job summary duties and responsibilities revealed the LPN should "Prepare and administer medications as ordered by the physician." Review of the above job summary document in LPN T's personnel file revealed she had signed acknowledgment of the job summary duties and responsibilities on 3/11/10. Review of the undated charge nurse job summary duties and responsibilities revealed the charge nurse should "Prepare and administer medications as ordered by the physician." Review of the above job summary document in registered nurse S's personnel file revealed she had signed acknowledgment of the job summary duties and responsibilities on 10/12/10. Refer to F333. B. Based on observation, record review, interview, and policy review, the provider failed to ensure filters on oxygen concentrators were cleaned for three of three sampled residents (4, 11, and 14) who used oxygen. Findings include: 1. Observation on 5/2/11 through 5/4/11 throughout the survey revealed resident 14 used continuous oxygen therapy from the concentrator when in his room or an oxygen tank when in the wheelchair. Review of the treatment records revealed a line labeled filters designated with an "N." The filter cleaning schedule for resident 14 was indicated by a highlighted box for initials on Sundays and Thursdays. Review of the treatment records revealed the following number of times without documentation of completion for filter cleaning: *January 2011 - 16 and 20. *February 2011 - 3, 6, 13, 17, 20, 24, and 27. *March 2011 - 3, 6, 10, 13, 17, 20, 24, 27, and 31. *April 2011 - 3, 7, 10, 14, 17, 21, and 28. Review of the 1/25/11 physician's order was for oxygen at two litters per minute per nasal cannula at naps, bedtime, and as needed for dyspnea. Clean filters two times weekly on Sunday and Thursday. Change the tubing twice monthly every other Sunday. Interview on 5/4/11 at 10:45 a.m. with employee N confirmed the oxygen filters were supposed to be cleaned as ordered by the night nursing staff. She did not know why it had not been completed on the above dates. Interview at 11:00 a.m. with the director of nurses confirmed the policy should have been followed. Review of the respiratory care policy for oxygen administration per concentrator revised November 2000 revealed: *Check the filter to make sure it was clean. *The procedure for filter cleaning twice weekly should have been placed on the day shift treatment sheet when oxygen was started. *Clean the external concentrator filters with mild soap and water twice weekly. Dirty filters could cause over heating of the concentrator unit. *Documentation should have been completed. 2. Review of resident 11's treatment sheet revealed an order for [REDACTED]. Interview on 5/3/11 at 5:45 p.m. with licensed nurse Fon 5/3/11 at 5:45 p.m. revealed there had been no physician's orders to clean the resident's oxygen concentrator filter or to change the resident's oxygen tubing. 3. Review of resident 4's treatment sheets for March 2011 and April 2011 revealed an order for [REDACTED]. The filters had not been initialed as having been cleaned on the following dates: *March 2011 - 3, 10, 24, and 30. *April 2011 - 7, 10, 14, 21, and 28.

Based on record review and interview, the provider failed to ensure one of two sampled hospice residents (20) received the correct dosage of medications ordered by the physician that had been given by two of two nurses (S and T). Findings include: 1. Review of resident 20's medical record revealed a physician's orders [REDACTED]. *[MEDICATION NAME] 2 to 4 milligrams (mg) every hour as needed. *[MEDICATION NAME] 0.5 mg to 1 mg every two hours as needed. Review of the medical record revealed a physician's orders [REDACTED]. Review of resident 20's physician's orders [REDACTED]. *[MEDICATION NAME] concentrate 20 mg/milliliter (ml) 4 mg scheduled every four hours. *[MEDICATION NAME] 2 mg/ml, one mg scheduled every four hours with those two medications being alternated. Review of the above [DATE] physician's orders [REDACTED].[REDACTED]. Review of a copy of the medication labels provided to the surveyor by the director of nursing revealed: *[DATE]--[MEDICATION NAME] sulfate 10 mg/5 ml-directions were "Give 2 mg to 4 mg (1 ml to 2 ml) every one hour as needed." *[DATE]--[MEDICATION NAME] sulfate 20 mg/1 ml--directions were "Give 4 mg (0.2ml) every 4 hours." Review of the [DATE] narcotic records for resident 20's [MEDICATION NAME] sulfate revealed the [MEDICATION NAME] concentration of the white container was 2 mg per ml. Further review revealed the brown container's [MEDICATION NAME] concentration was 20 mg per ml. Review of the [DATE] scheduled MAR for resident 20 revealed: *[MEDICATION NAME] sulfate 20 mg/ml give 0.2ml (4mg) 'po' (by mouth) was initialed by a nurse as given on [DATE] at 4:30 p.m. (that entry was written in the 6:00 p.m. slot of the MAR) and on [DATE] at 10:00 a.m. There were no other entries of the scheduled dose on the MAR for the [MEDICATION NAME] sulfate. *[MEDICATION NAME] 2 mg/ml-give 1 mg (1ml) 'po' every four hours was initialed by a nurse as given on [DATE] at 5:20 p.m. (that entry was written in the 4:00 p.m. slot of the MAR) and on [DATE] at 8:00 p.m. and on [DATE] at 8:00 a.m. There were no other entries of the scheduled dose on the MAR for the [MEDICATION NAME]. Review of the [DATE] prn (as needed) MAR indicated [REDACTED] *[DATE]--8:00 p.m.--[MEDICATION NAME] 2 mg (one ml) by mouth and [MEDICATION NAME] 1 mg (one-half ml) by mouth. *[DATE]--10:30 p.m --[MEDICATION NAME] 2 mg (one ml) by mouth and [MEDICATION NAME] 1 mg (one-half ml) by mouth. *[DATE]--12:15 a.m.--[MEDICATION NAME] 2 mg (one ml) by mouth and [MEDICATION NAME] 1 mg (one-half ml) by mouth. Interview with licensed practical nurse T on [DATE] at 6:35 p.m. revealed: *She confirmed she gave the above medications to resident 20 at the above time frames indicated. *She took the [MEDICATION NAME] out of the brown container that was the concentrated strength of 20 mg per ml. *She did not notice the concentration difference on the medication label of the container when she had used the brown container. Therefore she had taken the one ml that was 20 mg instead of 0.2 ml that was 2 mg which she should have taken for the [MEDICATION NAME]. *She was not aware of the medication error until the director of nursing contacted her regarding the error the next day. *She thought the [DATE] scheduled [MEDICATION NAME] and [MEDICATION NAME] physician's orders [REDACTED]. *There was a white container of [MEDICATION NAME] and a brown container of [MEDICATION NAME], and she did not realize the concentrations of the [MEDICATION NAME] were different in each container. Review of the [DATE] prn MAR indicated [REDACTED] *[DATE]--3:00 a.m.--[MEDICATION NAME] 2 mg (one ml) by mouth. *[DATE]--5:45 a.m.--[MEDICATION NAME] 2 mg (one ml) by mouth. Review of the [DATE] interdisciplinary note revealed resident 20 died at 12:55 p.m. Interview with registered nurse S on [DATE] at 6:10 p.m. revealed: *She confirmed she had given the above medications to resident 20 at the above time frames indicated. *She was unaware of the [DATE] scheduled [MEDICATION NAME] and [MEDICATION NAME] physician's orders [REDACTED]. *She had taken the [MEDICATION NAME] out of the brown container that was the concentrated strength of 20 mg per ml. *She had not noticed the concentration difference on the medication label of the container when she had used the brown container. Therefore she had taken the one ml that was 20 mg instead of 0.2 ml that was 2 mg that she should have taken for the [MEDICATION NAME]. *She stated there was a white container of [MEDICATION NAME] for resident 20 that had a different concentration that the nurse's had been using for the prn order of [MEDICATION NAME]. The white container's concentration of [MEDICATION NAME] had been [MEDICATION NAME] 2 mg/ml. *She was not aware of the medication error until the director of nursing contacted her regarding the error the next day. Interview with the director of nursing on [DATE] at 10:00 a.m. revealed: *She confirmed the above medication errors had been done by registered nurse S and licensed practical nurse T. *She had been made aware of the medication errors by a day nurse on [DATE] at 12:30 p.m., and she started her investigation at that time. *She thought the different concentrations of the [MEDICATION NAME] in the two different containers made the physician's orders [REDACTED]. *She stated registered nurse S and licensed practical nurse T had not had a medication error incident in the past. *She stated the prn order for the [MEDICATION NAME] and the [MEDICATION NAME] had not been discontinued by the physician, but the scheduled [MEDICATION NAME] and [MEDICATION NAME] orders from [DATE] should have been given as ordered.